Infection Control Manual

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Mercy University Hospital
Cork.
Infection Control
Manual
Nellie Bambury, CNS Infection Control
Reviewed February 2006
Index of Contents
1. Mercy University Hospital Infection Control Manual
1.1 Infection Control Mission Statement
2. Infection Control Programme
2.1 Responsibility/Accountability for Infection Control in MUH.
2.2 Infection Control Committee Meetings
3. Criteria for Reporting Infection
3.1 Reporting to Infection Control
3.2 Reporting by Catering Staff
3.3 Reporting to Public Health
3.4 Table of Diseases to report to Public Health
3.5 Outbreak of Hospital Infection
4. Hand Washing & Hand Disinfection
5. MUH Colour Coding Systems
5.1 “Special Risk” Infection Coding (Stickers)
5.2 Colour Coded Isolation Signs
5.3 Colour Coding for cleaning cloths/brushes/buckets etc.
6. Asepsis/ Aseptic Technique
6.1 Principles
6.2 Preparation of Trolley for Aseptic Technique
6.3 Preparation of the Environment for Aseptic Technique
7. Prevention of Hospital Acquired Infection
7.1 Wound Care
7.2 Urinary Incontinence/ Catheter Care
7.3 Prevention of Infections associated with IV Therapy
7.4 Management of Parental Nutrition
7.5 Prevention of Infection associated with Epidural Therapy
8. Body Substance Isolation
8.1 Background to Blood/ Body Substance Isolation
8.2 Standard Precautions
9. Isolation
9.1 Introduction
9.2 Guidelines for Isolation in the Mercy University Hospital
9.3 Rationale for Transmission Based Precautions
9.4 Synopsis of Types of Precautions & Patients requiring the
Precautions
9.5 Protective Isolation
9.6 Protective Isolation in St. Anne’s Leukaemic Unit (Draft)
9.7 Colour Coding for Isolation Rooms/Areas
9.8 Strict Isolation
9.9 Table- Isolation Categories - Methods for Specific Infections
10. Precautions for Specific Infections
10.1 Infectious Diarrhoea
10.2 Pulmonary Tuberculosis
10.3 Bronchoscopy (TB)
10.4 Meningitis
10.5 Clostridia difficile Infection
10.6 Hepatitis B, C/HIV Infections
10.7 Viral Haemorrhagic Fevers
10.8 Antibiotic Resistant Infections
10.9 Methicillin Resistant Staphylococcus Aureus (MRSA)
10.9a MRSA Decontamination Protocol
10.10 Multiple Resistant Gram Negative Rods (ESBLs)
10.11 Vancomycin Resistant Enterococci (VRE)
10.12 Norovirus (Winter Vomiting)
11. Laying out of bodies with dangerous communicable diseases
12. Cleaning /Disinfection Policy
12.1 Introduction
12.2 Methods of Decontamination
12.3 Chemical Disinfectants
12.4 Control of Substances Hazardous to Health (COSHH)
12.5 Selection of Disinfectant/ Cleansers/Antiseptics/Disinfectants of
choice in the MUH
12.6 Table- Summary of Methods for cleaning /disinfection of
equipment/environment- routine procedure
12.7 Guidelines for care/cleaning of mattresses/pillows
12.8 Guidelines for cleaning of Manual Handling Equipment
12.9 Interim Guidelines for cleaning/changing nebulizers, oxygen
masks, nasal prongs
12.10 MUH Guidelines for contract cleaning of the hospital
environment
12.11 Guidelines for dealing with spillage
12.12 Equipment Decontamination Cert
.13. Waste Management
13.1 Introduction
13.2 Categories of waste
13.3 Table- Coding system for bags/bins in use for waste disposal
and laundry arrangement
13.4 Guidelines for safe handling/disposal of clinical waste
13.5 Guidelines for safe use, handling and disposal of sharps
14. Collection of specimens for laboratory examination
MERCY UNIVERSITY HOSPITAL
Reference No.: Policies
1- 14
Policy Name: Infection Control Manual
Page(s) 1 of
Department: Infection Control Effective from : Feb. 2005
Prepared by: Nellie Bambury, CNS Infection
Control
Date revised: Feb. 2006
Approved by:Executuive Management Board
Ms. M. Dunnion, Nursing Director
Dr. J. Clair, Microbiologist
Stakeholders:Mercy University HospitalStaff, Patients, Visitors
Revision History
Date Changes By Version
POLICY STATEMENT:
To establish a set of Infection Control Guidelines which are scientifically valid
and yet relevant to the needs of the Mercy University Hospital, leading to
improvement in preventative measures and patient outcome.
