GUIDANCE AND PROCEDURES FOR INFECTION PREVENTION AND CONTROL
INFECTION PREVENTION AND CONTROL POLICY AND STRATEGY Document Profile Box Document Reference: Version:
Draft version 5
Ratified by: Date ratified: Name of originator/author:
George Marley / Christine McManus
Name of responsible committee/individual:
Infection Prevention and Control Committee
Date issued: Review date:
North East Ambulance Service NHS Trust Infection Control Policy/Procedure Version: 0001 Status: Draft 5 -1-
Document Location The source of the document will be found in the Quality System via ‘Docuviewer’ (Service-wide access) Revision History July 2008 New policy for NEAS Trust Approvals This document requires approval from the following: Clinical Governance Committee
Name Date of Approval Version
Freedom of Information Act 2000 Access This document will be available via the NEAS Publication Scheme Contents Paragraph 1 Policy Statement
Sources of Expertise and Support
Competence (Information and Training)
Infection Prevention and Control Procedures
Equality and Diversity Statement
Consultation, Approval and Ratification Process
Dissemination and Implementation
Monitoring and Compliance with this Policy
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Policy Statement 1.1
The North East Ambulance Service NHS Trust is committed to reducing the risks of healthcare associated infection and serious communicable diseases through a strategy aimed at dealing proactively with the outcomes and continually developing safer working practices.
The policy and strategy for the control of infection within NEAS NHS Trust has been developed in line with Ambulance Service Network (ASN) guidance 1 which takes account of current legislation and Government (Department of Health) policy and guidance.
An infection prevention and control plan is developed for each financial year to set a programme of work for that year
The infection prevention and control work is underpinned by robust and comprehensive infection prevention and control processes and procedures.
An annual infection prevention and control update is presented to the Trust Board to report on the progress made and to provide assurance of continued compliance with The Health Act 2006 and from April 2009 The Health and Social Care Act 2008 Code of Practice for the NHS on the prevention and control of healthcare associated infections (HCAI) and related guidance (Department of Health), hereafter called the Code of Practice.
The policy provides criteria to ensure patients are cared for in a clean environment, with the risk of HCAI kept to a minimum.
Additionally the Trust needs to comply with the current Care Quality Commission Standards for Better Health – core standard C4a, C4c, C21 and the NHS Litigation Authority Risk Management Standards for Ambulance Trusts (2009/10)
To confirm the Trust’s commitment to the control of infection and to set the strategic direction for infection control initiatives.
Procedures and guidance on infection prevention and control have been developed and reviewed and are available with the policy document to assist all clinical staff in ensuring they follow best practice in order to achieve the aim of a reduction in the incidence of HCAIs.
To promote education and training in all aspects of infection prevention and control.
The Trust’s Guidance and Procedures for Infection Prevention and Control document sets out the strategic and policy approach to the prevention and control of infection, and describes the organisational infrastructure in place including key accountabilities.
To ensure the Trust complies with The Health and Social Care Act 2008: this policy has been developed using the following guidance:
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• The Health and Social Care Act 2008. Code of practice for the NHS on the prevention and control of healthcare associated infections and related guidance (DH 2009) • National Guidance and Procedures for Infection Prevention and Control (ASA 2004) • Winning Ways: working together to reduce healthcare associated infection in England (DH, 2003) • Health Professions Council Standards of Conduct, Performance and Ethics (HPC,2003) • Joint Royal Colleges Ambulance Liaison Committee guidance (JRCALC 2004) • DH Guidelines for Infection Prevention and Control for Ambulance Trusts (2008)
This policy aims to ensure that all risks associated with the control of healthcare associated infections including inoculation incidents are adequately controlled.
Chemical, Biological, Radiological and Nuclear (CBRN) risks require specialist advice and training. The ASN provides this information and the Trust has a team of specialists who are trained to deal with these risks. The key principles contained within this policy are relevant to CBRN activities within the Trust, however the Emergency Planning Team are responsible for providing policies, procedures, training and risk assessments relating specifically to CBRN.
The Trust Board is collectively responsible for providing leadership and direction on health and safety matters. Members will have a full understanding of the risks, systems in place for managing the risks and appreciation of the causes of any failures. The Board are responsible for monitoring the effectiveness of infection prevention and control measures, through the annual infection prevention and control programme and report. The Board must have mechanisms to ensure sufficient resources are available and have effective arrangements in place to reduce the risk of healthcare associated infection and communicable diseases within the Trust and for meeting all statutory requirements.
Chief Executive has a key role in ensuring that systems are in place and being adhered to, in order to manage any significant risks facing the organisation. The Chief Executive is ultimately responsible for infection prevention and control measures, a responsibility which is discharged through the Director of Strategy and Clinical Standards/Director of Infection Prevention and Control (DIPC).
The Director of Strategy and Clinical Standards is the nominated Executive Director responsible for coordinating the management of the risks associated with infection prevention and control and is the designated Director of Infection Prevention and Control (DIPC) as outlined within the Health Act 2006.
The Infection Prevention and Control Manager (IPCM) is responsible for the development of this policy and subsequent procedures and any associated infection control initiatives. The IPCM will lead by example and adopt good practice at all times in order to ensure the implementation of effective infection prevention and control across the Trust and will provide advice and practical assistance in all matters relating to infection prevention and control and will also liaise with the Workforce Development Department to ensure this policy is effectively communicated to all appropriate personnel. All incidents regarding infection prevention and control, including reported outbreaks of HCAIs, will be reported and investigated. The IPCM will carry out root cause analysis (RCA) when required utilising the National Patient Safety Agency (NPSA) guidelines.
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The Infection Prevention and Control Committee is responsible for monitoring and reviewing the arrangements in place across the Trust to manage the risks associated with infection prevention control including provision of information, instruction and training, management of inoculation injuries and development of an infection control annual programme and report.
The Clinical Governance Committee is responsible for approving and monitoring adherence to the Infection Prevention and Control Policy and associated procedures.
The Estates Manager is responsible for liaising with the IPCM to ensure that all environmental policies and estates management are compliant with infection prevention and control best practice.
The Head of Workforce Development is responsible for ensuring that all clinical and non-clinical staff receive basic infection prevention and control training, including hand hygiene, use of personal protective equipment and inoculation incidents and that any external training providers are appropriately accredited.
Directors and Line Managers are responsible for ensuring they have a comprehensive understanding of their own remit within this policy and any associated procedures or guidance documentation. They will lead by example and adopt good practice at all times in order to ensure the implementation of effective infection prevention and control across the Trust. Duties include: • Leading by example, particularly in relation to good hand hygiene. • Completion of audit forms. • Ensuring staff within their control are familiar with this policy and associated procedures. •
Ensuring infection prevention and control risks are assessed and reduced as far as reasonably practicable for activities under their control.
• Facilitate and record required infection prevention and control training and updates of staff under their supervision to enable them to carry out their roles safely. •
Ensure that staff members responsibilities for infection prevention and control are reflected in personal development plans or appraisal.
• Ensuring staff involved in or affected by an inoculation incident are provided with adequate support. 4.10
Employees are responsible for familiarising themselves and complying with this policy and to adhere to the Trust’s procedures for infection control and have a duty to: •
Demonstrate good infection prevention and control and hygiene practice by complying with Trust IPC Policies/Procedures/Guidelines. North East Ambulance Service NHS Trust Infection Control Policy/Procedure Version: 0001 Status: Draft 5 -5-
Participate in audit of IPC practices when requested.
Undertake mandatory IP&C training.
Ensure that the vehicle in which they are carrying out clinical services is clean and fit for purpose before, during and after each patient treated or conveyed.
Adopt standard precautions to minimise the transmission of infection including blood borne viruses.
Correctly use the personal protective equipment provided by the Trust.
Organisational Framework – Infection Prevention and Control performance is monitored by the Infection Prevention and Control Committee and reports to the Clinical Governance Committee and Trust Board through the Director of Strategy and Clinical Standards/ DIPC.
Assurance Framework 5.1
The Trust has conducted an in depth assessment of all the risks associated with healthcare associated infections and all identified significant risks should be detailed in an appropriate action plan.
Sources of assurances include policies and procedures, internal performance management, Infection Prevention and Control Committee minutes and training records.
The Infection Prevention and Control Annual plan should be monitored by both the Infection Prevention and Control Committee and the Clinical Governance Committee.
The annual infection prevention and control report will include:
Detail progress against the annual infection prevention and control action plan.
Request ratification of the following years’ annual infection prevention and control action plan.
Demonstrate the effectiveness of the policy through the presentation of audit findings from station reviews, identifying improvements in infection prevention and control standards.
Assure continued compliance with the Health Act 2006 (Hygiene Code).
Assure compliance with Care Quality Commission core standard C4a and assist with compliance of core standard C4c and C21 of the Standards for Better Health.
Assure compliance with the NHS Litigation Authority Risk Management Standards for Ambulance Trusts
Demonstrate the reduction of infection control risks and their subsequent downgrading or where appropriate removal from the Risk Register.
Detail findings of any internal audits conducted. North East Ambulance Service NHS Trust Infection Control Policy/Procedure Version: 0001 Status: Draft 5 -6-
Implementing and ongoing involvement of the national cleanyourhands campaign.
Sources of Expertise and Support 6.1
The Trust has a dedicated Infection Prevention and Control Manager
The Infection Prevention and Control Committee has attendees with specific expertise in the area of Infection Prevention and Control.
The Trust is also a member of the National Ambulance Infection Prevention and Control Network which promotes infection prevention and control best practice in the ambulance sector.
Expert Infection Prevention and Control advice is available via the IPC Manager during office hours via telephone (0191 430 2190), mobile (07976561558) or e-mail.(insert numbers). Out of hours the Health Protection Agency (HPA) are available to provide specialist advice. The on-call microbiologist at the hospital concerned can be contacted.
Risk Assessment 7.1
Risk assessment should be carried out in accordance with the Trust’s Risk Management Strategy and associated documentation. Risks in respect to HCAI and serious communicable diseases may be identified on an ongoing basis via incident reporting procedures, complaints, claims, infection control audits and risk assessments.
Staff will undertake risk assessments as part of their working practice and the Trust will undertake an organisational risk assessment as part of the rolling risk assessment programme.
Competence (Information and training) 8.1
The Trust will ensure that their staff are provided with sufficient information, instruction and training in regard to managing risks associated with HCAIs including: •
All new Trust employees have IPC training including hand hygiene during the induction programme.
Infection Prevention and Control including hand hygiene being an integral component of all clinical courses (S009) as identified in the training needs analysis.
Infection Prevention and Control will be delivered to non clinical staff as identified in the training needs analysis (S008) as part of statutory and mandatory training.
All NEAS staff attending statutory and mandatory training will complete a selfstudy exercise learning workbook. The competed workbook is submitted to the statutory and mandatory facilitator.
Infection Prevention and Control including hand hygiene being an integral component of all clinical courses.
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Refresher training for all clinical staff.
Hand hygiene and infection prevention and control as part of the Trust’s risk management training programme.
The safe use and disposal of sharps and action to take in the event of an inoculation incident are included in initial clinical training. There are specific Occupational Health policies outlining action to be taken in the event of an inoculation incident.
Line managers are responsible for ensuring their staff are familiar with specific infection prevention and control procedures that they may encounter, according to their operational responsibilities and within their occupational work place.
Participation and completion of training will be monitored by the Workforce Development Department. Lack of any action will be identified through the Personal Development Review process.
Infection Prevention and Control Procedures 9.1
Infection prevention and control procedures are available within the Trust and have been developed to aid staff in minimising the risks of transmission associated with infectious diseases. The procedures are supported by additional guidance appended to the policy as a useful point of reference.
The procedures are communicated to staff via Clinical Practice and/or Health and Safety Circular, Training Bulletins and ‘Pulse’ newsletter articles. In addition they are also included in the risk management training programme.
Safe practice can be achieved by ensuring staff: • Are supported by management to deliver recommendations within these procedures. • Have received infection prevention and control training. • Understand and can apply the principles of risk assessment to minimise the risks of transmission of infectious diseases.
Safe infection control practice requires: • Knowledge of micro-organisms. • The diseases they cause. • An understanding of how they spread between humans
These procedures acknowledge that provision of a limited list of diseases may well inhibit the ability of staff to properly risk assess situations and utilise appropriate personal protection. For this reason, guidance on individual infectious diseases should be obtained via the Health Protection Agency: www.hpa.org.uk. The infectious disease section, whilst not exhaustive, is regularly updated by national experts and should provide a framework for risk assessment, based upon establishing: • • •
What the organism/disease is; How is it spread? How can staff protect themselves from transmission?
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Standard principles should be applied for all patients. These have been developed and provide protection for patients and healthcare workers. The use of standard principles is supported by the National Institute for Clinical Excellence. The full NICE guidelines can be accessed via: www.nice.org.uk. External expertise can be accessed through the Health Protection Agency, Occupational Health Services, NICE, National Patient Safety Agency. The Trust’s Policy for Implementation Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Practice Guidelines states that all clinical protocols adopted by the Trust will be aligned with JRCALC Guidelines except in the circumstances stated within the Policy. The Trust is committed to tackling the risks involved and reducing the impact of healthcare associated infections on patients, staff and the organisation. Infection Prevention and Control should be integral to the role of all clinical staff and should reflect their commitment to the provision of a safe environment for patients and staff.
All staff engaged in clinical practice on behalf of the Trust should be aware of and familiar with the following procedures for their own protection and that of their patients, and to support the Trust’s efforts towards reducing the incidence of healthcare acquired infection.
These procedures will be reviewed annually by the Infection Prevention and Control Committee or as and when significant changes make earlier review necessary to ensure that they follow the most current guidance.
Infection Prevention and Control procedures are available for the following activities:
Microbiology and the spread of infection
Standard principles of Infection Prevention and Control o Hand hygiene o Personal Protective Equipment o Sharps management including safe use and disposal of sharps, inoculation incidents
Aseptic technique and invasive procedures o Aseptic technique o Cannulation o Wound care
Cleaning and decontamination o Cleaning and disinfection solutions o Colour coding o Routine cleaning and disinfection o Body fluid and spillage management
Management of linen
Care of the deceased
Care of infected patients covering the following: North East Ambulance Service NHS Trust Infection Control Policy/Procedure Version: 0001 Status: Draft 5 -9-
o o o
Transportation of patients Classification of infectious diseases Control of infestations Protective measures Scabies Lice Fleas
Biological warfare agents
Major outbreaks and the Health Protection Agency (HPA)
Occupational Health and Safety Services (OHSS) available separately o Percutaneous (e.g. Needlestick) & Mucocutaneous Post Exposure Policy. o Blood borne virus – Post Exposure Policy o Guidance on management of blood borne virus infected healthcare workers who carry out exposure prone procedures. o Immunisation Policy o Meningococcal Infection Policy o Tuberculosis Policy o Varicella Vaccination and Immune Status Policy
Public Involvement 10.1
The Trust is committed to ensuring that in its effort to combat the spread of infection the general public is kept fully informed of its performance. The Infection Prevention and Control Annual Report is also available for public scrutiny. Details of the Trust’s Infection Prevention and Control initiatives including its policy and procedures are available to the public, under the freedom of information, via the Trust’s web-site.
Details of the Trust’s Infection Prevention and Control initiatives including its policy and procedures are available to the public, under the freedom of information, via the Trust’s web-site.
Under the Care Quality Commission health standards (formerly Healthcare Commission annual health check), members of the local authority health overview & scrutiny committee and service users and their representatives on Local Involvement Networks are invited to comment on the Trust’s Infection, Prevention and Control policy. This will include inspection of Trust vehicles and premises and access to Trust officers to answers questions arising from the policy.
