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Infection prevention and control manual

Contents

1 The national infection prevention and control manual

For information the National infection prevention and control manual has been adopted by trust.

The National infection prevention and control manual (NIPCM) for England is an evidence-based practice manual for use by all those involved in care provision in England and the principles are applicable to all care settings. The aim of the NIPCM is to ensure a consistent UK wide approach to infection prevention and control (IPC), however some operational and organisational details may differ.

The NIPCM has been adapted for use to support and facilitate healthcare providers to demonstrate compliance with the ten criteria of the Health and Social Care Act (2008) Code of practice on the prevention and control of infections and related guidance.

Pathogen specific guidance is out of remit of the NIPCM. Pathogen-specific guidance appropriate to England, is produced by other agencies, for example, UK Health Security Agency (UKHSA), and can be found in the A to Z of pathogens resource.

2 Quick guides

The quick guides below have been developed to incorporate local policy and procedure. They will provide you with the information required for the initial management of a patient with a specific organism or for a particular process, with any ongoing support provided by the Infection Prevention and Control team.

2.1 Antimicrobial resistance

2.1.1 What are antibiotics?

Antibiotics are used to treat or prevent some infections. They work by killing bacteria or preventing them from spreading. But they do not work for everything. Antibiotics do not work for viral infections such as colds and flu, and most coughs.

Read about antibiotics, what they are and what they do.

2.1.2 What is antimicrobial resistance?

Antimicrobial resistance (AMR) occurs when organisms that cause infection develop ways to survive treatments such as antibiotics.

Learn more about antimicrobial resistance.

Resistance is a natural occurrence but can be made worse by various things such as misuse of medicines, poor infection prevention and control (IPC) practices such as handwashing and cleaning, global trade and travel. The biggest worry is that new strains of bacteria may emerge that cannot be treated by any existing antibiotics.

2.1.3 How important is it that we tackle resistance?

As resistance continues to increase, more people will suffer for longer as infections become more difficult to treat, resulting in longer hospital admissions, routine surgical procedures becoming more dangerous to perform, and higher death rates. The impact of antimicrobial resistance can and will affect each one of us.

Learn what is antimicrobial resistance, what does it mean and why it matters.

Learn about why you should care about antimicrobial resistance.

2.1.4 Infection prevention and control precautions

2.1.4.1 Actions you can take
  • Antibiotics only treat bacterial infections. Ask your pharmacist to recommend other medicines to treat symptoms associated with other infections.
  • For most people, self care is the best way to treat an illness. This means getting plenty of rest, drinking fluids and taking a recommended dose of over the counter fever or pain-reducing medication. However, if symptoms do not resolve or worsen, contact a healthcare practitioner for a review or diagnosis.
  • If antibiotics are required take them exactly as prescribed and complete the course, never save them for later and never share them with others.
  • Good hygiene practices, such as handwashing, can prevent the spread of infection and reduce the need for antimicrobials.
  • Get vaccinated against preventable illnesses such as flu and measles.
  • If requested, take specimens to your GP to identify the microorganism causing symptoms so that the correct antimicrobials can be prescribed.

Good infection prevention and control practices can reduce the risk of antimicrobial resistance occurring. Colleagues must adhere to Infection prevention and control precautions to reduce the risk to patients, visitors and colleagues. This includes:

  • hand hygiene
  • respiratory hygiene
  • correct use and disposal of personal protective equipment (PPE)
  • good standards of cleanliness
  • supporting patients or service users’ awareness and involvement in the safe provision of care in relation to infection prevention and control
  • use published information from national or local public health campaigns to inform and improve the knowledge of patients or service users, care givers, visitors and advocates to minimise the risk of transmission of infections

Further information is available in Contained and controlled: The UK’s 20-year vision for antimicrobial resistance.

2.2 Bare below the elbows

2.2.1 Do you need to be bare below the elbows (BBE)?

Bare below the elbows (BBE) is required to:

  • reduce the risk of cross infection
  • enable effective hand hygiene
  • promote is professional image

One plain band is permitted but no other wrist or hand jewellery or false or painted nails are allowed.

Do you meet the following criteria:

  • based on a ward
  • a food handler
  • have contact with patients in a non-ward setting, for example in a clinic or patients home and undertake hands on care for example physical observations, injections, wound care or urine testing?
  • visit wards as part of your role and undertake hands on care for example physical observations, injections, wound care or urine testing?

If you have answered yes to any of the above bare below the elbows is required.

If you do not undertake hands on care but have face to face contact with patients or their environment you must have the ability to be bare below the elbows.

If you wear a uniform the trust stance is that bare below the elbows should always be adhered to in order to promote a professional image.

For colleagues who meet the criteria for being bare below the elbows but wear a bangle for religious reasons the bangle must be non-fabric and pushed up the arm and secured. Sleeves must be able to be pushed up during hands-on care but where it is not acceptable for the forearms to be exposed then over-sleeves can be worn for the episode of care.

On ward areas trust issued gilets are preferable to trust issued cardigans or fleeces. However, if trust issued cardigans or fleeces are worn then sleeves must be pushed up the arm and removed during any hands-on care.

2.3 Blood and body fluid spillages

Occupational exposure to blood, body fluids, excretions and secretions (except sweat) poses a potential risk of infection, particularly to those who may be exposed to these substances.

In clinical areas the management of blood and body fluid spillages is the responsibility of clinical colleagues. In all other areas only staff who are fully vaccinated against Hepatitis B and who are competent to do so should deal with blood or body fluid spillages.

It is the responsibility of all colleagues to ensure that their immunisation status for Hepatitis B is up-to-date. This can be obtained by contacting the occupational health provider.

2.3.1 Trust approved products

  • Clinell universal wipes, for small spillages.
  • Clinell Spill wipes, for large spillages including urine and vomit.
  • Guest Medical or GV blood spillage packs: not for use on urine or vomit spillages.
  • Haz-tab solution (10,000ppm), follow manufacturer’s instructions.
  • Chlor-Clean solution (1,000ppm), for environmental disinfection.

2.3.2 Best practice

  • Cover cuts or abrasions with a waterproof dressing before donning personal protective equipment (PPE).
  • Use the most appropriate product for the type and size of spillage.
  • Ensure all products are in date.
  • Always follow manufacturer’s instructions.
  • Replenish stock following use.
  • Clean hands after doffing personal protective equipment.
  • What product to use
  • On hard surfaces:

2.3.3 What products to use

2.3.3.1 On hard surfaces
  • Large spillage (containing urine and vomit), use a Clinell spill wipes.
  • Large spillage not containing (urine or vomit, use Clinell spill wipes or guest medical or GV spill kits.
  • Small spillage (less than the size of a 2p coin), use Clinell universal wipes.
2.3.3.2 On carpets and soft furnishings
  • Large spillage: absorb spill with Clinell spill wipes then use a carpet cleaner and, or steam cleaner.
  • Small spillage: use Clinell universal wipes then use a carpet cleaner and, or steam cleaner.
  • Cushions, covers, curtains: send to Tickhill Road Hospital laundry.
  • Haz-tab solution or blood spillage packs must not be used on soft furnishings or carpets except where chlorine resistant fabrics are specified.

2.3.4 Refer to supporting documents

Please see the National Infection Prevention and Control Manual webpage for supporting documents attached to this procedure as follows:

  • Chlor-clean poster
  • Haz-Tab poster

2.4 Chickenpox or shingles (Varicella Zoster virus)

2.4.1 Key points

  • Varicella (chickenpox) is an acute infectious disease. It is caused by varicella-zoster virus (VZV) and after the initial infection, VZV stays in the body (in the sensory nerve ganglia) as a latent infection
  • Reactivation of latent infection causes herpes zoster (shingles)
  • You cannot catch shingles from someone with chickenpox, but you can catch chickenpox from shingles if you have not had chickenpox before.