OBJECTIVES:
 To have recognised, organised ways of carrying out procedures in
accordance with high standards and to keep these standards uniform
throughout if possible.
 That all staff will have access to evidence based practice and that it will
serve as a good educational tool for staff.
 That it will be reviewed yearly and in the interim to issue additional
guidelines as necessary.
 Most importantly that the outcome will benefit our patients/clients.
1.1 Mercy University Hospital Mission
Statement
We are here to serve our patients, their families and friends, our fellow
workers and the wide community. We must protect them (and in doing so,
protect ourselves) from infectious diseases by formulating policies and
working to procedures, in accordance with the highest standards of medical
care.
We are committed to the compassionate care of those marginalized due to
infectious diseases. We must be ready to respond t the challenge of new
diseases. While it necessary to follow outlined procedures for patients
isolated due to infectious diseases, these patients will experience
individualized care, rather than minimized care and alienation.
We set standards which cover risk management and organisational controls
that are seen as firmly underpinning clinical governance. We have a statutory
duty to seek quality improvement by ensuring that service performance and
clinical quality are integrated. The value and quality elements of infection
control activities feature strongly in risk management and clinical governance
and control assurance programmes. We partake in surveillance and must
look at our patients as the centre focus of our mission.
2. Mercy University Hospital
Infection Control Programme
The core business of an Infection control Programme or service is to identify
and manage risks of infection to patients, staff and visitors. The outcome of
the service contributes to an organisation’s overall strategy for delivering low
risk, high quality care (Horton & Parker 1997)
2.1 Responsibility & Accountability for Infection
Control in the Mercy University Hospital
NOTE: BASED ON THE ABOVE IT IS THE POLICY OF THE MERCY
UNIVERSITY HOSPITAL THAT EACH AND EVERY EMPLOYEE OF THE
HOSPITAL HAS A RESPONSIBILITY TOWARDS CONTROLLING
INFECTION AND EDUCATED TOWARDS REMEBERING AT ALL TIMES
THAT IN DOING SO WE MUST NOT FORGET THAT OUR PATIENT MUST
ALWAYS BE OUR MAIN FOCUS.
(a) MUH Core Infection Control Team
The core Infection control Team is responsible for the day to day running of
the Infection Control Programme. Their role is to ensure that an effective
infection Control Programme has been planned, including surveillance of
Health Associated Infections and to co-ordinate it’s implementation and
evaluate the impact of such measures. Whilst the team will actively participate
in these areas, some aspects of the Infection Control may fall under the remit
of others. In such cases the Infection Control Team will provide advice and
direction, ultimately ensuring that all tasks reach completion. In summary
therefore the role of the Core Infection control Team is  Production of an Infection Control Programme with clearly defined
objectives.
 Production of written policies /procedures on Infection Control,
including update and evaluation. Departments i.e. Theatre, Endoscopy,
Out Patients, Pulmonary Function etc. have guidelines local to their
departments, drawn up in con junction with Infection Control.
 Surveillance – Participation in surveillance of all aspects of infection
and provide data which should be evaluated to allow for any change in
practice or allocation of resource to prevent Hospital Acquired
Infections and focusing on the resistant organisms which pose a
particular threat (see Surveillance Section – H Drive- Infection Control
folder
 Participation in audit to allow for a systemic and more critical look at
the effectiveness of the Infection Control service (Damani 1997).
MUH Core Infection Control Team
Dr. J. Clair
Microbiologist
Bleep 6656, Ext. 5718 (Hospital)
24 hr. 7 days
Ms. M. Coughlan
Surveillance Scientist
Bacteriology Dept.
Ext. 5579/519
Ms. N. Bambury
CNS Infection Control
Bleep 6625, Ext. 5717
Ms. C. O Neill
CNM2 Infection Control (Surveillance)
Bleep 6583, Ext. 5578
Ms. J.A. Buckley
Pharmacist
Tel. 5632
Monday- Friday.
Provisions are made for 24-hour access to the Core Infection Control
Team. The Microbiologist may be contacted (out of hours) by the
Medical staff/Director of Nursing/ Assistant Director of Nursing and the
Infection Control Nurses may be contacted (out of hours) by the Director
of Nursing/ Assistant Director of Nursing.
(b) Management Responsibility
It is the responsibility of the Chief Executive Officer (CEO) of the hospital to
ensure that adequate arrangements are made to control hospital infection.