This policy will be monitored for its effectiveness by the Infection Prevention and Control Committee. This will include: •
Responsibilities for IPC will form part of the job description for all staff.
Compliance with this role is monitored through the Personal Development Review (PDR) on an annual basis.
The PDR will also monitor the continuous professional development of staff.
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Compliance is monitored through the audit process, including local (Board) and national clinical key performance indicators.
The Trust Board will receive regular updates from the Director of Strategy and Clinical / DIPC.
It is fundamental to the Trust’s risk management system that all clinical and non-clinical adverse incidents, hazards and near misses are identified, recorded, analysed and control put in place to avoid their future re-occurrence.
All incidents regarding IPC, including reported outbreaks of HCAI, must be reported and investigated. These will be carried out by the IPC Manager .Root cause analysis should be applied according to the NPSA guidelines. In the case of suspected outbreaks, the Trust will co-operate fully with the Health Protection Agency (HPA), Strategic Health Authority (SHA) and Primary Care Trusts (PCTs) and acute Trusts during any investigation.
Equality and Diversity Statement 13.1
The Trust is committed to providing equality of opportunity, not only in its employment practices but also in the services for which it is responsible. As such, this document has been screened, and if necessary an Equality Impact Assessment has been carried out on this document, to identify any potential discriminatory impact. If relevant, recommendations from the assessment have been incorporated into the document and have been considered by the approving committee. The Trust also values and respects the diversity of its employees and the communities it serves. In applying this policy, the Trust will have due regard for the need to: • • •
Eliminate unlawful discrimination Promote equality of opportunity Provide for good relations between people of diverse groups
For further information on this, please contact the Equality and Diversity Department.
Consultation, Approval and Ratification Process 14.1
Consultation Process This policy has been discussed with the Infection Prevention and Control Committee which includes representatives from operational areas.
Policy Approval Process This policy has been submitted to the Policy Review Group for approval.
Ratification Process This policy has been approved by the Policy Review group and submitted to the JCC for ratification.
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Dissemination and Implementation 15.1
Dissemination Once ratified this policy will be added to the Document Quality Control System and added to the Intranet site to which all staff have access. Earlier versions of the document will be archived in the quality system. The policy will also be added to the Net Consent system once it is implemented. This system will require staff to read the policy before allowing access to IT systems, and will record the date and time staff members have read the document.
Implementation of Procedural Documents Information about this policy will be added to Statutory and Mandatory Training which is delivered to all staff on an annual basis.
Monitoring Compliance with this Policy 16.1
The effectiveness of this policy will be monitored and reviewed annually or when significant changes make earlier review necessary by: • • •
The Trust Board The Assurance Committee Infection Prevention and Control Committee
Monitoring arrangements will be though the agreed IPC audit programme identified in the IPC action plan on an annual basis. Any recommendations will be identified and a report completed and submitted to the IPC Committee and to the Director of Operations and Divisional Operation Managers for action to be taken.
The results of the audit programme will be produced as part of the IPC annual report and presented to the IPC Committee for agreement.
The effectiveness of the policy will be monitored on a regular basis via the Trust’s Executive Team. Key performance indicators relevant to IPC will be monitored by analysing data against an agreed Trust/National targets. •
KPI OP 4: to determine the effectiveness of the planned cleaning processes by measuring readings from 4 random swab samples taken by the Team Leader from 20 selected locations in the vehicle every 6 months. Target 90%
KPI HR 04: percentage of operational staff trained in infection control, set against quarterly targets of 25% increments. This is calculated quarterly.
A report will be produced on annual basis to the Infection Control Committee.******
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Appendix 1 Infection Prevention and Control Procedures Microbiology / Spread of Infection 1.
What is infection and how does it spread? 1.1
1.1.2. The term micro-organism, or microbe, is used to describe any organism which is too small to be seen with the naked eye. Many microbes normally live inside or on the surface of other organisms. Such organisms living on the human body are called commensals and are generally harmless. Micro-organisms capable of causing infection and disease are known as pathogenic. Pathogenic organisms or the toxins they produce, destroy body tissues. The pathogenic process causes signs and symptoms of infection e.g. pain, swelling, fever. 1.1.3
Micro-organisms may be classified as follows: • •
Bacteria are minute organisms about one-thousandth to five thousandth of a millimetre across. They are susceptible to a greater or lesser extent to antibiotics. Viruses are much smaller than bacteria and although they may survive outside the body for a time they can only grow inside the cells of the body. Viruses are not susceptible to antibiotics, but there are a few anti-viral drugs available which are active against a limited number of viruses. Pathogenic fungi can be either moulds or yeasts. For example, a mould which causes infections in humans is Trichophyton rubrum which is one cause of ringworm and which can also infect nails. A common yeast infection is thrush caused by an organism called Candida albicans. Protozoa are microscopic organisms, but larger than bacteria. Free living and nonpathogenic protozoa include amoebae and paramecium. Examples of medical importance include: Giardia lamblia, which causes enteritis (symptoms of diarrhoea). Worms are not always microscopic in size but, pathogenic worms do cause infection and some can spread from person to person. Examples include: threadworm and tapeworm. Prions are infectious protein particles. Examples: variant Creutzfeldt-Jakob disease.
The Chain of Infection
The process through which infection can be spread from one susceptible host to another is known as the chain of infection. If the chain is broken then infection will be prevented. CHAIN OF INFECTION
SUSCEPTIBLE INFECTIOUS Infectious Agent: HOST AGENT • Microorganism/germ/virus Reservoir:
PORTAL OF ENTRY
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• • • • • •
Patients Staff Equipment Environment e.g. dust, soil Animals / insects Food / Water
Portal of Exit / Entry: • In order to cause disease a pathogen must have a way to enter the body – a portal of entry. To transmit to another host it must be able to leave the body via a portal of exit. The route of entry and exit may be different, for example enteric infections enter the mouth and leave in the faeces, or they may be the same, for example, respiratory tract infections. •
Microorganisms use a range of different routes to find new hosts and one microbe may be able to spread by using more than one method. Respiratory Tract Alimentary Tract Skin and Mucosa Placenta
through inhalation of organisms (e.g. TB, diphtheria and mumps) through ingestion of contaminated food or water (e.g. salmonellosis and dysentery) through damaged skin or by inoculation (e.g. Hepatitis B via contaminated needles) via transfer or organisms from maternal circulation to the foetal circulation (e.g. rubella, cytomegalovirus and syphilis)
The modes of spread of infection: • It is important to remember that the one feature that distinguishes infection from all other disease is that it can be spread i.e. one person can ‘catch it’ from another, or via a vector (crawling or flying insects). Infection can also be caused by the environment, such as tetanus following a gardening accident. •
An infectious disease can be transmitted by:
Direct Contact – e.g. kissing, sexual contact, physical contact with an infected site, such as contact with discharge from wounds or skin lesions e.g. shingles, impetigo
Indirect – through sneezing or coughing, or when an intermediate carrier is involved in the spread of pathogenic microbes from the source of infection to another person e.g. hands, insects
Fomite: is defined as an object which becomes contaminated with infected organisms and which subsequently transmits those to another person e.g. bedpans, urinals, thermometers, oxygen masks, or practically any inanimate object.
Hands: of healthcare workers are probably the most important vehicles of cross-infection. The hands of patients can also carry microbes to other body sites, equipment and staff.
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Aerosols: Transmission of infection occurs when microbes exhaled or discharged into the atmosphere by an infected person are inhaled by another person e.g. chickenpox, mumps. The common cold and influenza are often cited as examples, but it is likely that hands and fomites are also important in the spread of respiratory viruses.
Ingestion: Infection can occur when organisms capable of infecting the gastrointestinal tract are ingested. When these organisms are excreted faecally by an infected person, faecal-oral spread is said to occur. Organisms may be carried on fomites, hands or in food and drink e.g. Hepatitis A, salmonella, campylobacter.
Inoculation: Infection can occur following a ‘sharps’ injury when blood contaminated with, for example Hepatitis B virus, is directly inoculated into the blood stream of the victim, thereby causing an infection. Inoculation includes blood splashes to the eye. Humans and animal bites can also spread infection by the inoculation mode.
Vectors: Any intermediate agent which can carry an infection between humans/other animals. Crawling and flying insects are an obvious example of intermediate carriers and need to be controlled. Insect bites may cause infections such as malaria.
Absorption: This is not a route of entry for infection, except in some tropical diseases.
Susceptible Host / Person at Risk:
Some people are at increased risk of infection: Elderly Very young Immunocompromised Chronic illness Receiving certain medications e.g. steroids Anyone with a break in the bodies defences e.g. surgical wounds, skin lesions, indwelling devices such as intravenous lines / catheters • Someone whose behaviour increases their risk for a particular disease e.g. HIV • • • • • •
Personal Protection 2.1 Standard Principles / Precautions of Infection Prevention and Control Ambulance staff who come into contact with blood or body fluids may be exposed to occupation risk from blood borne viruses e.g. HIV, Hepatitis B (HBV), Hepatitis C (HCV) or other pathogens. The most likely means of transmission of these viruses to ambulance personnel is by direct percutaneous inoculation of infected blood by a sharps injury, or by blood splashing onto broken skin, eyes or mucous membrane. 2.1.1 Body fluids which may contain pathogenic micro-organisms are: • •
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2.1.2 In addition, the following may also contain the organisms of HIV, HBV and HCV: • • • • • • • •
Blood Blood stained body fluids Semen Vaginal secretions Body tissues Cerebrospinal fluid, amniotic, pericardial fluids etc Unfixed human tissues and organs Exudative or other tissue fluid from burns or skin lesions
2.1.3 It is not always possible to identify people who may spread infection to others, therefore precautions to prevent the spread of infection must be followed AT ALL TIMES. These routine procedures are called Standard Principles or Standard Precautions. 2.1.4
All blood and body fluids are potentially infectious and precautions are necessary to prevent exposure to them. By close adherence to standard precautions, ambulance personnel will reduce the risk of contamination to themselves and others from infected body fluids.
2.1.5 Standard Precautions include: 1. Hand washing and skin care – the skin is a protective barrier, micro-organisms can be washed off. Breaks in the skin, cuts and abrasions can provide an entry/exit point for infective microbes and should be covered with waterproof dressings. 2. Protective clothing – reduce the risk of substances contaminating you by placing a barrier between the substance and yourself i.e. clothing, goggles, masks. 3. Safe handling and disposal of sharps 4. Spillage management 5. Waste management 6. Linen management 7. Maintaining a safe and hygienic environment – decontamination & cleaning procedures
Hand Hygiene Facilities
Hand washing facilities within the trust must not compromise standards by being dirty or poorly maintained.
Hand washing facilities should be adequate and conveniently located. Moist skin wipes and personal issue alcohol hand rub are provided for operational staff to use as an alternative method of hand hygiene when hand washing facilities are not available at point of patient care.
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Hand wash basins must be placed in areas where needed, the washbasin should not have a plug or overflow.
For existing hand wash basins with twist taps staff should use a paper towel to turn them off to avoid re-contaminating their clean hands. However for adaptations or new build premises the hand wash basin should have elbow or wrist operated mixer taps.
The Trust already provides hand wash basins in toilet areas. There should also be a separate designated hand wash basin in cleaners store, kitchens, and sluices which is not used for other cleaning purposes.
Use wall mounted liquid hand wash lotion dispensers at these hand wash basins. Keep them clean and replenished. Other types of products are not to be used particularly bar soap.
Ensure clean disposable paper towels are available in a dispenser next to the hand wash basin. Using soft disposable towels helps to avoid skin abrasion.
A foot operated lined pedal bin of the right size should be positioned near the hand washbasin and emptied when ¾ full.
Whilst on vehicles staff have access to alternative hand hygiene facilities (i.e. moist skin wipes and alcohol hand rub).
2.2.10 Staff should utilise hand washing facilities whilst in clinical areas of healthcare premises when appropriate. 2.2.11 The wearing of gloves is not an alternative to hand hygiene.
Hand Washing and Skin Care 2.3.1
Hand hygiene is the single, most effective method of preventing cross-infection.
There are two populations of micro-organisms found on the skin. The resident bacteria live in the deeper skin layers, they are not readily transferred and are usually not harmful. Transient micro-organisms do not normally live on the skin but are both readily acquired and transferred by touch. In clinical settings hands can cause cross infection by transferring these transient micro-organisms between patients but are easily removed by simple hand decontamination procedures. The wearing of gloves is not an alternative to hand hygiene.
Hands should be washed: Before – Patient contact Undertaking a care procedure An aseptic task Taking a break / going home Putting on protective clothing Eating, drinking, handling food
• • • • • •
After – Contact with patient surroundings Direct contact with a patient Handling contaminated items such as dressings, bedpans, urinals, urine drainage bags
• • •
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• • • • • •
Body fluid exposure risk Cleaning equipment / environment Handling dirty linen or waste Hands become visibly soiled Removal of gloves Going to the toilet, blowing nose or covering a sneeze
The World Health Organisation (WHO) Five Moments for Hand Hygiene:
Before patient contact
Before an aseptic technique After body fluid exposure risk
After patient contact
After contact with patient surroundings
WHEN? Clean your hands before touching a patient when approaching him/her WHY? To protect the patient against harmful germs carried on your hands WHEN? Clean your hands immediately before any aseptic task WHY? To protect the patient against harmful germs, including the patient’s own, from entering his/her body WHEN? Clean your hands immediately after an exposure risk to body fluids (and after glove removal) WHY? To protect yourself and the healthcare environment from harmful patient germs WHEN? Clean your hands after touching a patient and his/her immediate surroundings when leaving the patient’s side WHY? To protect yourself and the healthcare environment from harmful patient germs WHEN? Clean your hands after touching any object or furniture in the patient’s immediate surroundings when leaving – even if the patient has not been touched WHY? To protect yourself and the healthcare environment from harmful patient germs
2.4 Hand Washing Technique
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Hand washing is probably the most important method of protecting the patient and staff. Hand washing technique poster must be displayed above/next to hand wash basin. Hands should be washed at the point of care; the patient’s immediate environment in which healthcare staff-to-patient contact or treatment is taking place, as this represents the time and place at which there is the highest likelihood of transmission of infection via healthcare staff whose hands act as mediators in the transfer of micro-organisms..
Alcohol handrub is the recommended product in all patient care situations except when: • • • • •
Hands are visibly soiled. The patient is experiencing vomiting and/or diarrhoea. There is direct hand contact with bodily fluids i.e. if gloves have forgotten to be worn. There is an outbreak of Norovirus, Clostridium difficile or other diarrhoeal illnesses. In these instances hands should always be cleaned with liquid soap and water.
Most clinical areas of hospitals have hand washing facilities available and these should be utilised whenever necessary. Hand washbasins are not available on ambulance vehicles.
When staff are unable to access hand washing facilities it may be necessary to use other methods to decontaminate the hands. Alcohol handrub can be used effectively, although should not be used as an alternative if a hand basin is available. Staff should be aware of the alcohol handrub risk assessment.
Alcohol gel will not penetrate through soil such as blood or dirt, so hands should ideally be cleaned before gel is applied. If hands are not soiled, gel can be used alone. When using a gel, apply 5 – 10ml to visibly clean hands and rub using the hand washing technique, until the alcohol has evaporated and hands are dry. Only 3 -4 applications of alcohol gel should be used before hands will need to be washed as they will become ‘tacky’.
In order to help reduce bacterial count on hands/wrists and reduce the risk of transmitting infections, Operational staff should: •
Keep nails short (fingertip length) and clean, do not wear false nails or nail varnish, as they may harbour micro-organisms and become detached.
Not wear hand and wrist jewellery - with the exception of a plain wedding band and washable/wipe able wrist watch that can be decontaminated.