2.4.2 Symptoms

  • Chickenpox: may initially begin with flu-like symptoms, for example, aching limbs, headache, raised temperature. Clusters of vesicular spots (blisters) appear over 3 to 5 days. This is also known as cropping. The rash starts as small, red, itchy spots which develop a blister on top and become intensely itchy after about 12 to 14 hours. The rash usually starts on the face and scalp and then spreads to the trunk, abdomen and limbs. It is possible to be infected but show no symptoms. Diagnosis is made on clinical examination.
  • Shingles: the first signs of shingles are pain at the affected nerve site usually on one side of the body, especially the chest, followed by a rash of fluid filled blisters which can take from as little as a few days to several weeks to crust over. Individuals may also experience fever, headache and malaise for several days prior to the rash developing.

2.4.3 Transmission

2.4.3.1 Chickenpox
  • Airborne via respiratory secretions (FFP3 mask must be worn)
  • Direct contact from the blister fluid to mucous membranes
  • Indirect contact through contaminated articles such as clothing or bedding or equipment.
2.4.3.2 Shingles

Direct contact with vesicle fluid from an infected person which is then transferred via the mucous membranes of a non-immune individual.

 2.4.4 Incubation period

  • Chickenpox: 1 to 3 weeks.
  • Shingles: reactivation can occur many years after initial infection.

2.4.5 Treatment

  • Antiviral treatment may help symptoms if prescribed early enough following diagnosis
  • People at high risk of developing serious complications can be given immunoglobulin, so a clinical review will be required.

2.4.6 Infection prevention and control precautions

  • Standard precautions required for shingles management.
  • Transmission based precautions for chickenpox management, use of FFP3 mask.
  • Isolation for chickenpox until spots or vesicles have dried and crusted.
  • Isolation for shingles is not required if the spots or vesicles are covered with a dressing. If it is not possible to cover the spots or vesicles isolate until these have dried and crusted.
  • Treat linen as contaminated (red alginate bag) and waste as infectious (orange waste bag).
  • Twice daily environmental clean with Chlor-Clean (1,000 ppm).
  • Decontaminate patient equipment thoroughly with Clinell Universal wipes.
  • Terminal clean of the room required when isolation is discontinued.
  • Only non-immune colleagues (including domestics) must care for patients with chickenpox or shingles.
  • Advise any pregnant colleagues to contact occupational health for advice.
  • Commence contact tracing: patient contact list in supporting documents “colleague contact list” in supporting documents.
  • Notify the Infection Prevention and Control team of any suspected or confirmed inpatient cases:

2.5 Clostridioides difficile (C.diff)

2.5.1 Key points

There are 2 types of results for C.diff testing:

  • GDH positive or toxin negative: this is classed as colonisation and does not always require treatment but if symptoms persist speak to the microbiologist
  • toxin positive: if toxins are present this is classed as C.diff infection (CDI) and antimicrobial treatment will be prescribed

2.5.2 Risk factors

  • Aged over 65.
  • Current or recent antibiotics.
  • Long stay in hospital or care home.
  • Underlying digestive condition or recent surgery.
  • Immunosuppression.
  • Taking a proton pump inhibitor (PPI), for example, lansoprazole, omeprazole
  • Previous infection.

2.5.3 Symptoms

The illness ranges from mild self-limiting diarrhoea to profuse, explosive watery stools.

Often diarrhoea is foul smelling and the affected individual may experience abdominal cramps and fever.

Occasionally C.diff infection may lead to potentially fatal conditions such as pseudomembranous colitis, toxic mega colon and, or bowel perforation.

2.5.4 Stool sampling

Send a sample at the earliest opportunity for Bristol stool type (BST) 5, 6 or 7 stools if no other cause identified on diarrhoea assessment tool in quick guides.

Do not retest for C.diff if patients are still symptomatic or to see if clear of infection within a period of 28 days. If symptoms recur please speak to the microbiologist for advice.

If other infectious agents are suspected then a sample can be obtained.

2.5.5 Transmission

  • Commonly affects patients who have recently been treated with antibiotics but can spread easily to others
  • C.diff spores can survive for long periods on hands, surfaces and objects
  • Spread via faecal or oral route where bacteria on the hands is ingested.

2.5.6 Treatment

  • If clinically appropriate review and discontinue non-C.diff antibiotics to allow normal intestinal flora to be re-established.
  • Speak to the microbiologist who will advise on treatment regime.
  • Anti-motility agents should not be prescribed.

2.5.7 Infection prevention and control precautions

  • Standard precautions required.
  • Obtain sample and complete stool chart after every episode to monitor Bristol stool type (BST) and frequency.
  • Isolate patient until asymptomatic of Bristol stool type 5, 6 or 7 for 48 hours.
  • Use liquid soap and water for hand hygiene.
  • Encourage the patient with hand hygiene especially after using the toilet.
  • Treat linen as contaminated (red alginate bag) and waste as infectious (orange waste bag).
  • Twice daily environmental cleaning with Chlor-Clean (1,000 ppm).
  • Decontaminate patient equipment thoroughly with Clinell peracetic acid wipes or Chlor-Clean (1,000 ppm).
  • Dedicated commode if room is not ensuite.
  • Notify the Infection Prevention and Control team of any confirmed inpatient cases:

2.6 Contamination injury procedure

2.6.1 Occupational exposure to blood or body fluids

Contamination injuries including needlestick, bites, scratches, cuts, splash into eyes, mouth or into cuts or abrasions.

2.6.2 Contamination injury first aid

  • Encourage the wound to bleed.
  • Wash the contaminated area.
  • Do not suck the wound.
  • Dry and cover with a waterproof dressing.

2.6.3 Splash injury first aid

  • Irrigate eyes, mouth or affected area with water.
  • If contact lenses are worn rinse or irrigate with water remove lenses and irrigate again.

2.6.4 Procedure

  • Report incident to immediate manager.
  • Contact the 24-hour hotline on 0330 6600 365 for a risk assessment.
  • Visit accident and emergency immediately for advice and treatment if risk assessment determines this is necessary.
  • If follow-up treatment or support is required manager to refer staff member to occupational health through the trust’s occupational health referral system, OHIO.
  • Report the incident via the trust electronic reporting system (IR1).

2.7 Diarrhoea assessment tool

2.7.1 Section 1

  1. Has the patient got diarrhoea?
  2. If the answer to the above is yes then assess whether there are any underlying factors, for example:
    • inflammatory bowel disease
    • overflow
    • aperients
    • enteral feeding
    • patients normal bowel habit
    • new medication
    • medical treatment
    • antibiotics
  3. If there are underlying factors there should be a clinical review of the following:
    • General condition
    • bloods: WCC, CRP, Creatine
    • medication (if on antibiotics and or proton pump inhibitor consider Clostridioides difficile infection)
  4. If it is determined that it is non-infective diarrhoea a review or modification of treatment should be undertaken:
    • underlying cause
    • medication
    • review clinical response 24 to 48 hours
  5. If after review infection is suspected or there are no underlying factors, follow the procedure in section 2.

2.7.2 Section 2: infection suspected

If infection is suspected:

  • move to a single room
  • commence isolation precautions
  • obtain specimen
  • medical review including antibiotic therapy
  • maintain and monitor stool chart

2.8 Discharge cleaning guide and checklist

Maintaining a high standard of hygiene is essential in preventing the spread of infection in a hospital setting, therefore it is vital that decontamination of the environment and equipment is performed to minimise the risks to both patients colleagues.

When a patient is discharged the bed space or room must be cleaned thoroughly in preparation for new patients being admitted.

This guidance has been designed for all colleagues who are involved in the cleaning and preparation of a bed space or room. If there is any contamination with blood or body fluids colleagues must refer to the National Infection Prevention and Control Manual and the blood and body fluid spillage management quick guide.

For a patient with an infection please follow the terminal cleaning guide and checklist.