The chief Executive Officer with his colleagues on the Executive Management
Board (EMB) is responsible for implementing infection control policies and
procedures at a management level.
In addition to the overall official responsibilities of the Chief Executive Officer
and the Executive Management Board, the Nursing Management Structure
within the hospital must ensure that proper infection control policies,
procedures and recommendations are implemented and supported through
their directorate.
(c) Responsibility at Ward/Dept. Level
 At ward level the overall responsibility lies with the Senior Nurse
Manager (CNM2)
 Clinical Nurse Managers 1 (CNM1s) must also take responsibility
 Patient allocated nurses must take responsibility for their allocated
patients/areas.
 Senior Health Care Workers (HCWs) such as Medical Consultants,
Managers in the Allied Health Professional Groups- Catering, Domestic
Services, Technical Services etc. must act as role models and actively
promote infection control.
2.2 Infection Control Meetings
Daily/Weekly Meetings
The Core Infection Control Team meets on a weekly basis, in addition to the
nurse’s daily contact/consultation with the Microbiologist.
Infection Control Committee Meetings
“A root branch shift towards prevention of infection will be needed at all levels
if hospital acquired infection is to be kept under control. That requires
commitment from everyone involved and a philosophy that prevention is
everybody’s business, not just the specialists” (NAO 2000).
(A) Infection Control Committee meetings are held monthly. The
Microbiologist acts as Chairperson and the Infection Control Nurse as
secretary of the group. A representative from each Department in the
hospital is invited, preferably Staff Nurses representing the wards.
(B) In addition, twice annually, the Committee draws its membership from
the Chief Executive or a senior member of the management team
(Wilson 2002), Director of Nursing, Medical Consultant /Senior Nursing
representatives, Occupational Health, Engineering, Pharmacy, and
Supplies etc. The Chairman of the Committee is usually the
Microbiologist. Non Committee members should be invited to attend
Committee meetings where problems concerning their own
Departments are to be discussed. The function of this twice yearly
meeting is:
 That of supporting the development of an effective Infection
Control Programme.
 It is important that the members of the Committee voice areas of
concern and problems relating to either Infection Control
practice or policy, in particular that the Committee highlights
areas, which have not been addressed within their own sphere
of responsibility. The Committee should discuss implications,
approve Infection Control Policies and assist in implementation
and audit as a core process in quality management. Above all,
to advise when major decisions are to be made and to allocate
funding when/where necessary.
 The Committee will be given reports on current problems and on
the incidence of infection and evaluation of other reports
involving infection.
Emergency meetings may be necessary in the event of an
outbreak/major disaster (Ayliffe et al (2002))
3. Criteria for Reporting Infection
3.1 Reporting to Infection Control
It is important that the following should be reported to Infection Control
during Ward rounds or throughout the day as problems arise.
 Any single infection identified (positive or presumed positive) of a
serious specific nature e.g. Hepatitis/other viruses, T.B., Meningitis,
MRSA, C. difficile, ESBLs etc.
 Suspected gastro-enteric infection such as vomiting/diarrhoea,
especially involving more than one patient in a defined area.
 Any infected IV sites, heplock sites etc.
 Cellulitis.
 Any Hospital acquired infections (that is any infection not present or
incubating at the time of admission but occurring 72 hours later.
 Childhood infectious diseases e.g. measles, varicella, gastro-enteric
symptoms, P.U.O., etc. and infestations such as scabies, lice, fleas,
mice, cockroaches etc.
 The discharge/death of any “high risk” patient.
 More than one infection occurring within the same organism or
amongst the patients of one consultant, suggesting the beginning of an
outbreak.
 Re-admission of patients with post-op sepsis.
 Re- admission of a previously known MRSA affected patient.
 Any acute or unresolving infection, especially in “high risk” areas, e.g.
ICU, Theatre, Paediatric Unit, Leukaemia Unit, Oncology Unit, etc.
 Pyrexia of unknown origins (PUOs)
3.2 Reporting by Catering Staff
Food handlers should report any infections to their catering supervisor who, in
turn should report to Infection Control/Occupational Health. “Its importance
needs repeated emphasis; at pre-employment (with handout), at refresher
training and annually. Appropriate translation for non-nationals should be an
indispensable component. Reporting for food handler’s merits concerted,
ongoing focus. Training for managers is especially significant” (NDSC 2004).
 Sore throat with fever.