Cover wrist watches with gloves where there is a risk of it becoming contaminated by blood/body fluids. Decontaminate wrist watches regularly and whenever soiled. Washable watches should be cleaned in accordance with manufacturers’ guidance. Non-washable watches external parts should be wiped with detergent and dried.
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2.5 Hand cleaning techniques- poster
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2.6 Skin Care
A healthy, intact skin provides an effective barrier against infection. It is important to keep the skin in good condition by using the correct hand washing method, drying hands thoroughly and regular use of hand cream.
All cuts and abrasions should be covered with an impermeable waterproof dressing prior to and during any period of duty. The dressing’s integrity must be checked regularly while on duty and replaced if necessary. Any member of staff with extensive skin lesions must seek advice from the Occupational Health department e.g. eczema. Avoid unnecessarily subjecting skin to laceration in social / domestic activities e.g. DIY or gardening – cover arms and use gardening gloves.
Moisturiser creams should be used regularly following hand washing. The moisturiser helps to prevent dry skin, which in turn will reduce the risk of lesions developing. Hand cream should preferably not be shared, but used direct from dispensers or tubes for single person use only.
Personal Protective Equipment (PPE) 3.1
The choice of protective clothing selected depends on the anticipated risk of exposure to body fluid during the particular activity. Many clinical activities involve no direct contact with body fluid and do not require the use of protective clothing, for example, taking a pulse, blood pressure or temperature. 3.1.1
Employees have a responsibility to wear PPE that has been provided by the Trust and to co-operate with management on matters of health and safety. Staff must use their judgement in determining the likely requirements in each case.
The Protective Personal Equipment at Work Regulations (1992) requires that PPE is to be supplied and used at work wherever there are risks to health and safety that cannot be adequately controlled in other ways. The Regulations require that PPE: • • • •
Is properly assessed before use to ensure it is suitable. Is maintained and stored properly. Is provided with instructions on how to use it safely; and Is used correctly by employees.
Selection of PPE must be based on an assessment of the risk of transmission of micro-organisms to the patient or to the carer, and the risk of contamination of the practitioners’ clothing and skin by patients’ blood, body fluids, secretions or excretions. What to Wear and When •
No exposure to blood/body fluids anticipated → No protective clothing
Exposure to blood/body fluids anticipated, but low risk of splashing → Wear gloves and apron
Exposure to blood/body fluids anticipated, with high risk of splashing → Wear gloves, apron and eye/mouth/nose protection
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Body fluids that may be responsible for BBVI are: High risk: Cerebrospinal fluid Pleural fluid Breast milk Amniotic fluid Vaginal secretions Unfixed body tissues Peritoneal fluid Pericardial fluid Synovial fluid Semen Low risk: urine Faeces Saliva Sputum Tears Sweat Vomit Unless above contaminated with blood
3.2 Gloves - disposable 3.2.1
The function of gloves is primarily to protect staff and patients, and to reduce the transmission of micro-organisms during healthcare provision.
Gloves are classed as medical devices. •
Gloves acceptable to healthcare workers and conforming to European Community (CE) standards must be available.
The appropriate use of gloves in conjunction with effective hand hygiene will reduce the possible spread of infectious organisms.
Do not use powdered gloves or polythene gloves for healthcare activities.
Document any sensitivity to natural rubber latex in patients, carers and healthcare workers; alternatives to natural rubber latex gloves must be available (refer to Medical Device Alert DB 9601 for more information). Any member of staff developing skin irritations on their hands should seek referral to the Occupational Health Department.
Do not wear gloves unnecessarily, as prolonged or indiscriminate use may cause adverse reactions and skin sensitivity.
Gloves should not be worn while travelling to a call but should be fitted just prior to contact with the patient if contact with blood and/or body fluids is anticipated (after patient assessment).
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Gloves should be seamless, well fitting, powder and latex free (i.e. nitrile) and you ensure your gloves are appropriate for the task.
Wear gloves for invasive procedures, contact with sterile sites, non-intact skin or mucous membranes, all activities assessed as carrying a risk of exposure to blood or body fluids, and when handling sharp or contaminated instruments.
Gloves must be worn whenever contact with body fluids, mucous membranes or non-intact skin is anticipated, when dealing with contaminated equipment or with a patient with an infection or suspected infection. However emergency treatment should not be withheld in the absence of gloves but in these circumstances hands should be thoroughly washed as soon as possible.
Choice of size in the selection of gloves should be made on comfort – not too tight as to become restrictive, but also not too loose as to compromise grip and dexterity.
If there is the potential for gloves to become punctured during use, e.g. at an RTC, staff should consider wearing two pairs of gloves as an additional precaution.
Gloves are single use items. Put them on immediately before an episode of patient contact and remove them as soon as the activity is finished. Change gloves between different patients and between different tasks in the same patient, or if the glove becomes punctured, torn or damaged.
Dispose of gloves at the earliest opportunity after use i.e. immediately after the treatment that required gloves and placed in clinical waste bag.
Decontaminate hands after removing gloves.
Healthcare workers should select gloves on the basis of a risk assessment of the following: •
Who is at risk – the patient or the healthcare worker?
Gloves should only be worn if, there is anticipated or potential risk of exposure to
Blood Body fluids
Mucous membranes Hazardous substances
An intact skin provides a natural barrier to infection. During any patient or client contacts considered to be “social” rather than clinical interventions, the application of the six stage hand hygiene technique may be sufficient.
The following chart will enable the user to make an informed decision regarding the most appropriate glove for a specific task.
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Has the risk assessment identified that there is a risk of exposure to: • blood/body fluids • non-intact skin • mucous membranes • chemicals/hazardous substances
Gloves not required
Gloves can tear or puncture during use or leakage may occur through microscopic holes. Hands may become contaminated when gloves are removed. For these reasons gloves should not be seen as a substitute for good hand hygiene. To minimise the risk of contamination staff should: •
Keep nails short.
Avoid artificial nails.
Avoid wearing stoned/ridged rings.
Cover cuts/abrasions with waterproof dressings.
Inspect gloves regularly and change if defects occur.
Use gloves which change colour when punctured.
The Department of Health advocate double-gloving to reduce the likelihood of a percutaneous exposure during surgical procedures on patients with blood-borne infections. So, therefore, HCWs should double-glove when: •
Undertaking exposure-prone procedures (EPPs).
When glove puncture is likely to occur.
An EPP is defined as an activity ‘where there is a risk that injury to the HCW may result in exposure of the patient’s open tissue, to the blood of the HCW’ (DOH, 1998).
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The Department of Health also advocate double-gloving to reduce the likelihood of percutaneous exposure during surgical procedures on patients with blood borne infections.
It is important to ensure that gloves fit correctly. The Health and Safety Commission (1992) state that personal protective equipment is not suitable if it does not fit the wearer correctly.
Poorly fitting gloves can interfere with dexterity and performance. The use of ill-fitting gloves can affect the muscles in the hands and fingers – leading to fatigue.
Air occlusion can occur if gloves are worn for long periods causing excessive perspiration which creates an ideal environment for bacterial growth and skin breakdown. Friction may also occur when tightly fitting gloves rub against the skin causing irritation.
3.2.10 Gloves should as a minimum cover the wrist. Gloves with a longer cuff may be more suitable, for certain procedures. ‘Gauntlets’ (elbow length gloves) are available for protection of the forearm. 3.2.11 The MDA (2000) does not recommend the re-use of disposable gloves. The re-use of gloves can compromise glove integrity, performance and effectiveness and the washing of gloves is an unsafe practice. These products are designated for ‘singleuse’ and are intended to be used on an individual patient during a single procedure and then discarded. The packaging will display one of the following statements or symbol: •
‘DO NOT REUSE’
‘Use only once’
3.2.12 Staff education should help to negate the problems associated with the overuse and inappropriate use of disposable gloves. 3.2.13 Storage conditions can affect the shelf life of gloves. Details on all gloves purchased should show the expiry date and stock rotation should be maintained and should not be used if the expiry date is exceeded as this will compromise quality, effectiveness and performance. They should be stored away from heat, direct sunlight, dust etc. It is generally recommended that gloves are stored within a temperature range of 5oC – 30oC. 3.2.14 Glove selection may be influenced by a number of factors such as: •
The nature of the task
The needs of the member of staff undertaking the procedure
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The nature of the clinical environment
The specific needs of patient receiving treatment
3.2.15 Rubber Gloves - rubber colour coded general purpose gloves should be worn for any cleaning procedure. After use they should be washed with detergent and water and dried. When dealing with blood/body fluids, or after infected cases, these gloves should be disposed of in the clinical waste.
3.3 Disposable Aprons 3.3.1
Water-repellent protection should be worn when there is a possibility that contamination of the clothing with body fluids may occur or when cleaning the ambulance and equipment. Disposable aprons should be used for one procedure only and then discarded in the clinical waste. Staff must always ensure they have at least one complete spare uniform available for occasions when uniform contamination has occurred.
Coveralls are not required routinely. However these are provided for use when the risk of contamination or soiling of the uniform is considered beyond the scope of a disposable apron such as when dealing with infections caused by more hazardous organisms or chemical spills.
3.4 Sleeve protectors (when available for use by NEAS) 3.4.1
Cross-contamination can occur when healthcare staff wear the same long-sleeved clothing to lift numerous patients. As washing clothing between lifts is not normally possible, sleeve protectors can be used. The use of sleeve protectors should not lead to long-sleeved clothing not being washed regularly. Sleeve protectors can be worn to protect the wearer’s uniform from the wrist to the elbow, for example when lifting a patient where there is a risk of contamination from body fluids or skin cells.
Sleeve protectors: •
Are for single patient use.
Can be worn over the top of gloves.
Should be disposed of as clinical waste immediately after use.
Protect the sleeves of high visibility hazard jackets/fleeces.
Should be worn if there is a risk that clothing is likely to become soiled.
3.5 Visors/Eye Protection 3.5.1
These are worn when a particular procedure is likely to cause splashing of body fluids, particularly blood or tissue, into the eyes or face (e.g. during intubation). In the case of SARS or Avian Influenza completely sealed ‘chemical protection’ goggles must be used. Ideally eye protection equipment should be single use or personal issue but should this not be the case, following use, eye protection should be washed in hot soapy water, dried and stored ready for re-use.
3.6 Face Masks 3.6.1
Masks are generally ineffective against airborne infection however, they may offer protection against splashing of the mouth and face. Use of face masks is
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recommended during procedures when there is likely to be splash of blood or tissue into the mouth, or if the patient is prone to episodes of coughing or sneezing, or during intubation of patients who are suspected to have meningococcal disease, and in cases of suspected TB. Where patients have an uncontrolled productive cough (cannot cough into a tissue), consideration should be given to encouraging the patient to also wear a face mask. 3.6.2
High efficiency masks complying with FFP3 are recommended when caring for patients suspected to be suffering from Severe Acute Respiratory Syndrome (SARS). Face masks should fit correctly with no gaps at the sides. They must not be touched and should be discarded when wet. They should not be pulled up and down, but renewed after each episode of use. They are for single use only and should be disposed of in the clinical waste.
Pocket resuscitation masks eliminate the need for mouth-to-mouth contact during resuscitation, when other equipment is not available. Their use will minimise the risk of exposure to infection. These masks are re-usable, however the one-way valve is single patient use only. The valve should be disposed of as clinical waste. After use, the mask should be cleaned and disinfected and a new one-way valve put in place.
3.7 Bare below the elbow
The Department of Health recommends that NHS organisations adopt a ‘bare below the elbow’ policy which means that all staff in contact with patients should effectively wash their hands and wrists between each patient. It is not possible to this properly with cuffs, watches and jewellery.
Where possible and reasonably practicable staff should adopt ‘bare below the elbow’ when in uniform and/or performing direct patient care, this may involve removing inclement weather and/or health and safety sleeved garments whilst performing hand hygiene and/or clinical care procedures in a hospital/clinical setting.
When possible and practical removing sleeved items while in an ambulance to perform hand hygiene and/or clinical procedures.
Aiding effective hand hygiene procedures when using issued alcohol products by exposing your lower forearms; wrists and hands (again if this is reasonably practicable), when wearing fleeces and/or Hi-Vis jackets while working in external environment. This can be accomplished by rolling/pushing your sleeves to the elbow areas. Sleeves may then be rolled down after hand hygiene procedures have been completed.
Sharps management including safe use and disposal of sharps 4.1
Sharps include needles, scalpels, stitch cutters, glass ampoules, sharp instruments, razors, and broken crockery and glass, i.e. any article that can cut or puncture the skin by having a fine edge or point. Sharps must be handled and disposed of safely to reduce the risk of exposure to blood borne viruses. Always take extreme care when using and disposing of sharps. Avoid using sharps whenever possible.
All clinical procedures involving the use of sharps must be practised only by staff who have received the appropriate training and as a result are duly authorised to perform such tasks. Training will include the safe handling and disposal procedures for the sharps involved.
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Clinical sharps should be single use only and must be stored at all times in their designated containers on the vehicle or in response bags.
Procedures involving sharps should only be attempted in the vehicle when it is stationary and extreme care must be exercised when treating restless or aggressive patients. The needle should only be removed from its sheath once the patient has been prepared.
It is the personal responsibility of the individual using the sharp to dispose of it safely in a properly assembled sharps container of the appropriate colour code provided (BS 7320:1990 / UN 3291 standards).
Disposable gloves should be worn when handling sharps.
Sharps must not be passed directly from hand to hand and handling should be kept to a minimum.
Needles and cannulas should not be re-sheathed.
Discard sharps directly into a sharps container immediately after use and at the point of use. NEVER leave clinical sharps lying around.
Sharps should be discarded using a single handed technique. Do not hold the sharps container in the other hand. Do not ask someone else to hold it. Needles must not be bent or broken prior to use or disposal. Needle and syringes must not be disassembled.
When opening ampoules, care should be taken to avoid injury. The ampoule should be opened using ‘amp snap’ or sharps container designated for this purpose.
Sharps containers should be placed on a level, stable surface. They should not be placed on the floor or above shoulder height. Wall mounted boxes should be used in vehicles.
Training centre sharps containers do not contain blood products, they may therefore be disposed of when they become 2/3 full, regardless of the date.
Sharps containers should not be filled more than 2/3 full. They should be fully closed and labelled with the fleet number or station. ‘NEAS’ should be clearly written on the label to identify the origin of the container as North East Ambulance Service.
The aperture to the sharps container must be closed, but not locked, when carrying or if left unsupervised, to prevent spillage or tampering.
Under no circumstances should a sharps container be emptied of its contents or attempts be made to retrieve items from it.
Sharps containers should be disposed of safely in accordance with local procedures.
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Used sharps containers that become damaged should be placed into a larger secure container with the outer compartment appropriately labelled. They must not be placed into a clinical waste bag.
Incidents where adequate and appropriate measures have not been taken to dispose of sharps, thereby putting others at risk of injury, should be regarded as adverse incidents and reported using the incident reporting system.
4.2 Accidental Exposure to Blood / Body Fluids 4.2.1
These guidelines are to be followed in the event of a sharp injury or contamination incident. Further information can be found in the following Occupational Health Department Policies: •
Percutaneous (e.g. needlestick) & Mucocutaneous post exposure policy.
Blood borne virus – post exposure policy.
4.2.2 These may be defined as:
Inoculation of blood by a needle or other sharp
Contamination of broken skin with blood
Blood splashes to mucous membrane e.g. eyes or mouth
Swallowing a person’s blood e.g. after mouth-to-mouth resuscitation
Contamination where clothes have been soaked by blood
Body exudates or secretions through a wound or sore
Human bites or scratches
The risk of transmission of infection from a needlestick injury is low. When a sharp injury or contamination incident occurs the following course of action should be taken: •
Encourage bleeding from the wound by gently squeezing (do not suck the wound).