2.8.1 Key points

  • Hand hygiene must be performed immediately before and after any cleaning activities within the environment.
  • All colleagues must wear appropriate personal protective equipment.
  • Use detergent or antimicrobial wipes to clean the environment and equipment. Colleagues must refer to manufacturer’s guidance for further information.
  • It is the responsibility of the nurse in charge to ensure that each bed space or room is cleaned thoroughly and to sign part A of appendix A when satisfied the area has been cleaned to an acceptable standard.
  • If the cleaning is found to be of an unacceptable standard the process must be repeated before a patient can be admitted into the bed space or room and a new form must be used.
  • The nurse in charge must not accept an admission into a bed space or room that has not been thoroughly cleaned and dried.

The forms must be kept on the ward for three months for monitoring and audit purposes.

See appendix A for the checklist.

2.9 Managing pathology specimens safely

2.9.1 Key points

All specimens may contain micro-organisms capable of causing disease, they must be obtained, handled and transported with care to reduce the risk of transmission of infection to all people involved, under the Health and Safety at Work Act (1974) and the Control of Substances Hazardous to Health (Amendment) Regulations (2004).

2.9.2 Hazard group definitions

A biological agent is assigned to one of the following groups according to its level of risk of infection to humans:

  • group 1: unlikely to cause human disease
  • group 2: can cause human disease and may be a hazard to employees; it is unlikely to spread to the community and there is usually effective prophylaxis or treatment available
  • group 3: can cause severe human disease and may be a serious hazard to employees; it may spread to the community, but there is usually effective prophylaxis or treatment available
  • group 4: causes severe human disease and is a serious hazard to employees; it is likely to spread to the community and there is usually no effective prophylaxis or treatment available

See a list of Hazard group 3 and 4 organisms.

When dealing with specimens of suspected or confirmed hazard group 3 organisms, additional precautions may be required. These will be detailed in the respective procedures or advised by the consultant microbiologist.

All specimens from patients with known or suspected hazard group 3 organisms must be designated as high risk and a “Danger of Infection” label must be applied to both the container and the form. Labels can be ordered from the print room, order code DP5697.

Hazard group 4 organisms include viruses that cause haemorrhagic fever, for example, the Ebola virus. It is unlikely that group 4 organisms will be encountered within the trust. If this occurs or is suspected then advice must be sought from the consultant microbiologist or the infectious diseases physician (Royal Hallamshire Hospital, Sheffield) before any specimens are obtained, by contacting switchboard at the Royal Hallamshire Hospital (on 0114 271 1900) and asking for the on-call infectious diseases registrar. The patient would be transferred to an infectious diseases unit as a priority.

2.9.3 Infection prevention and control precautions

  • Follow standard infection prevention and control precautions including:
    • use of personal protective equipment, aseptic non touch technique, management of blood and body fluid spillages and hand hygiene
  • Clinical biochemistry, haematology, immunology, microbiology and virology specimens must be placed in the bag attached to the form and sealed. Several blood samples from an individual patient can be placed in the same bag but virology or serology samples require a separate form and bag. Blood cultures, urines, swabs, fluids, sputum and faeces samples must not be mixed with blood samples.
  • In instances where patients are requested to collect their own specimens, education on the specimen collection method, instructions on handling the specimen and prompt returning of the specimen to promote accurate results and patient safety is paramount.
  • Further information can be found in the pathology handbooks for each locality, including:
    • obtaining, packaging specimens or collecting high risk specimens
    • completing the request form
    • transporting specimens

Pathology handbooks:

Linked to transportation of sharps or specimens in quick guides.

2.10 Meticillin resistant Staphylococcus aureus (MRSA)

2.10.1 Key points

Staphylococcus aureus is a common bacterium that lives harmlessly on the skin and in the nose of about a third of the population. Most strains of Staphylococcus aureus are sensitive to the more commonly used antibiotics and are known as meticillin sensitive Staphylococcus aureus (MSSA). If the Staphylococcus aureus strain is resistant to the more commonly used antibiotics it is known as meticillin resistant Staphylococcus aureus (MRSA).

Both MRSA and MSSA are not a danger to healthy individuals, but people may become colonised. This is when bacteria settle at a particular site on the body without producing an immune response and there are no signs of infection. However, Staphylococcus aureus may cause serious infections such as bacteraemia (blood poisoning).

Screening required for:

  • patients with a previous history of MRSA (isolate patient until screen obtained)
  • patients that have undergone surgical procedures within the last month
  • patients admitted from another hospital facility
  • patients admitted from a nursing or residential care home facility
  • intravenous drug user
  • patients who self-harm (breaking the skin within the last month)
  • patients with chronic wounds, for example, leg ulcers
  • patients with indwelling devices, for example, urinary catheters.

2.10.2 Screening sites

  • Nose: use a blue swab. One swab to be used for both anterior nares (fleshy part of the nose). The swab can be pre-moistened if required by using the gel provided with the swab or with sterile water
  • Groin: use a separate blue swab. One swab to be used for both sides of the groin
  • Skin lesions or wounds: using a charcoal swab one swab to be taken from each site, the site and type of wound must be clearly identified, for example, self-injurious wound to left arm or ungradable pressure ulcer to right heel. Note, if there are clinical signs of infection the swab needs to be labelled for microscopy, culture and sensitivity as it may be a different organism causing infection
  • Invasive devices: one swab from each insertion site, for example, PEG, intravenous catheter, supra pubic catheter or tracheostomy site.

2.10.3 Transmission

  • People who are colonised can act as carriers and pose a risk of cross infection, especially to other vulnerable people
  • The bacteria can pass from one person to another by direct contact. The organism can also be shed into the environment, where other individuals may then acquire it.

2.10.4 Treatment

2.10.4.1 Colonisation
  • Suppression treatment recommended in hospital: skin and nasal decolonisation.
  • Not usually recommended for patients in the community except those at higher risk of developing infection.
  • Colonisation can lead to infection.
2.10.4.2 Infection
  • Most patients with MRSA will be colonised rather than infected and do not require systemic antibiotics.
  • However, if a wound or insertion site is displaying signs of infection, obtain a swab of the area for “culture and sensitivity”.
  • If systemic treatment is required seek advice from the consultant microbiologist.

2.10.5 Antimicrobial therapy

As antimicrobial use is a recognised risk factor for MRSA acquisition, all patients with MRSA should have their antibiotic therapy reviewed, and any unnecessary antimicrobial agents should be stopped.

2.10.6 Meticillin resistant Staphylococcus aureus bloodstream infection

Meticillin resistant Staphylococcus aureus (MRSA) blood stream infection (BSI), sometimes called MRSA bacteraemia, occurs when bacteria invade the bloodstream through a variety of different routes such as:

  • breaks in the skin, for example, cuts or surgical incisions
  • indwelling devices, for example, urinary catheters, intravenous cannulae
  • localised sites of infection, for example, infection in the urinary tract or the lung that spills over into the bloodstream

Blood stream infections can be short-lived and patients can remain asymptomatic. These short-lived blood stream infections normally go unnoticed and are cleared rapidly by the body’s immune system and are called transient or silent bacteraemia.

Blood stream infections can however persist for days or weeks and lead to patients being severely ill with clinical signs of sepsis (such as fever or rigors). In these instances successful treatment relies on eradicating or treating.