 Infected skin lesions (i.e. boil, infected wound) or cuts on exposed body
parts (hand, arm, face, neck or scalp).
 Pus containing discharges from the eyes, ears, nose or mouth/gums.
 Gastrointestinal illness- Gastrointestinal illness while on holiday,
especially overseas, should always be reported on return.
3.3. Reporting to Public Health Authority
Recent change has been made to the notifiable disease list. These changes
are based on recommendations of the Scientific Advisory Committee (SAC) of
the National Health Surveillance Centre (Surveillance, 2003 (NHSC)). A
subgroup of the SAC carried out a review, which involved extensive
consultation with key parties, at the request of the Department of Health and
Children.
The changes to the list of notifiable diseases are consistent with a European
Commission decision on the communicable diseases to be covered by the
community network (Decision No. 2000/96/EC, under Decision No.
2119/98/EC of the European Parliament and of the Council).
Under the amended regulations, “unusual clusters or changing patterns of
illness that may be of public health concern must also be reported. This is an
important development, particularly in the context of any potential deliberate
release of biological agents” (NDSC E-I 2004).
Infectious Disease Notification Booklets are available on all departments
throughout the Hospital and further supplies available from Infection control.
3.4 TABLE A
DISEASES AND THEIR RESPECTIVE CAUSATIVE
PATHOGENS SPECIFIED TO BE INFECTIOUS
DISEASES (Under the Disease Amendment (No. 3)
Regulations 2003 (S.I. No. 707 of 2003) NDSC).
DISEASE CAUSATIVE PATHOGEN
Acute anterior poliomyelitis Polio Virus
Acute infectious Gastroenteritis
Ano-genital warts
Anthrax Bacillus anthracis
Bacillus cereus food-borne
infection/intoxication
Bacillus cereus
Bacterial meningitis (not
otherwise specified)
Botulism Clostridium botulinum
Brucellosis Brucella species
Campylobacter infection Campylobacter species
Chancroid Haemophilus ducreyl
Chlamydia trachomatis
infection (genital)
Chlamydia trachomatis
Cholera Vibreo cholerae
Clostridium perfringens (type A
food borne disease)
Chlostridium perfringens
Creutzfeldt & New Variant
Jakob disease CJD & nvCJD
Cryptosporidiosis Cyptosporidium parvum
Diptheria Cornebacterium diptheriae
Echinococcosis Echinoccosis species
Enterococcal bacteraemia Enterococcus species (blood)
Enterohaemorrhagic E-coli E-coli of sero group known to be toxin
producing
E-coli infection (invasive E-coli (Blood, CSF)
Giardiasis Giardia lambia
Gonorrhoea Neisseria gonorrhoea
Granuloma inguinale
Haemophilus influenza
(invasive)
Haemophilus influenza (blood, CSF
or other normally sterile site)
Hepatitis A (acute) Hapatitis A virus
Hepatitis B (acute & chronic) Hepatitis B virus
Hepatitis C Hepatitis C virus
Herpes simplex (genital) Herpes simplex virus
Influenza Influenza A & B virus
Legionellosis Legionella species
Leptospirosis Leptospira species
Listeriosis Listeria Monocytogenes
Lymphogranuloma venereum
Malaria Plasmodium falciparum, vivax, ovale,
malariae
Measles Measles virus
Meningococcal disease Neisseria meningitidis
Mumps Mumps virus
Non-specific urethritis
Norovirus infection Norovirus
Paratyphoid Salmonella paratyphi
Pertussis Bordetella pertussis
Plague Yersinia pestis
Q Fever Coxiella buretii
Rabies Rabies virus
Rubella Rubella virus
Slamonellosis Salmonella enterica
Severe Acute Respiratory
Distress Syndrome (SARS)
SARS – associated coronavirus
Shigellosis Shigella species
Smallpox Variola virus
Staphylococcal food poisoning Enteroxigenic Staphylococcus aureus
Staphylococcus
aureusbacteraemia
Staphylococcus aureus (blood)
Streptococcus A infection
(invasive)
Streptococcus pyrogenes (blood,
CSF or other normally sterile sites)
Streptococcus pneumoniae
infection (invasive)
Streptococcus pneumoniae (blood,
CSF or other normally sterile sites)
Syphilis Treponema pallidum
Tetanus Clostridium tetani
Toxoplasmosis Toxoplasma gondii
Trichinosis Trichinella species
Trichomoniasis Trichomnas vaginalis
Tuberculosis Mycobacterium tuberculosis complex
Tularemia Francisella tularenis
Typhoid Salmonella typhi
Typhus Rickettsia prowazekii
Viral encephalitis, Viral
Meningitis
Viral Haemorrhagic Fevers Lassa VIRUS, Marburg virus, Ebola
virus, Crimean-Congo haemorrhagic
fever virus
Yellow Fever Yellow Fever Virus
Yersinosis Yersinia enterocolitica, Yersinia
pseudotuberculosis
There is a statutory obligation for Clinicians to report all of the above to
Public Health. In some instances e.g. Meningitis, even though it may
not be a definite diagnosis and treatment has commenced, it should be
reported by phone provisionally.