Wash the wound in soap and warm running water (do not scrub) or with disposable wipe if water is not available.
Cover the wound with a dressing.
Irrigate eye or mouth splashes with plenty of water or saline, face must be washed with soap and water.
Inform Control •
Contact control and inform them that you have had an inoculation incident. Control will then activate an Investigating Officer.
Proceed to the nearest Accident and Emergency Department for follow up, the staff will require the following information: o
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Liaise with the NEAS Investigating Officer and the Accident and Emergency Department in order to ensure safety and to ascertain the facts of the incident.
Contact the Occupational Health Department by the next working day to inform of injury and treatment received in A&E.
Further management, support and advice will be given by the Occupational Health Department.
Upon return to station •
Name, ward and hospital of the patient involved (if applicable). Description of the incident.
Report the incident to your Team Leader and enter details in the Accident Book. The Investigating Officer will report the incident to your Operational Manager. A Personal Injury Form (NEAS 07) should be completed by the member of staff as soon as possible. If any clothing has been contaminated with blood / blood infected body fluids, then remove and bag. Never continue duty with soiled clothing.
Aseptic Technique and Invasive Procedures 5.1 Aseptic Technique 5.1.1
Asepsis is defined as the absence of pathogenic organisms. Aseptic technique is used to describe clinical procedures that have been developed to prevent the contamination of wounds and other susceptible sites by using sterile equipment and fluids during invasive medical procedures and by avoiding contamination of the equipment by adopting a non-touch technique.
Using an aseptic technique (as appropriate to the setting and the clinical procedure to be undertaken), will contribute to effective infection prevention and control.
Aseptic non touch technique (A.N.N.T) keeps procedures as free from organisms as possible. The principles of aseptic technique are: •
Keeping the exposure to susceptible sites to a minimum.
Ensuring appropriate hand decontamination prior to procedure.
Using gloves (sterile or non-sterile, depending on the nature of the susceptible site)
Ensuring that all fluids and materials used are sterile.
Checking that all packs are sterile and show no evidence of damage.
Ensuring that contaminated and non-sterile items are not placed in the sterile field.
Not re-using single-use items.
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Reducing staff and/or bystander activity (wherever possible) in the immediate vicinity of the area in which the procedure is to be performed.
An aseptic technique should be used during any invasive procedure that bypasses the body’s natural defences, e.g. the skin and mucous membranes or when handling equipment such as intravenous cannulae.
Whilst it is difficult to maintain sterility, it is important to prevent contamination of sterile equipment. Poor aseptic technique can lead to contamination.
The principles of aseptic ‘no-touch’ technique play a vital role in preventing the transmission of infection in any environment. It is the responsibility of each staff member to understand these principles and to incorporate them into everyday practice. If aseptic technique cannot be applied, for example because of the nature of the emergency, it is suggested that the receiving hospital staff are informed at patient handover and that this is documented on a Patient Report Form.
Aseptic technique should be used on the following; •
Wounds healing by primary intention (before the skin has healed) e.g. traumatic wounds or surgical wounds
Suturing / gluing
Insertion of intravenous cannulae
5.2 Intravenous Cannulation 5.2.1 Due to increased risk of infection with pre-hospital cannulation, patients should only be cannulated where clinically necessary. Unjustified prophylactic cannulation, and cannulation purely on the basis that it has become expected by the hospital must not occur. As a general guide, cannulation would be considered appropriate where a drug or fluid needs to be administered, where this may be likely on-route to hospital or immediately on arrival at A&E, or where the patient’s condition is unstable and likely to deteriorate. All cannulations must have a valid reason including, evidence, observations and assessments which must be documented. 5.2.2
Peripheral intravenous cannula insertion is a commonly performed procedure and has an associated risk of infection because of the potential for direct microbial entry to the blood stream. Intravenous cannulae may be contaminated by the patient’s skin flora at the insertion site or by the introduction of other organisms via the cannula hub or injection port.
Intravenous cannulation should be carried out aseptically when ever the patient’s clinical condition allows a routine insertion, such as when a stable patient requires the administration of morphine. Good practice from Saving Lives High Impact Intervention No. 2 on peripheral intravenous cannula care recommends: 1. Gather equipment that is required and where possible there is a clear and clean area in which to carry out procedure this will prevent unnecessary movement and potential cross contamination.
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2. Explain the procedure to the patient. Obtain consent and understanding where possible. 3. Wash hands with soap and water, hand wipe or alcohol gel. 4. Apply the tourniquet. 5. Palpate the vein. 6. Make a sterile field – for example using a sterile cannula dressing pack. 7. Clean the site for venepuncture using 2% chlorhexidine gluconate in 70% isopropyl alcohol using a back and forth scrub movement (the use of friction in prepping skin prior to a procedure is key) – do not re-palpate the vein. 8. Leave skin to dry for 30 seconds. 9. Choose a cannula, open the pack and place the cannula aseptically in a sterile field. If this is not possible, another clinician should open the cannula packaging and present the cannula so that it can be grasped by the cannulating clinician without touching the outer surface of the packaging. 10. Decontaminate your hands and put on gloves. 11. Insert the cannula according to IHCD guidelines, ensuring that the insertion site is not touched. If insertion attempt is not successful, the same cannula should not be used again. 12. Use a sterile, semi-permeable, transparent dressing to secure the cannula. 13. Record the date and time of insertion on cannula dressing. 14. Dispose of any items used in the appropriate waste receptacles. 15. Decontaminate hands. 16. Record the date and time of insertion on a Patient Report Form. 17. Always ensure that the giving set and any syringes used for administering drugs through the cannula are handled aseptically, particularly between doses. 5.2.4
If any of the above steps cannot be performed due to the patient being in a time critical condition, the cannula must be labelled as ‘Emergency Inserted’. Hospital staff must also be made aware, so that the cannula can be replaced aseptically as soon as it is possible, normally within 24 hours.
Always ensure that the giving set and any syringes used for administering drugs through the cannula are handled aseptically.
5.3 Wounds: suturing and gluing 5.3.1
Sterile packs, sterile gloves and aprons should be available for all staff qualified in suturing and gluing. Aseptic technique must be applied throughout these procedures to ensure that only sterile items are used to keep exposure of the susceptible sit to a minimum. Hand hygiene must be maintained. If running water and liquid soap is not available, Clinell sanitising wipes must be used, then alcohol gel, before putting on gloves and after removing them.
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Cleaning and decontamination – specific cleaning procedures Providing a clean and safe environment for healthcare is a key priority for the NEAS and is a core standard in Standards for Better Health (2006). The Code of Practice 2008 places further onus and responsibility on the NEAS to ensure that local provision of cleaning services is adequately resourced.
6.1 Cleaning system 1: using detergent 6.1.1
Cleaning is a process which physically removes contamination but does not necessarily destroy micro-organisms. Cleaning with hot water and detergent will remove soil, organic material, micro-organisms and bacterial spores from items/objects. After cleaning, surfaces should be thoroughly dried. Use PPE as appropriate (goggles, aprons and gloves).
Cleaning is an essential prerequisite of equipment decontamination to ensure effective disinfection or sterilisation can subsequently be carried out.
Cleaning equipment, such as brushes, cloths and mop heads should preferably be colour coded for use in specific areas, and to reduce the risk of cross-contamination mops, disposable cloths and buckets must not be used or transferred between different areas. Re-usable cloths must be used. • RED – toilets, showers and sluice • BLUE – General areas (stations) • GREEN – Kitchen and dining areas (stations) • YELLOW - Ambulance (interior – all parts)
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Cleaning equipment must be stored clean and dry between uses. Do not store brushes or mops in disinfectant solution.
COSHH data sheets should be available on all sites where the products are supplied for reference.
6.2. Cleaning system 2: using disinfectant 6.2.1
Disinfection is a process used to reduce the number of viable micro-organisms and can apply to hand washing, skin preparation and equipment. Harmful micro-organisms can be destroyed by chemicals such as chlorine releasing agent, or by immersion in hot water e.g. 70-80 degrees C. Disinfection of equipment should be limited and, where possible single use equipment should be used.
6.3 Cleaning system 3: Sterilisation 6.3.1
Sterilisation is a process used to render the object free from viable micro-organisms, including spores and viruses, but not prions. All clinical instruments and equipment used to surgically penetrate, or that could come into contact with breaks in the skin, or mucosa MUST be sterile.
Sterile instruments can be obtained by purchasing pre-sterilised single-use items. These avoid the need for re-sterilisation and are a practical and safe method.
Sterilisation can only be undertaken by specialist Sterile Supplies Department. There needs to be a specific contract specifying the responsibilities of both parties. Sterilised equipment must be kept in their wrapping until the moment of use. Excessive handling should be avoided before application. If the outer wrapping is damaged, do not use, it will not be sterile.
6.4 Trust Premises and Vehicles 6.4.1
The environment plays a relatively minor role in transmitting infection, but dust, dirt and liquid residues will increase the risk. They should be kept to a minimum by regular cleaning and by good design features in equipment, fittings and fixtures. •
Work surfaces and floors should be smooth-finished, intact, durable, washable and should not allow pooling of liquids or be impervious to liquids.
Keep mops and buckets clean, dry and store inverted.
Provide single use, non-shredding cloth or paper roll for cleaning.
Keep equipment and materials used for general cleaning separate from those used for cleaning up body fluids.
Use general purpose detergent for all environmental cleaning (following the manufacturers’ instructions) unless disinfection is required.
When replacing paper hand towels, these must be put into the holder, and not placed on top. Paper towel and liquid soap dispensers of the cartridge type must be cleaned regularly.
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Vacuum cleaner bags must be changed as necessary and the brush cleaned of hair and fluff before storage.
Crockery and cutlery should be washed immediately after use in hot water and general-purpose detergent. Wherever possible, dry with disposable paper towels.
It is usually sufficient to clean floors by removing dust with a properly maintained filtered vacuum cleaner. They can then be cleaned by washing with hot water and general purpose detergent, using mops or suitable scrubbing machine.
Food preparation surfaces should be cleaned regularly with hot water and generalpurpose detergent. These areas should be kept in good repair to facilitate cleaning. Ovens and microwaves must be cleaned after use.
Cupboards and shelving cleaned on a regular basis, weekly where possible.
Crew rooms must be kept clean and tidy, cleaned on a regular basis, hard surfaces wiped daily.
Hard floors to be mopped daily, carpeted areas vacuum daily.
Hands must be washed thoroughly following any cleaning session.
Communal nailbrushes must not be used.
Refrigerators should be defrosted and cleaned regularly. Should a spillage occur or food become stale, the whole interior of the fridge should be cleaned with hot water and general purpose detergent and dried thoroughly.
Anti-slip shower mats must be washed with hot water and general-purpose detergent after use (cork type shower mats are not to be used).
Shower rooms and hand basins must be cleaned regularly with a cream cleanser, using a piece of disposable cloth which can be disposed of into a black waste sack.
Sluice rooms should be free from clutter/waste, no items stored on the floor and clean daily.
Toilets should be cleaned with a toilet brush weekly, more often if soiled, using a toilet de-scaling liquid. Toilet brushes should be cleaned after use in hot water and general-purpose detergent and stored dry in brush holder.
Waste bins must be cleaned at least weekly inside and outside with hot water and general purpose detergent. Sack holders should also be cleaned regularly as above.
Cleaning staff employed directly or sub-contracted by the Trust must follow the NHS Healthcare Cleaning Manual (NB the manual should be read in conjunction with the NPSA Safer Practice Notice). The manual details the specific cleaning task that should be undertaken, and the correct methods of cleaning and expected outcomes.
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6.5 Trust Office Areas 6.5.1
Office areas should be kept clean and in good repair.
The responsibility of the employee is to make sure that they are familiar with and follow the IPC procedures for their own area.
In all areas of the Trust it is important to observe good basic hygiene procedures.
Desk areas, computer key boards and other equipment used and shared by staff should be cleaned as scheduled by the Trust using materials supplied by the Trust. • • • • •
All visible surfaces wiped free of dust and visible dirt. Rooms tidied. Bins emptied. Refrigerator checked for out of date/unlabeled food items. Floors swept, mopped and vacuumed as appropriate.
6.6 Vehicle Cleaning 6.6.1
It is important to maintain high standards of hygiene within the ambulance to prevent the spread of infection. All staff have an individual responsibility to keep the ambulance clean and thus reduce the risk of cross infection to themselves, their colleagues and their patients. This can best be achieved by all crew members participating in frequent and routine cleaning activities. No emergency or urgent call should ever be delayed as a result of a vehicle being washed or cleaned. Crews must use their judgement in determining the most appropriate time to attend to vehicle and equipment cleaning in order to avoid any disruption to the vehicles deployment.
There is currently a programme of Intermediate and Deep Cleans carried out by Ambulance Hygiene Assistants (AHA) in order to improve overall vehicle cleanliness and are as follows: • • •
Accident and Emergency Ambulances will have a level 2 clean carried out at 12 week interval and level 3 at 48 weeks. Rapid Response vehicles will have a level 2 clean carried out at 12 week intervals and a level 3 at 48 weeks. Patient Transport vehicles will have a level 2 clean carried out at 24 weeks and level 3 at 48 weeks.
It is the responsibility of the AHA and the Ambulance Resource Assistant (ARA) to ensure that work instruction is maintained. The ARA supervisor is responsible for ensuring the work instruction is monitored and maintained.
6.7 The Vehicle Exterior 6.7.1
The exterior surfaces of all ambulance service vehicles should be maintained in a consistently clean and hygienic condition. Pressure washers on stations should be utilised as necessary. The use of PPE should also be considered, such as using eye protection when using high pressure washers. Hand protection is important and
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rubber household gloves or latex/nitrile gloves should be worn when using vehicle cleaning chemicals. 6.7.2
If operational pressures prevent thorough cleaning of the vehicle exterior, attention should be prioritised to the relevant safety and legal requirements i.e. windscreen, windows, lights, indicators, reflectors, mirrors and number plates. In addition cleaning should pay particular attention to any areas where dirt is likely to be transferred to the crew’s hands e.g. door handles. The usual detergent based cleaning agents are satisfactory for general exterior vehicle cleaning, however, if the exterior has become contaminated with blood or body fluids, the detergent clean should be followed by disinfection to eradicate the potential source of infection. PPE (disposable gloves and apron) should be worn in this case and these items must be disposed of into the yellow clinical waste bag.
6.7.3 If operational pressures prevent thorough cleaning of the exterior, the minimum cleaning standards required to comply with Health and Safety Law should be met (i.e. windscreen, windows, lights, reflectors, mirrors and number plates).
6.8 The Vehicle Interior– Daily Clean 6.8.1
Any dry dirt/dust on the floor or surrounding areas should be removed using a vacuum cleaner. Using the designated blue mop, the floor should be cleaned with fresh hot water and soap/detergent solution at the beginning of every shift, or at the earliest available opportunity. If the mop becomes contaminated with body fluids, it should be changed immediately. Otherwise, mops (preferably with disposable mop heads) should be changed regularly (at least weekly). Re-usable mop heads should be laundered weekly. Furniture and equipment should be washed as above using a disposable cloth and dried thoroughly with a disposable paper towel. Ambulance interior surfaces and sensitive equipment should be cleaned with sanitising surface wipes.
At the end of shift clinical waste bags should not be left on a vehicle; they should be removed, tied and put in the nearest clinical waste bin. Sharps boxes may be left on the vehicle but should be in the closed position. The interior of the vehicle should be checked for sharps and other discarded clinical waste and removed.
The cab of the vehicle should be vacuumed and cleaned with sanitising surface wipes as appropriate.