2.10.7 Infection prevention and control precautions

  • Enhanced precautions required, this includes a higher level of standard precautions but not necessarily full isolation precautions. Please discuss with the Infection Prevention and Control team.
  • Although isolation is not usually required the patient should be cared for in a single room.
  • Placement in a bay will require a risk assessment to be completed and other patients in the bay must not have any wounds or invasive devices.
  • Treat linen as contaminated (red alginate bag) and waste as infectious (orange waste bag).
  • At least once daily clean with Chlor-Clean (1,000ppm).
  • Enhanced cleaning in the areas where the patient has been on the ward with Clinell Universal wipes.
  • Notify the Infection Prevention and Control team of any confirmed inpatient cases:

2.11 Multidrug resistant organism (MDRO)

2.11.1 Key points

Multidrug resistant organisms (MDROs) continue to be a concern for health and social care settings. Some bacteria are naturally resistant to certain types of antimicrobials, whilst others develop or acquire resistance:

  • glycopeptide resistant enterococci (GRE) also known as Vancomycin resistant Enterococci (VRE)
  • carbapenemase-producing Enterobacterales (CPE)
  • extended spectrum beta-lactamase (ESBL) producing organisms, for example, Escherichia coli (E.coli) and Klebsiella species
  • multi resistant Acinetobacter species
  • multi resistant Pseudomanas species
  • any other antimicrobial resistant bacteria

2.11.2 Diagnosis

All the multidrug resistant organisms listed are detected from specimens sent to the laboratory. The patient may have clinical signs of infection, for example, diarrhoea, exuding wounds, urinary tract infection, respiratory tract infection.

2.11.3 Transmission

  • Most multidrug resistant organisms are spread by contact with an infected person and their excretions or secretions.
  • Transmission can also occur via contaminated hands, surfaces or objects.
  • Multidrug resistant organisms can spread rapidly, so effective management of affected patients is essential.

2.11.4 Treatment

2.11.4.1 Colonisation
  • No antimicrobial treatment required.
  • Colonisation can occur when the organisms are present in areas such as the large bowel or on skin or wounds but are not causing infection.
  • Colonisation can lead to infection.
2.11.4.2 Infection
  • As there may be limited therapeutic options for treatment of multidrug resistant organisms discuss antimicrobial management with the microbiologist.
  • Treatment should be guided by laboratory results.

2.11.5 Infection prevention and control precautions

2.11.5.1 Colonisation
  • Standard precautions required.
  • Patients colonised with any of the multidrug resistant organisms listed should be placed in a single room but if this is not possible other patients in the bay must not have wounds or invasive devices.
  • Patients may come out of their room providing that they are not displaying symptoms, for example, diarrhoea, urinary incontinence.
  • Encourage the patient with hand hygiene especially after using the toilet.
2.11.5.2 Infection
  • Transmission based precautions required:
    • wear fluid repellent surgical mask and eye protection if risk of contamination to the face or eyes
    • wear a long-sleeved fluid repellent gown if there is risk of extensive splashing of blood, body fluids, secretions or excretion onto skin or clothing
  • Patients with carbapenemase producing enterobacterales (CPE) or vancomycin resistant enterococci (VRE) who are symptomatic with diarrhoea must be isolated in a single room with ensuite facilities or dedicated commode.
  • Risk assessment is required for patients with other multidrug resistant organisms to determine appropriate placement and the need for isolation.
  • Use liquid soap and water for hand hygiene.
  • Encourage the patient with hand hygiene especially after using the toilet.
  • Treat linen as contaminated (red alginate bag) and waste as infections (orange waste bag).
  • Twice daily environmental cleaning with Chlor-Clean (1000ppm).
  • All equipment to be decontaminated thoroughly with Clinell Universal wipes.
  • Terminal clean of the room required when isolation is discontinued.
  • Notify the Infection Prevention and Control team of any confirmed inpatient cases:

2.11.6 Swabbing guidance

  • Contact screening is required for carbapenemase producing enterobacterales (CPE) but not for the other multidrug resistant organisms. Screening is via a rectal swab. Please refer to the Royal Marsden swab procedure (staff access only).
  • No further swabbing required for infected or colonised patients.

2.12 Norovirus

2.12.1 Key points

  • Norovirus is a common gastrointestinal infection that tends to occur during autumn and winter.
  • Noroviruses are highly infectious and are transmitted easily from person to person, contaminated food or water or by contact with contaminated surfaces or objects.
  • Outbreaks are common in areas such as hospitals, care homes and schools due to population proximity.
  • Although norovirus gastroenteritis is generally mild and of short duration, the illness can be severe among vulnerable population groups such as young children and the elderly.

2.12.2 Symptoms

  • Acute onset of non-bloody watery diarrhoea and, or vomiting which may be projectile.
  • Abdominal cramps.
  • Muscle pains.
  • Headache.
  • Malaise.
  • Low grade fever.

2.12.3 Transmission

  • Contact via hands.
  • Person to person via faecal-oral route.
  • The virus particles can be inhaled or ingested when a patient vomits.
  • Ingestion of contaminated food and drink.
  • Environmental contamination from faeces or vomit.

2.12.4 Incubation period

Typically, between 12 and 48 hours.

2.12.5 Period of infectivity

Whilst individuals are symptomatic and for a further 48 hours after the cessation of symptoms.

Prolonged shedding of the virus can occur in persons that are immunocompromised and young children.

2.12.6 Treatment

  • Dehydration is the most common complication and the avoidance of, or correction of this is the mainstay of clinical treatment.
  • The elderly and immunosuppressed are particularly vulnerable to the effects of dehydration and should be monitored and treated accordingly.

2.12.7 Infection prevention and control precautions

  • Standard precautions required. A face mask must be worn if patient is vomiting.
  • Obtain sample.
  • Isolate patient in a single room or cohort several patients with the same infection in a bay until patient is asymptomatic for 48 hours.
  • Use liquid soap and water for hand hygiene.
  • Treat linen as contaminated (red alginate bag) and waste as infectious (orange waste bags).
  • Twice daily environmental cleaning with Chlor-Clean (1,000ppm).
  • Decontaminate patient equipment thoroughly with Clinell Universal wipes.
  • Terminal clean of the room required when isolation is discontinued.
  • Dedicated commode if room is not ensuite.
  • Notify the Infection Prevention and Control team of any suspected or confirmed inpatient cases:

2.12.8 Additional advice

  • Symptomatic patients must not be routinely transferred to other healthcare facilities and routine investigations should be postponed if possible. If unavoidable the ward or department at the receiving facility must be informed, as well as the transport or ambulance service.
  • Patients should only be discharged to a residential setting when they have been asymptomatic for at least 48 hours. Patients can be discharged to their own home if they still have diarrhoea but must be improving clinically.
  • Visitors should be advised to postpone their visit, although the wellbeing of the patient should also be considered. They must be informed of the infection risk and provided with advice on minimising risk.

2.13 Patient equipment and general cleaning guide and checklist

The safe decontamination of equipment between patients is an essential requirement of routine infection prevention and control practice. The transmission of infections associated with equipment is widely acknowledged. Inadequate decontamination processes have been frequently responsible for outbreaks of infection in healthcare settings.

Depending on the function of the patient equipment in use, cleaning frequencies may be classified as either:

  • between patients
  • daily
  • weekly
  • periodically

All equipment must be decontaminated thoroughly according to the risk of infection associated with the use of a particular piece of equipment. Equipment must be cleaned using neutral detergent and warm water or with detergent wipes. For disinfection purposes Chlor-Clean solution or antimicrobial disinfectant wipes (for example, Clinell Universal wipes) are recommended. Equipment should be labelled using indicator tape once decontaminated thoroughly.

If equipment is contaminated with blood or body fluids please refer to the quick guide for blood and body fluid spillages.

If any equipment is found to be damaged, it must be taken out of use and reported, repaired or replaced as per Trust guidance.

The clinical environment is also a reservoir for microorganisms and must be kept clean, tidy and free from clutter. Periodic cleaning of areas within treatment rooms, linen rooms, therapy or activity rooms and storerooms (for example, cupboards and shelving) should be included on the nursing cleaning checklist.

Support services have responsibility for ensuring the ward or department is cleaned on a frequent basis; however, clinical colleagues must address any concerns they have if standards are not being met.