When cleaning the vehicle, protective household rubber gloves must always be worn, and doors and windows must be opened to ensure adequate ventilation. These protective measures are to protect against the harmful qualities of the cleaning agents. Disinfectants are classified as irritants, meaning that regular and prolonged skin exposure can lead to sensitisation of the skin and, in chronic cases to dermatitis and eczema.
6.9 Vehicle Interior Cleaning – After Each Patient Journey 6.9.1
In addition to the above measures, vehicle cleaning should take place after each patient journey. It is good practice to use sanitising surface wipes to clean all surfaces that may have been contaminated, including stretcher handles and clinical surfaces. This need only take a few minutes.
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Where an ambulance has become contaminated with blood or body fluid, cleaning must take place on completion of the call. Decontamination should normally be carried out where there is access to water and cleaning equipment, such as at hospital or on station. Remember to use PPE as appropriate and discard any disposable items that have been in contact with blood or body fluids as clinical waste. It is advisable to provide as much ventilation as possible during cleaning activities.
Regular ‘damp dusting’ should be undertaken throughout the shift. This simply involves cleaning the area with detergent/sanitising wipes, paying particular attention to the stretcher cot, mattress and horizontal surfaces.
6.10 Vehicle Deep Clean – Fleet support staff 6.10.1 All ambulance interiors and exteriors should be subject to a comprehensive clean at 12 (level 2) and 48 (level 3) week intervals. Deep cleaning is co-ordinated by the Fleet Department, using dedicated vehicle cleaners. The Equipment Support Staff and Fleet Team Leaders have responsibility to adhere and maintain the following procedure to ensure that the cleaning program is conducted efficiently with minimal operational impact. The ambulance should be cleaned according the protocol. 6.10.2 ARA will carry out level one clean on all vehicles, prior to handing over to crews for operational duty, paying particular attention to handles, control levers, gear selector, switches and steering wheel. 6.10.3 Ambulance/patient compartment area: 1. Utilise Personal Protective Equipment (PPE) as required. 2. Remove all equipment and consumables from ambulance. 3. Carefully inspect floor, side door tracks, clamp tracks and any other at risk areas for blood spillages and sharps. Any hazards identified must be dealt with according to the Infection Control Policy. An incident report form must be completed if hazardous sharps are found. 4. Vacuum ambulance floor (if necessary). 5. Patient entrance and doorsteps, floor area, must be swept, mopped, cleaned and must be damp (sanitise) wiped. 6. Steam clean difficult to clean areas (e.g. gaps between fixtures) and exterior door frames. 7. Steam clean floor edges. 8. Steam clean ambulance interior surfaces. 9. Work methodically to wipe down any other surfaces/grab rails/cupboards etc. with detergent/sanitising wipes/disinfectant solution. Steam clean floor edges and other difficult to reach floor areas. 10. Windows must be damp (sanitise) wiped and then cleaned with glass cleaner. 11. Use the floor scrubber machine with appropriate pads to maintain the ambulance floor. 6.10.4 Ambulance Cab: 1. Door panels and pockets – all rubbish removed from pockets, clean with hot soapy water, disinfect and dry. 2. Cab floor – rubbish removed, vacuumed, clean with hot soapy water, dried. Ref: NEASPOL
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3. Windscreen to be cleaned with hot soapy water and polished dry, with the exception of the new Isoclima which must be cleaned inside with Isopropylic alcohol, 100% for stubborn stains and 50% diluted with water for general cleaning. 4. Window cleaned with glass cleaner and polished. 5. Dashboard to be cleaned with hot soapy water and dried. 6. Instrument panel, steering wheel, communication equipment, portable radio, gear selector, handbrake, door handles – damp (sanitise) wiped. 7. Seats to be cleaned with hot soapy water and dried. 6.10.5 Exterior: 1. Clean Exterior panels with hot soapy water using brush and rinsed with pressure washer. 2. Wheels to be scrubbed with hot soapy water and pressure washed. 3. Exterior mirrors, vehicle lights, auxiliary lights - wash with hot soapy water and rinse. 4. Tail lift must be extended fully, dropped to the floor and pressure washed. 6.10.6 Monitoring: 1. Note completed clean in vehicle log book. 2. Ensure clean is logged as directed by the Fleet Operations Manager. 3. The Fleet Engineer must be informed if any vehicle arrives in an unacceptable state.
Decontamination of Equipment 7.1
The aim of decontaminating equipment is to prevent potentially harmful pathogenic organisms reaching a susceptible host in sufficient numbers to cause infection.
Certain items of equipment are classified as ‘single-use only’. Single Use means that the manufacturer: •
Intends the item to be used once then thrown away.
Considers the item unsuitable for use on more than one occasion.
Has insufficient evidence to confirm that re-use would be safe.
Single patient use means that the item can be reused if re-processed using an appropriate method and is used on the same patient only. The duration of use is dependant on undertaking a risk assessment of individual factors. NB. The MHRA (MDA) (2000) guidance suggests that re-processing and re-using such items may pose hazards for patients and staff if the re-processing method has not been validated. Therefore re-use of single use products is not advisable unless the outcomes have been taken into account. The Consumer Protection Act 1986 will hold a person liable if a single use item is re-used against the manufacturers’ recommendations.
Re-useable equipment, including vehicles, should be appropriately decontaminated between each patient using a risk assessment model.
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Risk Assessment for Decontamination of Equipment:
Application of Item
Items/surfaces not in contact with patient e.g. floors, walls Items/surfaces that come into contact with healthy skin or not directly in contact with patient e.g. trolley bed handles, side rails.
Clean and dry
In contact with intact mucous membranes or contaminated with virulent or readily transmissible organisms (body fluids) e.g. Laryngoscope blades. In contact with a break in the skin/mucous membrane, or introduction into sterile body areas e.g. cannulae, forceps
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Clean and dry, but if contaminated with blood, body fluids or suspected transmissible organisms – disinfect. Disinfect or single-use
A-Z of Equipment/Vehicle Care and Cleaning Equipment
Single use – disposable
Bedpans / Urinals (Disposable)
Single patient use only. Dispose of in hospital macerator, or, after emptying, place in Clinical Waste bag for incineration. Clean between each use. Refer to manufacturers instructions.
Blood Glucose Monitor Body Bags (Disposable)
Single patient use only
Empty, wash and dry thoroughly after each use. Store inverted. Check fabric and straps intact. All parts should be visibly clean with no blood or body substances, dust, dirt, debris or spillages. When visibly soiled clean using hot water and detergent, rinse and dry thoroughly, or clean with detergent wipe. Clean after every patient use. Clean with detergent then disinfect using chlorine releasing agent (e.g. Milton), dry thoroughly Single use – disposable.
If contaminated with blood / body fluids Cervical Collars Re-usable - after each patient use
Ensure material is intact and equipment is functional. Apply detergent and leave for 2 - 3 minutes. Dry thoroughly with absorbent towels. Dispose of as clinical waste
If contaminated with blood / body fluids Defibrillator and Paddles - all parts should be visibly clean Daily
Wipe with surface wipes.
Straps / Wires
Wipe over with damp cloth, detergent and hot water
After each patient
Decontaminate with sanitising wipe. Dry thoroughly with absorbent towels.
If contaminated with blood / body fluids
Wipe with a damp cloth, detergent and water (ensuring none enters the equipment), and then disinfect with surface wipe.
ECG Equipment Electrodes Straps / Wires
Machine Endrotracheal mounts
Use disposable electrodes Wipe over with damp cloth, detergent and hot water, or sanitising wipe. Wipe with sanitising wipe, keep covered when not in use, refer to manufacturers instructions. Catheter Single use - disposable North East Ambulance Service NHS Trust Infection Control Policy/Procedure Version: 0001 Status: Draft 5 - 41 -
Must be used with patient air bacterial filter
After each use
Apply detergent and leave for 2 - 3 minutes. Dry thoroughly with absorbent towels. Dispose of all materials in Clinical Waste bag.
Following use on known or suspected infectious patient
Apply detergent and leave for 2 - 3 minutes. Dry thoroughly with absorbent towels. Dispose of all cleaning materials in Clinical Waste bag.
In-line Bacterial Filter
Single patient use only.
Forceps, Magill’s, Spencer Wells
Dispose of into Clinical Waste bag. Single use – disposable
Grab/hand rails Hand held Radio/mobile phones
After each patient use clean rails that have been touched. Clean using detergent wipe at least daily – and if contaminated when necessary.
Single use – disposable
Lancet holder (for BM Testing) Lancet device
Wipe with surface wipe after each use. Single use – disposable
Single patient use only
Place in appropriate colour coded bag for laundry or disposal
Medical gas equipment
Clean after each patient use, replace single-use items after use. Preferably use disposable mop heads which should be changed after each use. String mops, which are difficult to dry, can quickly become a source of infection. After use, the mop should be washed in detergent and hot water, wrung out and allowed to stand with head uppermost to dry. Regularly replace the mop head and water during use.
Oxygen/Nebuliser Masks and Tubing
Single patient use only. If contaminated, dispose of into Clinical Waste bag.
Pillows if in use – clean after each patient use.
Disposable pillow cases, the pillow should be encased in an intact waterproof cover, clean with detergent and hot water and dry thoroughly. If integrity of cover is breached – dispose of pillow as clinical waste. Single use – disposable
Resuscitator (Bag and Mask).
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Must be used with patient air bacterial filter. Disinfected according to manufacturer's instructions.
Check visor, strap and casing intact. Clean using detergent wipe. Use disinfectant then a surface wipe
If contaminated with blood / body fluids Sphygmomanometer Cuffs After each use
If soiled, apply detergent and leave for 2 – 3 minutes. Dry thoroughly with absorbent towels
Re-usable - after each patient use
Ensure material is intact and equipment is functional. Apply detergent and leave for 2 - 3 minutes. Dry thoroughly with absorbent towels. Clean with detergent, then use chlorine releasing agent and dry thoroughly
If contaminated with blood / body fluids Stethoscopes
After each patient use Stretcher Mattresses – all parts must be visibly clean.
Suction Catheter / Tubing
Suction (Electronic Unit) Bottle (disposable) Suction (Electronic (reusable)
Wipe earpieces and bell with disinfectant wipes. Earpieces must be changed when damaged. Check that cover is intact. At start and finish of each shift and when visibly soiled, clean with detergent and hot water and leave for 2 - 3 minutes. Dry thoroughly with absorbent towels. Clean after each patient use with sanitising wipe. Single patient use only. Dispose of in Clinical Waste bag. Single patient use only. Dispose of in Clinical Waste bag.
Bottle Empty in hospital sluice. Apply detergent and leave for 2 - 3 minutes. Dry thoroughly with absorbent towels.
Suction Unit (Hand Held)
Unit is re-useable, but the aspirate bottle is for single patient use. Dispose of aspirate bottle ONLY in Clinical Waste bag.
Umbilical scissors / clamps
Vomit bowls (Disposable)
Single patient use only. Dispose of in hospital macerator, or, after emptying, place in Clinical Waste bag. Clean after each patient use.
Wheelchairs – all parts must be visibly clean Work surfaces
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Cleaning of Vehicles and Equipment Prior to Inspection, Service or Repair
Vehicle and equipment should be checked in accordance with OPS 01 and form NEAS 17 (Vehicle/equipment check sheet) and completed. Any item of equipment listed found to be in need of repair should in the first instance be reported in accordance with QSSD 602.
At the earliest convenience an entry must be made in the Location’s Non-compliance file, the equipment must be cleaned of all organic material, by the professional user or other appropriately trained staff, before attaching a RED LABEL to the defective item, which much be completed fully and then place in the quarantine area.
A corrective work order will be generated from the maintenance management system.
All reusable medical devices must be decontaminated in accordance with instructions as well as legislative and best practice requirements.
It is also important to ensure that vehicles going for maintenance or repair are sent to workshops, including external contractors, in a state which is safe for non clinical staff to work in.
In the case of the vehicle then consult QSSD 643, all clinical waste should be removed and the sharps box should either be removed or placed in the closed position. The interior and equipment should be checked for sharps and contamination, and cleaned if necessary. If cleaning and checking of the vehicle has not been possible workshops should be notified of the risk and advised of any precautions to take.
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Flowchart for Decontamination Prior to Service or Repair Does the item require dismantling to ensure decontamination? Has the item been in contact with blood or body fluids?
Can the item be dismantled by ambulance personnel?
Dismantle and clean using Standard Principles
Decontaminate using the appropriate method.
Is it visibly soiled?
Yes Visible soiling must be removed from external surfaces and a RED LABEL must be completed fully and attached to the defective item, place in quarantine area.
Wipe with detergent and disposable wipes. Dry thoroughly. Attach RED LABEL, place in quarantine area.
Complete and attach RED LABEL, place in quarantine area.
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Body fluid and spillage management
Effective management of blood and body fluid spillage is a crucial factor in controlling the spread of infection. Exposure to any such fluid constitutes a risk to all staff and others in the immediate environment. These risks can be minimised by dealing promptly with the spillage by appropriate cleaning and disinfection.
For large spills the use of absorbent powder / Mediscreeen or Sporicidal wipe from a spillage kit should be used. The spillage kit should always be kept in a designated, easily accessible place and should contain the following: • • • • • • • •
Non-sterile disposable gloves Protective over suit / disposable plastic apron Disposable paper towels Disposable cloths Clinical waste bag Disinfectant spray (Mediscreen) Absorbent granules / Mediscreen or Sporicidal wipe Scoop and scraper
The kit should be replenished after use. 9.3
Use of personal protective equipment is necessary when dealing with body fluid spillages, for large spills in excess of 10-20mls or so, the following method should be used: • • • • •
Do not pick any broken glass, even with gloved hands. Use scoop and scraper, or two pieces of rigid card if such equipment is not available, and place glass into the sharps container. Absorbent granules from the spillage kit should be applied by being liberally sprinkled directly onto the spill where it will congeal the fluid. Once the fluid has been stabilised cover it with a paper towel until it is convenient for the spillage to be safely dealt with. Clear spillage up, clean and disinfect area with appropriate cleaning agent and disposable cloth. Wear PPE use Sporicidal wipe which can be placed dry over spillage to soak up contents, and then wipe area with sanitising wipe.
Spillage of low-risk body fluids: Detergent and water • • • • • • • • •
Keep area sectioned off until spillage has been safely dealt with. Wear protective clothing. Mop up organic matter with paper towels or disposable cloths and dispose of as clinical waste. Clean surface thoroughly using a solution of detergent and hot water with paper towels or disposable cloths. Rinse and dry the surface thoroughly. Dispose of materials as clinical waste. Clean the bucket/bowl in fresh soapy water and dry. Dispose protective clothing as clinical waste. Wash hands. North East Ambulance Service NHS Trust Infection Control Policy/Procedure Version: 0001 Status: Draft 5 - 46 -
Spillage of higher risk fluids: Disinfection • • • • • • • • • •
Section off the area containing the spillage until it has been safely dealt with. Ventilate area if possible. Wear protective clothing. Apply absorbent granules to the spillage Chlorine based disinfectants must not be used to treat urine spills. Once fluid congealed use scoop to pick up organic matter. Clean the area thoroughly with disinfectant. Clean bucket with fresh soapy water and dry. Discard protective equipment as clinical waste. Wash hands.
Management of linen
10.1 Germs in most soiled and fouled linen are unlikely to cause infection in healthy workers provided care is taken. To further minimise the risk: • Maintain standard principles of infection prevention and control • Dispose of used linen promptly into the appropriate linen bag • Wear an apron and gloves when dealing with contaminated laundry • Remove any protective clothing and wash hands before returning to other duties. • Cover any cuts and abrasions with waterproof dressing. 10.2 Single use disposable linen where available is preferable. 11.
11.1 The majority of bacteria and viruses will not survive away from the host and would not present a high risk of infection transmission on clothing. However, within a mass of body fluids there would be a greater number of organisms that would also survive longer. There is no conclusive evidence that uniforms (or other work clothes) pose a significant hazard in terms of spreading infection. There is no conclusive evidence of a difference in effectiveness between commercial and domestic laundering in removing microorganisms. Cuffs may become heavily contaminated and are more likely to come in contact with patients. It is therefore advisable that staff adopt ‘bare below the elbows’ when delivering care; the only exception is where a high visibility jacket is required for personal safety and/or protection. 11.2 Studies show that the public believe there is a risk and do not like seeing healthcare staff in uniform away from the workplace. 11.3 Staff should be provided with sufficient uniforms for recommended laundry practice. 11.4 The responsibility for uniform laundering rests with the individual member of staff. Uniforms and other work clothes should be washed as soon as possible and in accordance with the care label instruction – preferably on as hot a wash as the fabric will tolerate.
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11.5 Wash uniforms separately from other clothes and avoid over loading of washing machine. 11.6 A ten minute wash at 60°C is sufficient to remove most micro-organisms, using detergents means that many organisms can be removed from fabrics at lower temperatures. Where possible tumble dry and iron. Clean uniforms must be stored away from any sources of contamination. 11.7 On occasions uniforms may be exposed to splashes of blood / body fluids. This should be avoided as far as possible by the use of PPE – aprons. For cases of extensive soiling or contamination is foreseeable, a disposable suit should be worn as an outer garment, in addition to other PPE items necessary. After use the suit should be disposed of as clinical waste and the uniform checked to ensure it has been fully protected. 11.8 If contamination of the uniform occurs with either blood or body fluids, arrangements should be made for the crew to return to base for shower to remove any skin contamination and a uniform change. All staff should keep at least one complete spare uniform in their station locker. 11.9 Once off duty, staff should always change into ‘home’ clothes as soon as preferably before leaving the workplace.
11.10 Reflective clothing should be wiped over with sanitising / detergent wipe in order to thoroughly clean after each shift and following any contamination. Periodic washing using manufacturer’s instructions will ensure the clothing is kept in serviceable condition. 12.
Care of the deceased
12.1 Standard principles of IPC procedures must be followed in the event of a patient dying in transit, or in the case of a crew needing to move a deceased patient. 12.2 The procedure for ‘Recognising Life Extinct in Adults’ should be followed to ascertain circumstances in which resuscitation should/should not be carried out. 12.3 Handling and transport • The body must not be handled unnecessarily. • Patients who are contaminated with, or may leak blood/body fluids must be placed in a heavy-duty disposable plastic body bag. • Protective clothing must be worn at all times – including disposable gloves, and a disposable plastic apron if contamination of uniform is likely. • If there is any risk of infection, hospital staff must be warned. • Upon completion of the job, the vehicle and all appropriate equipment must be decontaminated using detergent and hot water. • All materials used must be disposed of into a clinical waste bag, which must be sealed and labeled and sent for incineration.
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Transportation of patients best practice guide to minimise the risk of acquiring a HCAI 13.1
Procedure for A&E ambulance services
13.1.1 NEAS and contracted services working within the responsibility of NEAS have a duty to ensure that they provide suitable and sufficient information on each patient’s infection status whenever a patient is to be moved from the care of one organisation to another so that any risks of alert conditions to the patient and others may be minimised. 13.1.2 Alert conditions may give rise to an outbreak of infection amongst patients, visitors and or healthcare staff. An outbreak exists when there are more cases of a particular disease than expected in a given area, or among a specific group of people, over a particular period of time. 13.1.3 It is expected that where a diagnosis of a patient’s infection is known, staff should be given the following information. However, staff are expected to use Standard Principles for infection prevention and control AT ALL TIMES so that, in general it is not necessary to know whether a patient is carrying an infection. Appropriate PPE must be worn when there is a risk of exposure to bodily fluids. 13.1.4 The medical staff requesting transfer of a patient are responsible for deciding if the patient should be transported singly and this information needs to be made clear at the time of the booking. 13.1.5 Information regarding a patient’s infection status may be obtained in the following ways: • • • •
Patient provided medical history (e.g. previous MRSA or Clostridium difficile). Medical history provided by other persons i.e. family/household members (e.g. diarrhoea/vomiting symptoms). Patient history provided by admitting body i.e. General Practitioner (e.g. provisional diagnosis). Clinical assessment of the patient o Respiratory – productive cough o Gastrointestinal – diarrhoea and / or vomiting o Circulatory – signs of sepsis / raised temperature o Presence of a rash / cellulitis o Clinically infected wound / indwelling device o Recent foreign travel
13.1.6 Information obtained regarding the patients infection status and the source of this information must be written on the Patient Report Form (PRF) and verbally reported to the receiving healthcare personnel. It may be necessary to call in advance of the patient’s arrival if it is anticipated that isolation facilities will be required. 13.1.7 All vehicle interior items and clinical equipment must be decontaminated or disposed of after each patient.
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13.2 Procedure for Patient Transport Services
13.2.1 Before accepting any patient for transportation the initiating establishment must be asked if the patient has any medical conditions that may cause a significant risk of cross infection to another person. 13.2.2 Patients that pose a significant infection control risk must be transported individually and the accompanying staff should employ PPE if appropriate. 13.2.3 Providing that the vehicle is decontaminated daily or immediately following visible contamination the risk of cross infection will be minimised. 13.2.4 Patients suffering from diarrhoea and/or vomiting should avoid non urgent travel until their symptoms have settled. Infected wounds ideally should have clean dry dressings applied. 13.2.5 Any concerns regarding infection control issues must be addressed with the initiating establishment, healthcare staff or their infection control team. If the matter is still unresolved contact your duty manager who can take the enquiry to the NEAS IPC Manager. 13.2.6 Effective communication between health care professionals will enable suitable measures are in place in order to minimise infection risks to both staff and patients. 13.3
Transporting patients from closed wards
13.3.1 Patients are generally not transported from closed wards bur every rule has its exceptions: •
A patient with diarrhoea and or vomiting may require urgent clinical care so may need to be moved from a community hospital to an acute hospital. They should not travel with other patients.
A patient may be going to their own home, they must not travel if experiencing diarrhoea or vomiting. They may travel with other patients providing they are asymptomatic.
13.3.2 If a hospital requests transportation for a patient they have a duty to inform you of any infection control issues but it is always asking them if they have not volunteered the information. 13.3.4 If the vehicle is soiled by vomit or faeces from a patient suspected to have either C diff or norovirus, D&V or gastroenteritis the vehicle should be taken off the road and cleaned this may entail a deep clean depending on the extent of the soiling. Otherwise normal cleaning procedures apply between journeys. 14.
Classification of Infectious Disease
14.1 Infectious diseases are classified into three categories according to the infection control precautions required. Further information can be obtained from the Health Protection Agency at www.hps.org.uk.
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14.2 Category One Diseases: this includes a number of infections for which there is a minimal or no risk of person to person spread. Standard principles should be maintained. Disease
Mode of Transmission
Direct contact with skin lesions.
Wear gloves when handling lesions.
Viral infection causing weakness, headache, sore throat and enlargement of the lymph nodes and spleen. Viral infection of the respiratory tract. Passed by coughing and sneezing.
Direct contact with saliva.
Do not use mouth to mouth resuscitation, use a bag and mask. None likely to be effective. Vaccinations are available from GP’s
Bacterial respiratory infection which can cause headache, muscle aches, cough, diarrhoea, pneumonia, mental confusion, and kidney or liver damage
Bacterial infection of the skin which often blisters and may weep. Glandular Fever
A relatively new disease that is originally contracted from airborne droplets but it is known that it cannot be passed on by person to person contact. There is no risk from being in the vehicle with an infected patient. Leptospirosis (Weil’s Disease)
Bacterial infection which can cause influenza like symptoms and may lead to jaundice, heart failure or meningitis. Passed to humans by rat urine.
None between humans.
Bacterial infection of the skin and nerves causing tissue destruction. Passed by long term, intimate, direct contact.
Long term, intimate direct contact.
Parasitic infection which causes shaking, headache and red blood cell destruction. Passed to humans via mosquito bites or blood transfusion.
None between humans.
Meticillin Resistant Staphylococcus Aureus (MRSA)
Staphylococcus Aureus (SA) is a common bacteria found on 30% of the population as part of their normal skin Ref: NEASPOL
Direct contact. MRSA does not represent
Wear gloves when handling open wounds and dispose of them after each
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flora. Most strains of SA have acquired resistance to some antibiotics and MRSA has acquired resistance to the most commonly used antibiotics. In normal healthy people MRSA does not pose a threat to health. Infections are rare but if one does occur the infection is trivial and affects the skin, resulting in infected cuts or boils which are easily treated. In people that are unwell (and therefore already have a reduced resistance to infection) open wounds or invasive procedures such as cannulation, airway intubation or surgery, cause breaks in the skin which can allow MRSA bacteria to enter deep into the body and cause more severe infections which can be difficult to treat.
a specific hazard to ambulance personnel or their relatives but is a cross infection risk to other patients. The main mode of transmission to other patients is via handling by healthcare workers and this is usually caused by not disposing of gloves or cleansing hands between handling open wounds on different patients.
patient use. The most important prevention strategy is hand washing with soap and water or if this is not immediately available, cleansing with an alcohol hand rub solution. The risk of transmission of MRSA within the ambulance service is generally low, both for the staff and for other patients. Transmission is related to direct contact with an infected or colonised individual, usually via the hands, or indirect contact with organisms in dusty contaminated equipment and surfaces. There is no need for MRSA patients to be transported separately from other patients as long as wounds are covered and unless there are other clinical indications to do so.
Bacterial infection of the eye. Occurs in new born babies as a result of infection acquired during birth.
Direct contact with exudate.
Wear gloves when handling eye.
Intimate direct contact.
Stretcher linen should be removed after journey and placed in a red laundry bag.
Penetrating skin wounds only.
Staff are vaccinated by the Occupational Health Department.
Parasitic skin infestation causing intense itching. Passed by intimate direct contact. There is no risk from being in the vehicle with an infected patient. Tetanus
Bacterial infection of the nervous system causing muscle contractions. Gains access to the body by way of penetrating wounds.
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Whooping Cough (Pertussis)
Bacterial infection of early childhood causing an exhausting cough. Adults are not normally infected.
Airborne droplets. Bacteria can only live for a very short time once outside of the body.
14.3 Category Two Diseases: This includes a number of infections which pose slightly higher risk, but for which standard principles of IPC should be effective. Disease
Mode of Transmission
Direct contact with exudate.
Wear gloves when handling exudate. Disinfect vehicle after use.
Airborne droplets. Direct contact with rash.
None likely to be effective and no vaccine is available.
Direct contact with excreta and vomit.
Wear gloves and aprons if necessary.
Bacterial infection of the skin often causing boils. Chickenpox
Viral infection causing skin rash, spots and blisters. Childhood illness which provides natural immunity. Cholera
Bacterial infection of the intestines causing diarrhoea, vomiting and severe dehydration, often fatal. Diphtheria
Bacterial infection of the throat causing a membrane like exudate of clotted serum, white cells, bacteria and dead surface tissue cells to form which obstruct the upper air passages and often require a tracheotomy.
Airborne droplets although the bacteria can only live for a short time once outside of the body.
Bacterial inflammation of the bowel causing abdominal pain, fever and frequent passage of stools containing blood and mucus.
Direct contact with excreta and vomit.
Wear gloves and aprons if necessary.
Direct contact with excreta and vomit.
Wear gloves and aprons if necessary. Disinfect vehicle after use.
Direct contact with excreta and vomit.
Wear gloves and aprons if necessary.
A viral inflammation of the brain causing fever, vomiting, seizures, mental confusion, coma and death. Enteric Fever
Bacterial infection of the bowel causing headache, fever, loss of appetite, abdominal discomfort and constipation. In severe cases, delirium, diarrhoea, skin rashes and enlargement of the liver or spleen may occur.
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Internal disorders caused by bacteria or fungi. Symptoms include nausea, vomiting, loss of appetite, fever, abdominal pain and diarrhoea.
Direct contact with excreta and vomit.
Wear gloves and aprons if necessary.
Direct contact with excreta and vomit.
Wear gloves and aprons if necessary.
Exchange of blood and blood stained body fluids.
Staff are vaccinated by The Occupational Health Department.
Bacterial or viral inflammation of the intestine and stomach lining causing fever, abdominal pain, diarrhoea and vomiting. Hepatitis B
Viral inflammation of the liver (which can be fatal). 10% of those that do recover become carriers and may develop cirrhosis or cancer of the liver. Four out of five carriers have a very low infectivity, the remainder, and those suffering acute Hepatitis at the time, are highly infectious.
The prime risk of infection for ambulance staff is by accidental self inoculation, or the entry of infectious material through broken skin, or the mucous membranes of the eye, nose or mouth. Simple contact between blood and intact skin does not constitute a risk.
HIV / AIDS
The Human Immunodeficiency Virus (HIV) causes a deficiency in a person’s immune system which may render it unable to provide protection against common infections. A person infected with HIV may go on to develop AIDS (Acquired Immuno Deficiency Syndrome) over the following weeks, months or years. An AIDS diagnosis is given when the immune system has been damaged by HIV causing a number of specific infections and/or cancers which may be fatal.
Exchange of blood and body fluids but not saliva or tears. The prime risk of infection for ambulance staff is by accidental self inoculation, or the entry of infectious material through broken skin, or the mucous membranes of the eye, nose or mouth. Simple contact between blood and intact skin does not constitute a risk.
Infestations e.g. fleas, lice
Parasitic infestation of the skin causing intense irritation.
Wear disposable gloves and apron. Disinfect vehicle after use.
Do not use mouth to mouth
Viral infection causing skin rash, mouth Ref: NEASPOL
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spots, fever, cough, and conjunctivitis. A childhood infection giving lifelong natural immunity.
Direct contact with saliva.
resuscitation, use a bag and mask. Vaccinations are available from GP’s for the rare adult that escaped childhood infection.
Do not use mouth to mouth resuscitation, use a bag and mask.
Meningitis and Septicaemia
Meningitis is a viral or bacterial inflammation of the lining of the brain. Symptoms may include fever, vomiting, headache, stiff neck, aching limbs and joints, a dislike of bright light, drowsiness and a rash. Bacterial meningitis is rare but can cause permanent deafness or brain damage and can be fatal. Viral meningitis is more common but the effects are mild and most people make a full recovery. Some bacteria that cause Meningitis may also cause Septicaemia (blood poisoning) as well. This can develop quickly and is evident from a rash which can be anything from tiny red spots to large blotchy bruises. Both bacterial Meningitis and Septicaemia require urgent treatment.
Spread during coughing, sneezing and kissing but the germs cannot live outside of the body for more than a few seconds and are not easily passed from one person to another. The prime risk to ambulance staff is by conducting unprotected mouth to mouth resuscitation. There is no risk from merely being in the ambulance with a patient.
The bacteria which causes meningitis is carried in the nose and throat of 10-15% of the general population without any harmful effect at all, it is very rare that they overcome the body’s defences and cause meningitis. Mumps
Viral infection causing malaise, fever, and swelling of the salivary glands.
Airborne droplets. Direct contact with saliva.
A childhood infection giving lifelong natural immunity. In adult men, can cause painful inflammation of the testicles, sterility is very rare.
Do not use mouth to mouth resuscitation, use a bag and mask. Vaccinations are available from GP’s for the rare adult that escaped childhood infection.
Viral infection causing fever, sore throat, headache, and vomiting. In severe cases stiffness of the neck and Ref: NEASPOL
Direct contact with excreta and vomit.