Any non-essential notices or displays should be removed to ensure that the tidiness of the general environment is maintained. Notices or posters should be laminated, if possible, in order that they can be cleaned or wiped as necessary.

The visual check is designed to provide assurance that cleaning has been carried out in accordance with the requirements stipulated above. The person in charge is responsible for walking around and visually inspecting the area or equipment to ensure cleanliness standards are of an acceptable level.

The cleanliness of each piece of equipment should be assessed by visual inspection of all surfaces for visible dust, dirt, smears, splashes or other organic matter.

Special attention should be paid to any hard to reach areas or the undersides of equipment such as commodes, shower chairs, hoists et cetera.

Equipment or items used as part of therapy programmes or activity sessions are to be included as appropriate and fall within the same procedures.

For any therapy or activity items which cannot be easily checked for cleanliness, wiped or kept clean (such as some craft materials, textile objects et cetera) their use should be assessed and managed as part of the usual therapy or activity risk management and hazard control procedures in line with local and trust arrangements, with advice sought from Infection Prevention and Control team as necessary. For some items bespoke cleanliness and usage guidance or procedures may be required.

The contents of the cleaning schedule should be reflected in the checklist

Please refer to appendix B for the visual or cleaning check for clinical staff

2.14 Patient placement and assessment of infection risk

2.14.1 Key points

  • Assess all patients on admission for infection risk and complete the infection control admission risk assessment which is under corporate templates on the clinical tree in SystmOne.
  • Continue to review infection risk throughout the admission.
  • Inform the Infection Prevention and Control team of any patients requiring specific placement (isolation) for infection reasons:
  • Seek advice from the Infection Prevention and Control team if the patient cannot or will not isolate.
  • Isolate for the shortest possible time to avoid a deterioration in the patients mental health and review regularly.

2.14.2 Categories of isolation

  • Source isolation: the infectious or colonised patient is isolated to prevent cross infection to other non-affected individuals
  • Protective isolation: this is used to protect a susceptible patient where their immune system is compromised to avoid infection from others.

2.14.3 Priority for a single room

  • Patients with airborne transmissible infections such as influenza, SARS-CoV-2, chickenpox, measles et cetera.
  • Patients with, or suspected infection or colonisation with multiple antibiotic resistant organisms.
  • Diarrhoea and, or vomiting.
  • Patients with methicillin-resistant Staphylococcus aureus (MRSA)
    in sputum who are coughing or have exfoliating skin conditions.

2.14.4 Infection prevention and control precautions

  • Refer to National infection prevention and control manual (NIPCM) for guidance relating to transmission based precautions.
  • Ensure doors to isolation rooms are kept closed. If patient safety is compromised, a documented risk assessment must be completed and reviewed at every shift.
  • Ensure appropriate signage is displayed on the door to the isolation room or bay without compromising patient confidentiality.
  • Ensure adequate provision and appropriate use of personal protective equipment (PPE).
  • Only cohort nurse for the shortest possible time to minimise risk of re-infection or re-colonisation.
  • Avoid moving patients unless clinically necessary.
  • Avoid non-essential treatments, therapies and appointments. For urgent, essential treatments the receiving organisation or department and transport provider must be informed that isolation precautions are in place.
  • Undertake a terminal clean of rooms once isolation is completed or the patient is discharged or transferred elsewhere.

Refer to terminal cleaning guide and checklist.

Refer to supporting documents:

  • Chlor-Clean poster
  • isolation poster
  • isolation room cleaning checklist

2.15 Respiratory illness pathway

All new admissions or transfers with respiratory symptoms must be isolated in a single room.

Undertake lateral flow device (LFD) testing to exclude COVID-19.

Testing is required for any patient who develops symptoms at any time during their inpatient stay.

Ensure fluid repellent surgical mask and eye protection are worn when taking swabs.

2.15.1 COVID-19 lateral flow device positive

  1. Inform Infection Prevention and Control team.
  2. Isolate in a single room: cohort nursing can be undertaken for patients with the same respiratory organism.
  3. Isolate for 5 complete days (the day of the swab is day 0).
  4. No further swabs required.
  5. Isolation can be discontinued at day 6.
  6. If the patient is severely immunocompromised liaise with appropriate clinician and obtain advice from Infection Prevention and Control team if required.

2.15.2 COVID-19 lateral flow device negative

  1. Complete viral swab for influenza.
  2. Clinical review required and obtain other relevant pathology specimens or investigations, for example, sputum, chest x-ray, C-reactive protein (CRP).

2.15.3 Influenza positive

  1. Inform Infection Prevention and Control team.
  2. Isolate in a single room: cohort nursing can be undertaken for patients with the same respiratory organism.
  3. Isolate for 5 complete days (the day of the swab is day 0).
  4. No further swabs required.
  5. Isolation can be discontinued at day 6.
  6. If the patient is severely immunocompromised liaise with appropriate clinician and obtain advice from Infection Prevention and Control team if required.

Patients can be discharged to their own home, at any time in the isolation timeframe, if deemed safe and appropriate.

Patients being discharged to a care home or hospice will require a single lateral flow device test within 48 hours before discharge.

2.16 Respiratory infection

2.16.1 Key points

Respiratory infections are common and can spread easily between both adults and children.

The symptoms of respiratory infections are very similar, and it is not always possible to tell if a patient has COVID-19, influenza or another respiratory infection based on symptoms alone.

Symptoms of respiratory infections include:

  • continuous cough
  • high temperature, fever, or chills
  • loss of, or change in normal sense of taste or smell
  • shortness of breath
  • unexplained tiredness, lack of energy
  • muscle aches or pains that are not due to exercise
  • not wanting to eat or not feeling hungry
  • headache that is unusual or longer lasting than usual
  • sore throat, stuffy or runny nose
  • diarrhoea, feeling sick or being sick

2.16.2 Transmission

Droplet, airborne or by direct or indirect contact.

2.16.3 Incubation period

Between 2 and 14 days depending on the organism.

2.16.4 Period of infectivity

Between 12 hours and 32 days depending on the organism. Some organisms can be infectious before the onset of symptoms.

Information for individual organisms is available in the infection prevention and control manual and A to Z of pathogens.

2.16.5 Infection prevention and control precautions

  • Standard and transmission-based precautions are required.
  • Personal protective equipment must be worn including fluid resistant surgical face masks (FRSM).
  • Eye protection may need to be used if there is a risk of contamination to the eyes.
  • Aerosol generating procedures (AGPs) are considered to have a greater likelihood of producing aerosols compared to coughing. Transmission is by mucous membrane contact or inhalation. FFP3 masks are required. The list of AGPs can be found in the National infection prevention and control manual (NIPCM).
  • Where there are several patients with the same organism or infection, they may be cohort nursed in a bay. Ensure patients are at least two metres apart and keep privacy curtains closed to minimise opportunities for close contact.
  • Isolate the patient until the patient has been asymptomatic for 48 hours.
  • The door to the single room or bay must always remain closed.
  • Treat linen as contaminated (red alginate bag) and waste as infectious (orange waste bags).
  • Twice daily environmental cleaning with Chlor-Clean (1,000ppm
  • Decontaminate patient equipment thoroughly with Clinell Universal wipes.
  • Dedicate a toilet if in a bay or the single room is not ensuite.
  • Terminal clean of the room is required when isolation is discontinued.
  • Community colleagues should plan to visit symptomatic patients last, where possible.
  • Notify the Infection Prevention and Control team of any suspected or confirmed inpatient cases:

Linked to respiratory pathway in quick guides.

2.17 Scabies

2.17.1 Key points

  • Scabies is a contagious skin condition caused by an immune reaction to the mite Sarcoptes scabiei.
  • The typical clinical presentation of infestation is intense itching associated with burrows, nodules and redness.
  • Crusted scabies, also known as Norwegian scabies is a more severe form of scabies with a hyper infestation of lots of scabies mites.
  • Outbreaks are most common in winter and tend to occur in populations in close, prolonged contact.