Wear gloves and aprons if necessary. Disinfect vehicle after use. Staff are vaccinated by the
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back, muscle ache, twitching and paralysis may occur.
Occupational Health Department.
Rubella (German Measles)
Viral infection of the lymph nodes causing slight fever, swollen nodes and a skin rash.
Staff are tested for natural Rubella immunity and vaccinated if necessary by the Occupational Health Department.
None. Precautions are unlikely to be effective and no vaccine is available.
If contracted during the early months of pregnancy can lead to congenital heart disease, physical deformities, cataracts, deafness and mental retardation of the foetus. An attack confers lifelong natural immunity. Shingles
Viral infection caused by the reactivation of an earlier infection with Chickenpox. Symptoms include inflammation of the nerve ganglia near the spinal cord, localised pain and skin rash on the trunk. Severe cases cause a rash around the eye and vision impairment.
Direct contact with rash.
Contact with shingles may cause Chickenpox in individuals without natural immunity. Tuberculosis
Bacterial infection usually affecting the lungs but can also affect the bowel, lymph nodes, skin, bones or other vital organs. Symptoms include fever, fatigue, weight loss, night sweats, coughing and blood streaked sputum.
Staff are vaccinated by the Occupational Health Department.
Direct contact with saliva, excreta or vomit.
Wear gloves and aprons if necessary. Do not use mouth to mouth resuscitation, use a bag and mask.
Parasitic infection causing headache, back and limb pain, shivering, cough, constipation, skin rash, delirium, prostration, weakness of the heart action, stupor, coma or death.
14.4 Category Three Diseases: This includes a number of high-risk infections for which special precautions and procedures should be followed. Smallpox
Mode of Transmission
Severe viral infection causing fever, headache, muscle ache and a blistering rash, often fatal.
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Mode of Transmission
Viral inflammation of the brain causing fever, headache, neck stiffness, anxiety and disorientation. This progresses to a fear of swallowing, choking, panic, hallucinations, coma and death. Viral Haemorrhagic Fevers (Lassa, Marburg, Ebola, Congo) Initial symptoms include fever, malaise, headache and muscle and joint pains. Nausea, vomiting and diarrhoea may also occur. Ebola and Marburg often cause a measles-like rash after 4-7 days. Obvious bleeding is a later or terminal event. Pyrexia may last as long as 16 days with temperatures up to 41o , severe cases result in coma and death.
Airborne droplets. Direct contact with rash, saliva, urine and cerebro-spinal fluid.
Mode of Transmission
Airborne droplets possibly if patient is suffering pulmonary infection. Accidental inoculation or contamination of broken skin or mucous membranes by infected blood or body fluids.
14.4.1 These guidelines should be read in conjunction with those set out in the Ambulance Service Basic Training (ASBT) Manual on Category III infectious diseases. They should be followed for the conveyance of patients suffering from or suspected to be suffering from highly infectious diseases to the High Security Infectious Diseases Unit (HSIDU/ward 25) at Newcastle General Hospital. Ambulance and Control staff should be aware that special precautions are needed with these types of cases as there is a risk of the spread of infection by contact with infected blood, vomit, excreta and possibly air droplets. 14.4.2 Requests for the transportation of a patient to Newcastle General Hospital will come from Consultant for Communicable Disease Control. The Physician-in-charge will inform the Ambulance Control of the level of containment appropriate for the journey required. Where containment requires the use of a Transit Isolator, the Trust will arrange the provision of the isolator and the transportation of the patient by the NEAS to NGH. 14.5 Transportation of Patients
14.5.1 Action by Ambulance Control 14.5.2 When a request for transportation is received, the Duty Control Manager/Officer must inform the Chief Executive, Director of Operations and Communications Manager. The Duty Control Manager/Officer should be aware that a crew of three is necessary. The third member of the crew will drive the vehicle, but they will not take part in patient handling. The Duty Control Manager/Officer should inform the Police of the impending movement and seek advice on the most suitable routes. 14.5.3 Control must log the times when the crew:• • • •
Leave the station Arrive at the pick-up point Leave the scene and their expected time of arrival Complete the case (i.e. arrive back at their home station) North East Ambulance Service NHS Trust Infection Control Policy/Procedure Version: 0001 Status: Draft 5 - 57 -
14.5.4 The Duty Control Manager/Officer should arrange an escort through the appropriate Operational Locality Manager or in the absence the Operations Manager. The escort should not come into contact with the patient or crew after contact has been made with the patient but simply follow the ambulance and cope with any unforeseen events. 14.6 Action by Ambulance Crew
14.6.1 On being notified of an exotic disease case staff should proceed to the agreed ambulance station. The third crew member is required to drive the ambulance and must not take any part whatsoever in patient handling procedures. The vehicle should be prepared in accordance with Section 17.5 of the ASBT manual. The bulkhead door and all windows (if applicable) in the patient compartment must be closed. All items of equipment considered unnecessary for the transfer should be removed from both the cab and the saloon compartment and left at the station for later collection. Where fitted, tape must be applied around both sides of the bulkhead door, to prevent air movement into the cab. 14.7 Personal Protection
14.7.1 Only staff who have received specific appropriate training can transport infectious cases. Staff should remove all clothing (except underwear) and put on a disposable suit. Contact lenses should not be worn unless essential. If contact lenses are worn during a transfer, they should be removed for disinfection immediately on completion of the transfer and replaced either with spectacles or with clean contact lenses. Watches, rings, etc should be removed and put in a place of safety in the escorting vehicle together with spare uniform/clothing, etc. 14.7.2 All staff must wear disposal overalls, disposable overshoes, gloves, FFP3 mask and goggles before entering the place from which the patient is to be collected. Whilst it is not necessary for the driver to wear overshoes, eye protection or a mask, they must be available in the cab (see Section 17.5 of the ASBT manual). 14.8 Journey Arrangements
14.8.1 The route selected should be adhered to, with any necessary diversions reported to Ambulance Control by the escorting vehicle. The escorting vehicle is responsible for keeping Ambulance Control updated on throughout the process. 14.8.2 If it becomes necessary to stop the vehicle e.g. in the event of a breakdown, remain with the vehicle. The escort vehicle driver will notify Control and may attempt repairs. If repairs are not successful, the escort vehicle will arrange for the vehicle to be towed to its destination or will seek alternative assistance. On arrival at NGH, the ambulance will be directed to the appropriate area to unload the patient. 14.8.3 Before entering the patient’s home or location, the crew will don disposable gloves, facemask with respiratory filter and safety eyewear. The patient should be provided with and asked to wear a facemask with a respiratory filter. The crew will transfer the patient to the ambulance using any necessary manual handling aids, care should be taken to ensure that all items of ambulance equipment are collected before leaving the address. When the patient is secured in the vehicle, the crew should carry out a communication check with the escorting officer. If satisfactory, they should then
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contact Ambulance Control, report mobile and provide an estimated time of arrival (ETA) at the designated hospital. 14.8.4 Any necessary patient care procedures should be carried out but the crew should avoid unnecessary patient handling. 14.9 Disinfection of Vehicle
14.9.1 After the admission of the patient the crew will remove all disposable items and bedding, placed in correct colour coded clinical waste bag and labelled for incineration as directed by Newcastle General Hospital policy. The ambulance will be taken to the decontamination area. Any ambulance equipment used on-route should be placed into a sealed clinical waste bag, secured and labelled ‘infectious for incineration’. Unless directed otherwise the vehicle crew will then carry out a thorough disinfection of the interior of the vehicle and its equipment by washing down with hot water and detergent followed by disinfection with a 10,000ppm hypochlorite solution or alternatives approved by the hospital. Disinfection by fogging must not be used. 14.10 Personnel decontamination
14.10.1 Personal decontamination will be undertaken on the directions of HSIDU, NGH staff and will include disposal of items of clothing and shower and changing facilities. The crew and duty officer must satisfy themselves that all necessary procedures have been completed before reporting their status to Ambulance Control. 4.11 Medical Surveillance
4.11.1 Medical surveillance will depend upon the instructions given by the Consultant in Charge of the HSIDU and the Consultant for Communicable Disease Control on the day. This largely will depend upon the level of containment, i.e. high or medium risk and the subsequent diagnosis of the patient’s illness. The attending crew will be required to undergo surveillance for a period of 21 days from the last possible date of exposure to infection. 4.11.2 There need be no restriction on work or movement within the UK, surveillance will simply be the daily monitoring of body temperature and the reporting of any suspicious symptoms. During surveillance those suffering any rise of temperature above 38°C will be kept under surveillance at home and, if fever persists for more than 24 hours, advice sought from a Consultant in Infectious or Tropical Diseases. 4.11.3 It could be possible that A&E staff will already have had contact with such patients before their illness is formally diagnosed. The Advisory Committee on Dangerous Pathogens (ACDP) have issued guidance that most pre-diagnosis Category 3 patients can be safely managed by following the Standard Infection Control precautions and the safe disposal of clinical waste. Any resuscitation pack regime must include the use of either the bag & mask, or resuscitation pack. Under no circumstances should any from of direct oral resuscitation be carried out. 4.12 Contact Tracing
4.12.1 Should a patient treated by the Trust subsequently be found to have an infectious disease or illness, it may be necessary for the Ambulance Clinician or Out of Hours
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staff to be traced. This form should be completed on receipt of a call from an Infection Control Department, Duty Microbiologist, Occupational Health Department or other responsible person.
Date call received in ambulance control: ____/____/______ Time: ____:____ Call received from (name and position): ……………………………………………………………… Patient’s name: …………………………………………………………………………………………. Patient conveyed from: ………………………………………………………………………………… Patient conveyed to: …………………………………………………………………………………… Date of journey: ____/____/______ Incident no: _____________ Advice from caller: ……………………………………………………………………………………… …………………………………………………………………………………………………………….. Contact no. for further advice: …………………………………………………………………………. Vehicle Call Sign: ……………………………………………………………………………………….. Trust staff ID/Names #1: ……………………………………………………………………………….. Trust staff ID/Names #2: ……………………………………………………………………………….. Vehicle Call Sign: ……………………………………………………………………………………….. Trust staff ID/Names #3: ……………………………………………………………………………….. Trust staff ID/Names #4: ………………………………………………………………………………… Information passed to Crew (identify crew #) ………………………………………………………… ……………………………………………………………………………………………………………… Date & time information passed to Crew or Senior Officer (detail): ……………………………….. Signed (Duty Control Manager): ………………………………………………………………………. Name (Print): ……………………………………………………………………………………………..
This form should be copied to the Clinical Development Manager
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14.12.2 Ambulance Control Staff should: • Know what to advise staff in case of inoculation injury. • When appropriate, inform operational ambulance personnel about patients who may pose a risk of transmission of infection. 15.
Other Communicable Diseases
In general those conditions in this section do not require any special procedures or action by staff other than close observation of the Standard Principles of Infection Prevention and Control. The majority of patients do not require any special travel arrangements unless stated. If a member of staff contracts any of the diseases in this section it is reportable under RIDDOR regulations. 15.1 Hepatitis A
15.1.1 Presenting symptoms are fever, loss of appetite, diarrhoea, tiredness and nausea. It is caused by a virus, commonly referred to as Infectious Hepatitis or Yellow Jaundice. The virus is present in the stool of infected persons so transmission is via faecal-oral route. It may be contracted by eating contaminated food. Anyone not immune can become infected and the virus present in stools for up to two weeks prior to display of symptoms. 15.1.2 No specific treatment, although recovery can take several weeks, no special precautions are required by staff other than observing standard principles. 15.2 Hepatitis B
15.2.1 Presenting symptoms are fever, loss of appetite, diarrhoea, tiredness and nausea. The virus is found in all body fluids of an infected person; can be transmitted by sexual contact, injection or puncture of the skin, contact with blood or body fluids via open cuts, sores and mucous membranes. 15.2.2 Vaccination is available for NEAS working in the clinical environment through Occupational Health. 15.2.3 No special procedures required by staff other than rigid adherence to Standard Principles. 15.2.4 Any incident resulting in staff exposure to blood or body fluid must be reported as soon as possible. 15.3 Hepatitis C
15.3.1 Parenterally transmitted virus, with many infected people having no symptoms, there is a possibility of developing chronic illness. 15.3.2 Presenting symptoms are anorexia, nausea/vomiting and abdominal discomfort. 15.3.3 Spread by blood to blood contact, no special precautions required by staff other than adherence to standard principles.
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15.4 Clostridium difficile
15.4.1 C. difficile infection (CDI) causes serious illness and outbreaks among hospital inpatients. Normally affects the elderly, the debilitated and patients who have had antibiotic treatment. 15.4.2 It is important that when a patient presents with diarrhoea, the possibility that it may have an infectious cause is considered. Patients with suspected potentially infectious diarrhoea should be isolated. 15.4.3 In a typical case of Clostridium difficile associated disease (CDAD), mild to moderate diarrhoea starts within a few days of commencing antibiotics, although antibiotics taken 1-2 months previously may still predispose to infection. There may be abdominal pain, stomach cramps/tenderness, fever, loss of appetite and nausea. Transmission
15.4.4 Clostridium difficile is present in the faeces of 3% of healthy adults, 7% or asymptomatic care-home residents and 20% of elderly patients on long-stay wards. It is transmitted from patients with symptomatic CDAD either directly, via the hands of healthcare workers, through the accumulation of spores in the environment or on contaminated fomites such as commodes. 15.4.5 C difficile spores can survive in the environment for months or years, heaviest contamination is often on floors, commodes, toilets, bedpans and bed frames, which are subject to faecal contamination. People can become infected by touching these contaminated surfaces. 15.4.6 The bacteria are shed in faeces. Touching even the smallest amount of infected faeces, and then touching your mouth can cause infection with Clostridium difficile. It can be spread from person to person by poor hygiene, by failing to wash hands properly after going to the toilet, or after handling contaminated food. 15.4.7 Spread does not occur from an asymptomatic carrier in the absence of diarrhoea. 15.4.8 Two or more cases of diarrhoea that are suspected or known to be infectious occur within a few days at a care home or other community setting should be reported to the local Health Protection Unit (HPU). Prevention
• • • • • •
Control of antibiotic usage by strict antibiotic prescribing policies. Strict adherence to infection prevention and control standard procedures. Any patient with diarrhoea should be isolated. Hand hygiene by washing with liquid soap and water will effectively decontaminate the hands from both the spore and vegetative forms of the organism. Hand hygiene before and after each patient contact, after environmental contact and when moving between ‘clean’ and ‘dirty’ sites on the same patient is recommended in the World Health Organisation (WHO) Five Moments for Hand Hygiene. Alcohol hand rubs or other disinfecting agents are not as effective as soap and water in reducing spore contamination on the hands and therefore should not be used in cases of suspected infective diarrhoea.
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• • • • • • • • • •
Transfer and movement of patients should be reduced to an operationally effective minimum. Where patients need to attend departments for essential investigations, they should be ‘last on the list’ unless earlier investigation is clinically indicated. The receiving area should be notified of the patient’s CDI status in advance of the transfer. The patient should be called to the facility when it is ready for them and their transfer planned so that they are not held in communal waiting areas. Ambulance personnel involved in transfer of CDI patients should adopt infection prevention and control precautions when in contact with the patient i.e. wear disposable gloves and aprons for all contact with them and their environment. After transport of the patient with CDI, the risk of cross-infection to other patients is minimal. Good infection prevention and control practices and cleaning should suffice to prevent cross-infection. Faecal soiling should be cleaned and treated using a sporicidal cleaning agent i.e. chlorine containing agents. All clinical waste and linen from patients with CDI, including any linen etc should be considered contaminated and should be managed in accordance with local guidelines. Effective communication with all parties and staff involved in the transferring of patients/clients to another care setting. Staff who have diarrhoea should not work unless they have been symptom free fro 48 hours or the diarrhoea has been shown to be non-infectious and not a risk to others.