2.17.2 Symptoms

  • Intense itching, especially at night.
  • A raised rash or spots.
  • The spots may look red but they may be more difficult to see on dark skin, you should be able to feel them.

View images and visual examples of scabies.

2.17.3 Transmission

  • Scabies mites are not able to jump or fly.
  • Transmission usually occurs through direct and prolonged periods of skin-to-skin contact (approximately 10 or more minutes) although it can be spread indirectly through the sharing of towels and bedding.
  • Crusted scabies is highly contagious and can occur even after brief skin-to-skin contact, such as a handshake.

2.17.4 Incubation period

Can be up to 8 weeks following exposure.

2.17.5 Treatment

  • Recommended treatment is permethrin (5%) cream (Lyclear).
  • The cream is usually applied at night and needs to stay on for 24 hours.
  • Follow manufacturer’s instructions.
  • 2 applications of treatment are required 7 days apart.
  • Any contacts should be treated at the same time as the index case.

2.17.6 Infection prevention and control precautions

  • Standard precautions required, although for close contact work long sleeved gowns or sleeve protectors can be used.
  • Isolation for scabies is not usually required after the first course of treatment, however those with crusted scabies are highly contagious and must be isolated until treatment has been completed in full.
  • Treat linen as contaminated (red alginate bag).
  • Patient clothing worn in the period prior to completion of the first 24-hour treatment to be laundered as infectious.
  • Cleaning for scabies: routine cleaning regime will be sufficient.
  • Cleaning for crusted scabies: twice daily environmental cleaning with Chlor-Clean (1,000ppm).
  • Terminal clean of the room required for crusted scabies when isolation is discontinued.
  • Notify the Infection Prevention and Control team of any confirmed inpatient cases:

2.18 Sharps management

2.18.1 Key points

Sharps are responsible for a significant number of injuries to colleagues each year. The safe use and disposal of sharps will reduce the risk of injury and the acquisition of blood-borne viruses (BBVs) to both colleagues and patients. Factors associated with an increased risk of occupationally acquired blood-borne viruses include:

  • deep injury
  • visible blood on the device which caused the injury
  • injury with a needle which had been placed in the source patient’s artery or vein
  • injury with a hollow bore needle
  • advanced progression of human immunodeficiency virus (HIV) related illness in the source patient

The term “sharps” includes items such as needles, scalpels, razor blades, broken glass and any other sharp items that may cause a penetrating injury, laceration or puncture to the skin.

It is recommended that healthcare colleagues who handle sharps or are exposed to blood or body fluids are offered Hepatitis B vaccination.

2.18.2 Legislation

The Health and Safety (Sharp Instruments in Healthcare) Regulations (2013) requires employers to take specific risk control measures to avoid the unnecessary use of sharps.

Where risks are identified, the sharps in health care regulations require the employer to take specific risk control measures.

  1. Where the employer has identified a risk, steps must be taken to avoid the unnecessary use of sharps.
  2. Where it is not reasonably practicable to avoid the use of medical sharps, the sharps regulations require employers to:
    • use safe sharps (incorporating protection mechanisms) where it is reasonably practicable to do so
    • prevent the recapping of needles
    • place secure containers and instructions for the safe disposal of medical sharps close to the work area

Under regulation 8 there is also a duty of employees to notify their employer of a sharps injury as soon as practicable after the event.

2.18.3 Safer sharps

A range of syringes and needles are available with a shield or cover that slides or pivots to cover the needle after use and the following factors should also be considered:

  • the device must not compromise patient care
  • the device must perform reliably
  • the safety mechanism must be an integral part of the safety device, not a separate accessory
  • it should be easy to use and require little change of technique
  • activation of the device must be convenient and allow care given to maintain appropriate control over the procedure
  • the safety mechanism must be deployed before disposal
  • the device must not create other safety hazards or sources of blood exposures
  • single handed or automatic activation is preferred
  • activation must manifest itself by means of an audible, tactile or visual sign to the health professional and is not reversible when activated

2.18.4 Drawing up medication and fluids

Filter straws and blunt filter needles are the accepted practice for the Trust to ensure that practices are as safe as possible and comply with the legislation.

A straw (a sterile long, thin plastic tube) or blunt needle (a needle-like construct with a blunt end and wide bore) must be used to draw up medication and fluids. A medical straw is best for large volumes of liquid and the blunt needle for smaller amounts in ampoules.

As a standard safety measure, blunt needles used for aspirating from “break neck” glass ampoules should have a filter built in, if not a filter straw should be used. Some injections (for example, depot) cannot be drawn up using a blunt filter needle. On these occasions a blunt needle without a filter must be used as indicated in the manufacturer’s instructions.

Some medications are only supplied as prefilled multi dose pen devices for patient self-administration. Where the patient is unable to self-administer and there is no alternative solution colleagues should use the device to administer according to prescriber’s instructions. Where it is necessary to remove the needle to allow for multi dose administration, a suitable needle removal device must be used carefully following manufacturer’s instructions.

2.18.5 Sharps containers

2.18.5.1 Assembly
  • Ensure the colour of the lid and the label match, for example, yellow label, yellow lid.
  • Ensure the sharps container is correctly assembled according to manufacturer’s instructions.
  • Once assembled and prior to putting into use, attempt to pull the lid and container apart to ensure it has been assembled correctly.
  • Colleagues must ensure traceability of sharps containers in case of adverse incident by labelling the sharps container at the time of assembly with:
    • point of origin
    • date
    • name of person assembling the container (print name not signature)
2.18.5.2 Location
  • Must be stored out of reach of patients, the public and others who may be at risk.
  • Must be in a safe and secure position in the clinical area so they cannot be tipped over. Use either a tray or a wall or trolley bracket to secure.
  • Should not be stored on the floor or above shoulder level.
  • Should be placed on a secure, stable surface, at or just above waist height.
  • Must be taken to the point of use to ensure immediate disposal of the sharp after use.
2.18.5.3 Safe use
  • Always ensure that the correct sharps container is used for the segregation and disposal of waste in accordance with the trust’s waste policy.
  • Never overfill a sharps container and leave a sharp protruding out of the container.
  • Damaged sharps containers should be placed in a larger container which should then be locked.
  • Under no circumstances must the contents of one container be decanted into another container.
  • Always use safe sharp systems where available.
  • When not in use the temporary closure mechanism must be deployed.
  • The person using the sharp must dispose of it into a sharps container immediately after use and at the point of use.
  • Sharps must not be left for someone else to clear away or handed to someone else for disposal.

2.18.5.4 Disposal

  • Sharps containers must be disposed of when the manufactures fill line is reached.
  • Ensure sharps container lid is securely locked prior to disposal, following manufacturer’s guidelines.
  • Ensure the sharps container is labelled at the time of disposal with:
    • date of locking
    • name of person locking the container name of person assembling the container (print name not signature)
  • Sharps containers awaiting final disposal must be stored securely in a locked area.

2.18.6 Transporting sharps

Colleagues who travel in the community and carry sharps (used or unused) in the course of their work must follow a safe system of working:

  • the transportation of sharps and sharps containers must be undertaken in a responsible and safe manner
  • it is best practice to use a red transport box with a green label (UN3291) to carry sharps containers and to carry the trust’s transport document
  • sharps containers must be kept out of sight in a locked vehicle
  • check the car at the end of each journey to ensure no sharps have been dropped or spilled in the vehicle
  • lease or pool vehicles must be checked before handing them back by the driver

Where larger sharps containers are required that are too big to put into a transport box the following control measures must be used:

  • the lid must be securely attached to the container
  • the temporary closure must be in place
  • the sharps container must be secured in the boot and not able to roll around
  • the parcel shelf must be in place

2.18.7 Patient’s sharps disposal from own home

Where required colleagues must provide education to patients on the safe use and disposal of sharps, for example, colleagues involved with the needle exchange scheme within the drugs and alcohol service.

Sharps containers must not be disposed of in the household domestic waste stream.

It is the responsibility of the integrated care boards (ICBs) to organise collection and disposal of sharps waste from patients’ homes if the waste is not generated by healthcare providers.

2.18.8 Contact details for local authority needle collection

Doncaster
Rotherham
North Lincolnshire

2.18.9 Sharps found in public areas

Only pick up discarded sharps if you have been trained to do so. If found on trust owned sites estates can be contacted for support as they have equipment required to deal with this safely including anti-stab gloves, litter pickers and sharps containers.

If the sharps are found in a public place or non-trust owned sites, either accessible or inaccessible then report it to the relevant council for the locality:

The incident must be recorded on the incident reporting system.

2.18.10 Contamination injury

Safe systems of work must be adhered to and refer to sharps risk assessment for list of control measures. Please also check with your line manager to determine if there is a service specific risk assessment in your area.

However, there may be occasions when despite all precautions being adhered to colleagues may receive a contamination injury. If this happens the quick guide to contamination injury management procedure must be followed.

2.18.11 Source testing

The source (from whom the contamination occurs) if known, must be informed of the incident and a history obtained which should include details of whether they are known to have a blood-borne virus or belong to a high-risk group (for example, people who inject drugs, people who change their sexual partner frequently). The responsible clinician or emergency department should be informed of the results to aid the risk assessment process in determining the need for treatment.

It is recommended that the source be tested for Hepatitis B, Hepatitis C and HIV with informed consent given. If the source is unable to consent or refuses to give a history or have blood taken the incident will be assessed as unknown source. This must be recorded on SystmOne.

If the source is a patient, the colleague who has sustained the injury should not be involved in the pre-test discussion or the taking of blood samples.

When an incident occurs in which a colleague may have exposed a patient to their blood or another patient’s blood, this should be reported immediately to the responsible clinician for an assessment of the risks involved and to the line manager.

The 24-hour hotline 0330 6600 365 can be contacted for further advice and will arrange an appointment for the colleague to have blood taken for source testing if required.

If the incident occurs in the community setting the patient sustaining the injury (recipient) should be advised to go to the local Emergency Department for assessment.

Pre-blood test and post-blood test counselling is an important part in the management of colleagues and patients who have suffered a contamination injury that may have exposed them to a blood-borne virus. Individuals may need referring to a specialist service for counselling via the trust or their general practitioner.

2.19 Terminal cleaning guide and checklist

Maintaining a high standard of hygiene is essential in preventing the spread of infection in a healthcare setting. Some organisms, including Clostridioides difficile spores, can survive in the environment; therefore, it is vital that decontamination of the environment and equipment is performed to minimise the risks to both patients and staff. When areas are used for the isolation of patients with known or suspected infections, the whole environment will require thorough decontamination after the patient vacates the bed space or room or when isolation precautions have been discontinued. This must include all equipment and medical devices. This is called a terminal clean.

This guidance has been designed for all colleagues who are involved in the cleaning or disinfection and preparation of a bed space or room after an outbreak of infection or once isolation precautions for infectious patients are discontinued. If there is any contamination with blood or body fluids staff must refer to the National Infection Prevention and Control Manual and the blood and body fluid spillage management quick guide.

2.19.1 Key points

  • Hand hygiene must be performed immediately before and after any cleaning activities within the environment.
  • All colleagues must wear appropriate personal protective equipment (PPE) including disposable gloves and plastic aprons. Goggles or face protection may also be required when mixing specific cleaning products or when splashing is anticipated. Refer to control of substances hazardous to health (COSHH) information for further guidance.
  • A combined detergent or chlorine releasing agent of 1,000 parts per million or equivalent must be used to clean the area and equipment. However, some specialist equipment may not tolerate chlorine and colleagues must refer to manufacturer’s guidance in these instances.
  • It is the responsibility of the nurse in charge to ensure that each bed space or room is cleaned thoroughly and to sign part B when satisfied the area has been cleaned to an acceptable standard.
  • If the cleaning is found to be of an unacceptable standard the process must be repeated before a patient can be admitted into the bed space or room and a new form should be used.
  • The nurse in charge must not accept an admission into a bed space or room that has not been thoroughly cleaned and dried.

The forms must be kept on the ward for three months for monitoring and audit purposes.

See appendix C for the terminal clean checklist.

2.20 Toy cleaning guide and checklist

The safe decontamination of toys between use is an essential requirement of routine infection prevention and control (IPC) practice. Although toys may appear to be physically dirty after use, the bacteria isolated from their surfaces are generally non-pathogenic to children with normal immune function and probably no worse than other objects in the environment. However, there is an appreciable (1 in 10) risk of cross-infection with the use of toys in a clinic (McKay and Gillespie 2000).

Toys with hard surfaces are preferred as these are less likely to be contaminated and are more easily cleaned and must be stored in a designated container that is rigid and washable. The schedule will also assist in the identification of damaged toys or those that cannot be easily cleaned.

Toys and play equipment must be decontaminated thoroughly according to the risk of infection (Health Protection Agency 2010). Hard surface toys or play equipment should be cleaned routinely with neutral detergent and warm water and dried thoroughly. Alternatively, Clinell Universal wipes may be used.

Soft toys, including dolls clothes and bean bag covers, must be laundered in a washing machine according to manufactures instructions. Heat labile items should be washed on the hottest cycle possible for that item.

The checklist is designed to provide assurance that cleaning has been carried out in accordance with the necessary requirements. The healthcare professional in charge is responsible for being satisfied with the standard of cleanliness and ensuring the checklist is completed.

2.20.1 Schedule

  • All hard toys and equipment must be cleaned weekly and also during use if they become soiled or contaminated.
  • All soft toys, including dolls clothes and bean bag covers, must be cleaned monthly or earlier if they become soiled or contaminated.
  • Plastic storage containers must be cleaned weekly and thoroughly dried.
  • Sandpits should be covered for protection and the sand must be sieved monthly and replaced every three months. If the sand becomes contaminated or soiled it must be replaced immediately.
  • Containers for water play must be emptied daily and thoroughly cleaned and dried.
  • Water play toys should be non-porous and dried thoroughly after use and stored dry.
  • Play dough or plasticine should be single patient use only.

If play equipment is contaminated with blood or body fluids staff must refer to the policy for the management of blood and body fluid spillages.

2.20.2 References

Mckay I and Gillespie T.A. (2000) Bacterial contamination of children’s toys used in a general practitioner’s surgery. Scott Med Journal Feb:45(1):12-3

See appendix D for the toy cleaning checklist.

2.21 Tuberculosis (TB)

2.21.1 Key points

  • Tuberculosis (TB) is a bacterial infection.
  • There are two forms of tuberculosis: tuberculosis affecting the lungs; and tuberculosis causing infection elsewhere in the body, including the glands, bones and nervous system
  • Extrapulmonary tuberculosis (where pulmonary or laryngeal disease has been excluded) does not require transmission-based precautions, however, if undertaking a procedure on a lesion while the patient is considered infectious, a risk assessment should be completed to determine appropriate patient placement and use of respiratory protective equipment (RPE).
  • If the patient has symptoms, this is called active tuberculosis.
  • If the patient does not have symptoms, this is called latent tuberculosis. In some cases, after infection the bacteria can remain latent in the body for a long time (even lifelong), causing no symptoms of disease. Individuals with latent tuberculosis infection are not infectious; however, under favourable conditions, for example, immunosuppressed, the bacteria can start multiplying (reactivate) and cause clinical disease.

2.21.2 Symptoms

  • Typical symptoms can include extreme tiredness or fatigue, loss of appetite or weight, night sweating and fever.
  • Additional symptoms for pulmonary tuberculosis include increasing breathlessness and a persistent productive cough lasting more than 3 weeks, which may be bloody.
  • Additional symptoms of extrapulmonary tuberculosis vary but may include persistently swollen glands, abdominal pain, pain and loss of movement in an affected bone or joint, confusion, persistent headache and seizures.