Inter-healthcare infection control transfer
15.4.9 If a patient / client being transferred is suspected or confirmed as being infectious, the Infection Prevention and Control team (IPCT) should be contacted at the receiving facility within normal working hours BEFORE the transfer is carried out and BEFORE transport is arranged. 15.4.10 A ‘confirmed risk’ patient/client is one who has been confirmed as being infected with C diff. Patients/clients with ‘suspected risk’ include those waiting for laboratory tests to identify infections/organisms or who have been in recent contact with infected patients/clients. 15.4.11 Transfer and movement of patients should be reduced to an operationally effective minimum. Where patients need to attend departments for essential investigations, they should be ‘last on the list’ unless earlier investigation is clinically indicated. In advance of the transfer, the receiving areas should be notified of the patients CDI status. Ambulance personnel should adopt infection prevention and control precautions when in contact with the patient. 15.4.12 After transport of the patient with CDI, the risk of cross-infection to other patients is minimal. Good infection prevention and control practices and cleaning should suffice to prevent cross-infection. Faecal soiling should be cleaned then treated with appropriate sporicidal cleaning agent (i.e. chlorine-containing agents, impregnated wipes). Cleaning agents and materials are available in blood / body fluid spillage kits.
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Meticillin Resistant Staphylococcus Aeureus
15.5.1 Staphylococcus aureus is a common bacterium found on 30% of the population as part of their normal skin flora and on dust-collecting surfaces in public buildings such as hospitals. In normal healthy people it does not pose a threat to health. However, hospitalised patients undergo many invasive procedures which cause breaks in the skin and affect other defence mechanisms. Intravenous lines, surgical wounds and urinary catheterisation enable bacteria to enter sterile areas of the body and cause infection. MRSA Colonisation
15.5.2 Colonisation is when a person carries S. aureus (including MRSA) on areas of their body such as the nose and the skin, and occasionally in folds such as the axilla (armpit) or groin. It can live on the body without causing harm, and most people who are colonised do not go on to develop infection. Less than 5% of colonising strains in the healthy population who have not been in hospital are meticillin-resistant but it is more common in vulnerable people who are in contact with the healthcare system. MRSA Infection
15.5.3 MRSA infections usually occur in healthcare settings and in particular in vulnerable patients/clients. Clinical infection with MRSA occurs either from the patient’s/client’s own resident MRSA (if they are colonised) or by cross-infection from another person, who could be a symptomatic carrier or have a clinical infection. S. aureus infects a range of tissues and body systems. •
Wounds – S. aureus/MRSA are common causes of wound infection, and can occur either by accidental injury or surgery. The wound will be red, inflamed and may also be swollen and painful. The wound may break open or fail to heal, and a wound abscess could develop.
Superficial ulcers – pressure ulcers, varicose ulcers and diabetic ulcers are often sites of MRSA colonisation or infection.
Invasive devices – (intravenous lines, feeding lines, renal dialysis and urinary catheters). S. aureus/MRSA may infect the entry site of an invasive device, causing local inflammation with pus. It is from this MRSA can enter the bloodstream, causing a bacteraemia.
Deep abscesses – If MRSA or S.aureus spreads from a local site to the bloodstream, it can lodge at various sites in the body (lungs, kidneys, liver or spleen) and cause one or more deep abscesses distant from the original site.
15.5.4 This is when an infection spreads further into the body and MRSA/S. aureus is present in the blood. Septicaemia can follow typical symptoms include high fever, a high white cell count, rigors (shivers), disturbance of blood clotting with a tendency to bleed, and failure of vital organs.
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Precautions to be taken
15.5.5 Colonisation with MRSA may be long term. For a healthy person, MRSA colonisation is asymptomatic and does not present a risk. MRSA colonisation does no present a risk to other healthy individuals, and carriers should therefore continue to live a normal life without restriction. Good hand hygiene practice and standard infection precautions should be followed by all staff all of the time, to reduce the risk of any cross-infection. Ambulance transportation
15.5.6 The risk of cross-infection from an MRSA colonised or infected patient to other patients in an ambulance environment is minimal. Good infection prevention and control practices and routine cleaning should suffice to prevent cross-infection. MRSA infection or colonisation should not be a barrier to good clinical care. Consequently, inter-hospital transfers should not be prevented or delayed. 15.5.7 Most MRSA carriers (colonisation) may be transported with other patients in the same ambulance without any special precautions, other than changing bedding used by the carrier. High risk categories of susceptible patients should not be transported in the same ambulance as a known MRSA-positive patient. Lesions should be covered wherever possible with an impermeable dressing. 15.5.8 Those patients with wounds or infected areas of the skin can be transferred with other patients as long as any wounds or skin lesions are covered by dressings or normal clothing. 15.5.9 The ambulance service should be notified in advance by the responsible ward staff, if considered necessary by the infection control team. 15.5.10 There is no evidence that ambulance staff or their families are put at risk by transporting patients with MRSA. To minimise the risk of cross-infection with any infectious agent, ambulance staff should use an antibacterial hand rub after contact with all patients as part of good, basic infection prevention and control practice. 15.5.11 If any further measures are required in special circumstances, the infection control team should inform the ambulance service. 15.5.12 No additional cleaning of the ambulance is required after transporting an MRSApositive patient. Those patients who have MRSA:
• • •
On exposed areas of skin or where a heavy colonisation on multiple body sites is identified. Co-existent with extensive eczema or psoriasis. Coughs with sputum colonisation.
It is recommended that:
• • • Ref: NEASPOL
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Hand should be decontaminated with alcohol hand rub after patient contact.
15.5.13 Normal cleaning of the vehicle after the patient has left is sufficient, any equipment which the patient has come into contact with should be cleaned with detergent solution and dried thoroughly or cleaned using sanitising wipe. 15.6
15.6.1 Norovirus is easily transmitted from one person to another. It can be transmitted by contact with an infected person; by consuming contaminated food or water or contact with contaminated surfaces or objects. It is highly contagious, however one of the ways to protect against the infection or to help prevent others becoming infected, is by practising good hygiene. 15.6.2 There is no specific treatment for norovirus apart from letting the illness run its course. Drinking plenty of fluids will help prevent dehydration especially in the very young or elderly. 15.6.3 It is able to survive in the environment for many days. Always clean your vehicle thoroughly between patients. If your vehicle has been actually contaminated with vomit or faeces suspected to be norovirus or C.diff, clean up the gross soiling before sending if for deep cleaning. 15.6.4 Hand washing is more effective than alcohol gel in the presence of Norovirus so wash your hands at every opportunity including after you have handed your patient over, before eating or after going to the toilet. 15.6.5 Wear an apron and gloves when dealing with a symptomatic patient. 15.6.6 Symptoms include vomiting, diarrhoea, fever, nausea, abdominal cramps. 15.6.7 Inform the receiving hospital if your patient has a history of or there is a suspicion of norovirus diarrhoea or vomiting. 15.6.8 Symptoms usually last 24 to 48 hours and staff must remain off duty until 48 hours after last episode of diarrhoea or vomiting. 16.
Infestations with Ectoparasites
16.1 Ambulance personnel may occasionally come into contact with patients who are infested with parasites, which live on or in the skin. There are three types of ectoparasite which crews are likely to encounter which are lice, fleas and scabies. Infection with lice carries a strong social stigma due to a long-standing association with dirt and poverty. Human lice feed by sucking blood, and lice are only transmitted by close contact with an infected person. 16.2 Lice
16.2.1 There are three species of lice which infect humans, producing three different conditions: • Pediculosis pubis caused by the crab or pubic louse
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• Pediculosis humanus caused by the body or clothing louse • Pediculosis humanus capitis caused by the head louse They are bloodsucking insects which are host-specific therefore cannot survive away from the human body for more than a few days. In addition to the louse itself, eggs (nits) are usually present firmly adhered to the person’s hair or to the clothing. 16.2.2 Pediculosis Pubis (the crab louse/pubic louse) • This is the most sedentary human louse and dies quickly when separated from its host. It lays several eggs on a single hair. • The egg takes 6-8 days to incubate and the life cycle from egg to egg is about 3 weeks. They are transmitted through close physical contact. • Clothing, bed linen and toilet seats do not play a role in the transmission. • The pubic louse is about 1-2mm in length and lives in the genital and peri-anal area, it can infect all coarse body hair (axilla, beard, eyebrows and eyelashes). Itching, often intense, is the main symptom, but may begin some months after onset of infestation. 16.2.3 Pediculosis Humanus (The clothing / body louse) • Primarily seen where there is overcrowding and poor sanitation. In the United Kingdom it is most likely to be seen in street dwellers and vagrants who are not able to change their clothes regularly, bedding can also become infested. Transmission occurs during contact between fully clothed persons. • The body louse lays its eggs and resides in the seams of the clothing rather than on the host. The body louse leaves the clothing only to obtain a blood meal from its host. • Nits present in the clothing are viable for up to one month. Mature lice who have no access to the body usually die of starvation in 5 days at low temperatures and more quickly at high temperatures. Adult lice live 13-30 days. Symptoms can take weeks to develop in a first infestation. Heavy infection with lice usually causes allergic reactions such as itching. 16.2.4
Pediculosis Humanus Capitis (Head lice)
• Head lice are wingless arthropods that infect the head and feed by sucking blood. • Anyone with hair can get head lice but the most commonly affected groups are primary school age children and their families and contacts. • No age group or social class is exempt. • Head lice make no distinctions between social class, home location, standards of personal hygiene or age. • The eggs are tear-shaped, 1mm long and are securely glued to the hair shaft close to the scalp. The eggs hatch after 7-10 days. The full-grown louse is 3mm long and lives for about 20 days. Empty egg sacks are white and shiny, and may be found further along the hair, as the hair grows out. 16.3
Sarcoptes Scabiei (Scabies)
16.3.1 Scabies is an allergic reaction caused by a tiny parasite mite which burrows into the epidermis of the skin. The body’s immune system reacts to the mite’s droppings and saliva resulting in an immune reaction which causes intense itching. Incubation period Ref: NEASPOL
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is up to 8 weeks after contact with an infected person. It may take up to 2 weeks before symptoms present. 16.3.2 Lesions occur mainly on the hands, finger webs, wrists, inside of arms, abdomen / waist, groin and under buttocks. Scabies is spread from person to person by prolonged direct skin to skin contact. Mites do not survive away from their host and a low risk for contraction to ambulance crews providing standard precautions are observed, especially hand hygiene. 16.4
16.4.1 There are several thousand varieties of flea. Infestation is usually with dog, cat or bird fleas, which will bite humans in the absence of the preferred host. The human flea is more likely to be introduced from outside the hospital, but is now rare. 16.4.2 Like lice, fleas are bloodsucking insects, and are able to survive for several months in the environment without feeding. Measures to eradicate fleas from the environment may be necessary. 16.4.3 Unlike lice, fleas may leap from one person to another. Although fleas may transmit infectious disease, this is not a problem in the UK and the main consequence of flea infestation is a flea bite, which can be intensely irritating. 16.5
16.5.1 Standard precautions should be taken if there is any suspicion of infestation, especially hand washing and the use of PPE. The use of disposable linen is recommended if available and should be disposed of as clinical waste. If re-usable items are used all items of linen should be red bagged and laundered appropriately. 16.5.2 In general, no specific cleaning of the vehicle is necessary other than close attention to the area immediately occupied by the patient. The trolley, adjacent walls and floor should be washed with general purpose detergent and hot water, or wiped with sanitising wipes. In cases where there is visible infestation with fleas, crews may wish to request a return to bases to change clothing. Any member of staff who suspects they may have become infested should contact the Occupational Health Department or visit their GP for further advice. 17.
Biological Warfare Agents
17.1 These agents include Anthrax, Plague, Smallpox and some of the viral haemorrhagic fevers. Generally these organisms do not survive easily in the general atmosphere and the risk is therefore minimal. None of the diseases present an immediate risk and therefore there is time to seek expert medical advice from A&E and subsequently from public health consultants. 17.2 Some staff have been trained in the use of specialised PPE and decontamination procedures, particularly for Chemical, Biological, Radiological and Nuclear (CBRN) threats / incidents. ONLY these staff should deal with incidents in which such agents are thought to be involved. All other staff should remain at a safe distance and await support from trained staff.
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17.3 In the event that staff are inadvertently contaminated they should report this to the ambulance incident officer who will arrange appropriate after care and support. Special ‘pods’ are strategically placed throughout the country and are available to assist ambulance services in dealing with incidents of this nature. Incidents of this nature are normally dealt with by implementation of the Major Incident Plans and all staff should ensure that they are familiar with their contents. 18.
Major outbreaks and the Health Protection Agency (HPA)
The Local and Regional Services Division of the HPA provide specialist support to prevent and reduce the impact of infectious diseases, chemical and radiation hazards, and major emergencies. Local teams are based within Newcastle and Durham and involved in a range of activities including; • • • • •
Local disease surveillance Laboratory services Alert systems Investigation and management of health protection incidents and outbreaks Delivery and monitoring of national action plans for infectious diseases at local level
In the case of a major outbreak, the HPA will coordinate the response and investigation. The HPA are responsible for holding and updating national outbreak plans, as well as many disease-specific major incident plans, working with microbiological and clinical colleagues.
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Ambulance Service Association (2004) Ambulance Service Basic Training Manual. ASA , London. Coia, J.E. Duckworth, G.J. Edwards, D.I. Farrington, M. Fry, C. Humphreys, H. Mallaghan, C. Tucker, D.R. (Joint BSAC/HIS/ICNA Working Party on MRSA). (2006). Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. The Journal of Hospital Infection. Vol 63, 63S, S1-S44. Department of Health (2008) Ambulance Guidelines Reducing infection through effective practice in the pre-hospital environment. Healthcare Associated Infection and Cleanliness Division, DH, London. Department of Health (2009) The Health and Social Care Act 2008, Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. DH, London. Department of Health (2006) The Health Act 2006. Code of Practice for the Prevention and Control of Healthcare Associated Infections. DH, London. Department of Health (2007) Essential steps to safe, clean care: reducing healthcare associated infections. DH, London. Department of Health, (2008) Essential Steps to safe, clean care – managing MRSA in a non-acute setting: a summary of best practice. DH, London. Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. DH, London. Department of Health (2006) Standards for better health. DH, London. Department of Health (2007) Uniforms and work wear – an evidence base for developing local policy. DH, London. Department of Health (DH) and Health Protection Agency (HPA), (2008) Clostridium difficile infection: How to deal with the problem. DH and HPA, London. Health Protection Agency (HPA), (2007) HPA Regional Microbiology Network: A good practice guide to control Clostridium difficile. HPA, London. HSG 95 (18) Hospital laundry arrangements for used and infected linen. NHS Executive, 1995. Infection Control Nurses Association, (2002) Hand decontamination guidelines. Infection Control Nurses Association. National Health Service (NHS) Litigation Authority (2008) Risk Management Standards for Ambulance Trusts. NHS Litigation Authority, London. National Institute for Clinical Excellence (NICE), (2003) Prevention of healthcare-associated infection in primary and community care. (no.1) Standard Principles. NICE, London.
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National Patient Safety Agency(NPSA), (2009) The national specifications for cleanliness in the NHS: A framework for setting and measuring performance outcomes in ambulance trusts. NPSA, London. www.npsa.nhs.uk The Ambulance Service Association (ASA), (2004) National Guidance and Procedures for Infection Prevention and Control. Managing Healthcare Associated Infection & Control of Serious Communicable Diseases in Ambulance Services. ASA, London.
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