2.21.3 Incubation period

  • Between 14 and 70 days.
  • Immunocompromised individuals may have a shorter incubation period.
  • Those with latent tuberculosis infections may never develop tuberculosis disease.

2.21.4 Period of infectivity

  • While symptomatic and for 2 to 4 weeks after starting antibiotic treatment.
  • While viable bacilli are discharged in sputum.

2.21.5 Treatment for tuberculosis

Standard anti-tuberculosis treatment consists of a combination of 4 different antibiotics, usually taken daily for a minimum 6-month period

Multidrug-resistant tuberculosis (MDR TB) and extensively drug resistant tuberculosis (XDR TB), these are difficult to treat. Advice will be given by the tuberculosis nurse specialist or chest physician.

2.21.6 Infection prevention and control precautions

  • Single room isolation with door closed on suspected or confirmed smear positive pulmonary or laryngeal tuberculosis. Community patients will be encouraged to remain at home whilst infectious.
  • Follow standard precautions for extrapulmonary tuberculosis (where pulmonary or laryngeal disease has been excluded).
  • Follow transmission-based precautions for airborne spread if undertaking a procedure on a lesion while the patient is considered infectious.
  • FFP3 masks or hoods for routine care and aerosol generating procedures (AGPs).
  • Treat linen as contaminated (red alginate bag) and waste as infectious (orange waste bag).
  • Decontamination of the environment in hospital, use a cleaning and disinfection product, for example, Chlor-Clean (1,000ppm) at least once a day.
  • Decontamination of medical devices or equipment in hospital and community, use a high-performance disinfectant, for example, Clinell peracetic acid wipes.
  • The tuberculosis specialist nurse or chest physician can give specialist advice for the individual patient:
  • Notify the Infection Prevention and Control team of any confirmed inpatient cases:

2.22 Transportation of sharps and specimens

Do you obtain specimens for transportation to local laboratory? If yes, follow the steps below.

  1. All packaged specimens must be transported in a box with a yellow label (UN3373), this is a legal requirement.
  2. Place specimen container into request form bag.
  3. Place request form bags containing specimens into a transportation bag (tertiary receptacle), which contains absorbent material.
  4. If using more than one bag, separate bloods from non-blood specimens.
  5. Bagged or sharps waste cannot be transported in this box.

Do you carry out sharps procedures? If yes, follow the steps below.

  1. It is best practice to use a transport box with a green label to transport sharps containers, however there may be occasions where bigger sharps containers are required that do not fit into the transport box and control measures are required:.
  2. Container must be assembled correctly with the lid secured.
  3. Temporary closure must be in place.
  4. The container must be secure in the boot and not able to roll around.
  5. The parcel shelf must be in place.

The trust’s transport document should be carried in all vehicles carrying sharps.

Bagged waste can also be transported in this box.

If you use the red insulated bag to transport equipment the sharps container can be placed inside the bag.

2.23 Ward outbreak

2.23.1 Key points

An outbreak is defined as:

  • an incident in which two or more people experience a similar illness linked in time or place
  • a greater than expected rate of infection compared with the usual background rate for the place and time when the outbreak has occurred

2.23.2 If outbreak suspected

  • Escalate to service manager as per usual protocols.
  • Isolate patients where possible.
  • Obtain appropriate specimens for laboratory examination
  • Inform the medic or who else responsible for the care of the affected patients.
  • Contact the Infection Prevention and Control team at the earliest opportunity for advice:

If urgent specialist advice is required out of office hours or weekends and bank holidays this must be escalated through the normal channels and a decision made by the on-call manager if contacting the Consultant Microbiologist is required. If it is, please contact the Microbiologist for the locality the patient is in:

  • Doncaster and North Lincolnshire areas contact Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTHFT) on 01302 366 666.
  • Rotherham area contact the Rotherham NHS Foundation Trust (TRFT) on 01709 820 000.

2.23.3 Infection prevention and control precautions

  • Refer to National infection prevention and control manual (NIPCM) for guidance relating to transmission based precautions.
  • Ensure doors to isolation rooms are kept closed. If patient safety is compromised, a documented risk assessment must be completed and reviewed at every shift.
  • Ensure appropriate signage is displayed on the door to the isolation room or bay without compromising patient confidentiality.
  • Ensure adequate provision and appropriate use of personal protective equipment (PPE).
  • Avoid moving patients unless clinically necessary.
  • Avoid non-essential treatments, therapies and appointments. For urgent, essential treatments the receiving organisation or department and transport provider must be informed that isolation precautions are in place.
  • Undertake a terminal clean of rooms once isolation is completed or the patient is discharged or transferred elsewhere.

2.23.4 Refer to supporting documents

  • Chlor-Clean poster.
  • Terminal cleaning guide and checklist, see appendix C.
  • Isolation poster.
  • Isolation room cleaning checklist.

Linked to patient placement or assessment of infection risk quick Guide

3 Supporting documents

See supporting documents (staff access only):

4 Pathology specimen handbooks

5 Contact information

Advice can be obtained from:

  • the Infection Prevention and Control team on:
  • the consultant microbiologist for urgent or out of hours advice, please escalate through usual processes prior to contacting to ascertain if appropriate, if urgent or out of hours advice is required then contact the microbiologist for the locality the patient is in:
    • Doncaster and North Lincolnshire areas contact Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTHFT) on 01302 366 666.
    • Rotherham area contact The Rotherham NHS Foundation Trust (TRFT) on 01709 820 000.
  • the UK Health Security Agency (UKSHA) on 0300 3030 234. It will automatically re-direct staff during out of hours

6 Notifiable diseases and causative organisms

Registered medical practitioners (RMPs) attending a patient must notify the United Kingdom Health Security Agency (UKHSA) when they have “reasonable grounds for suspecting” that the patient has a notifiable disease and causative organism.

The most current guidance and forms to undertake this can be found on the notifiable diseases and how to report them.

8 Training

All staff must undertake 000 infection prevention and control level 1 training every three years via e-learning. This will be recorded on the electronic staff record (ESR) system.

Clinical staff must undertake 000 infection prevention and control level 2 training annually (completing level 2 training will update the level 1 training on your matrix). This training can be completed via e-learning. This will be recorded on the electronic staff record system.

Specific topics level 3, by request directly to the Infection Prevention and Control team. This training is undertaken as requested, will be delivered face to face by the Infection Prevention and Control team and recorded on the electronic staff record system.

9 Monitoring arrangements

Non adherence to procedures will be monitored via IR1 reports, post infection reviews, outbreak reports, clinical visits and clinical audit. This will be undertaken by managers or matrons and the Infection Prevention and Control team. This will be reported to the infection prevention and control committee (IPCC) on a quarterly basis.

10 Appendices

10.1 Appendix A discharge cleaning checklist for non-infectious patients

Refer to appendix A: discharge cleaning checklist for non-infectious patients (staff access only).

10.2 Appendix B visual or cleaning check for clinical staff

Refer to appendix B: visual or cleaning check for clinical staff (staff access only).

10.3 Appendix C terminal clean checklist

Refer to appendix C: terminal clean checklist (staff access only).

10.4 Appendix D toy cleaning checklist

Refer to appendix D: toy cleaning checklist (staff access only).

Document control

  • Version: 6.3.
  • Unique reference number: 451.
  • Approved by: clinical policy review and approval group.
  • Date approved: 4 March 2025.
  • Name of originator or author: senior infection prevention and control nurse specialist.
  • Name of responsible individual: chief nurse.
  • Date issued: 11 August 2025.
  • Review date: 30 April 2027.

Page last reviewed: November 11, 2025
Next review due: November 11, 2026

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