Notification of a Suspected Outbreak
Suspected outbreaks of infection should be immediately reported to the
Infection Control Team.
3.5 Investigation of a Suspected Outbreak
The Infection Control Team should investigate the suspected outbreak
and initiate appropriate routine infection control measures. If the
outbreak is deemed major, hospital management should be notified. A
major outbreak is not dependent so much on numbers of people
affected but rather the nature of the infectious agent, the pathogenicity
and the transmissibility of the organism. The Microbiologist should,
therefore, determine the occurrence of a major outbreak and any
outbreak should be regarded as major, if there are exceptional
implications for Hospital resources e.g. ward closures or possible
media attention.
In the event of a major outbreak the Infection Control Team should
meet as an emergency with Infection Control Committee and draft
others as deemed necessary, determined by the nature of the
outbreak, and to include as appropriate:
 Director of Nursing/Assistant Director of Nursing
 Hospital Manager
 Infection Control Team
 Ward Sister - caring for infected patients
 Consultant - treating infected patients
 Director of Support Services
 Health Care Assistant Manager
 Other – as deemed necessary.
Function of the Emergency Committee
 Co-ordinate nursing/medical care of patients.
 Implement/monitor infection control measures.
 Investigate the cause/extent of the outbreak.
 Provide information/guidelines for staff/hospital departments and
for patients relatives where appropriate.
 Ensure that actions required are taken and that adequate
resources are available to deal with the outbreak.
 Co-ordinate communication with outside agencies including the
media and Community Health Service; NB – Only Hospital
Management or someone delegated by Management should
communicate with the media (See Mercy University Hospital
Nursing & Personnel Policies).
End of Outbreak
When the outbreak has been controlled, a final meeting of the group
should be held to:
(A) Review the experience of all participants in management of
outbreak.
(B) Identify any shortfalls/difficulties that were encountered.
(C) Revise the outbreak control plan in accordance with results and
recommend, if necessary, structural or procedural improvements
which would reduce the chances of recurrence and write a
coherent, final report. This report should be presented to the
Infection Control Committee, to the Departments involved in the
outbreak, to management etc. It should include details of the
cause of the outbreak, control measures undertaken and their
effectiveness, the number of cases and recommendations to
prevent future occurrences (Horton, Parker 2002).
4. Hand Washing/Hand Disinfection
What! Will these hands ne’er be clean?
William Shakespeare (Macbeth)
4.1 Introduction
The evidence for supporting a link between hand washing and contact
transmission of infection is dated in history. It was first established by Oliver
Wendell Holmes in the US (1843) and in Europe by Semmelweiss (1861)
(Horton, 2002). It was again well supported by Larson (1981). They both
showed a drop in the rate of puerperal sepsis and its associated mortality
when medical staff washed their hands between examining women during
childbirth.
Hand washing is one of the most important procedures for preventing the
spread of disease. Hands are the principle route by which cross infection
occurs (Elliot, 1992). Hand washing is an infection control practice with a
clearly demonstrated efficacy and remains the corner stone of efforts to
reduce the spread of organisms. The current spread of antibiotic-resistant
organisms can be attributed, at least in part, to a failure by health care
professionals to wash their hands either as often or as efficiently as the
situation requires (Heenan, 1996). The National Prevalence Studies
(Emmerson et al, 1999) demonstrated that 10% of patients admitted to
hospital acquire a hospital infection. A Hospital Acquired Infection (HAI) is
any infection not present or incubating at the time of admission but occurs 72
hours later.
The Strategy for the Control of Antimicrobial Resistance in Ireland
(SARI) was launched in 2001 by the then Minister for Health and it provided a
blue print for the prevention and control of antimicrobial resistance. Amongst
its recommendations were the development of guidelines in relation to
infection control in the hospital and in the community setting and hand
hygiene is the key component of this.
As part of the remit under SARI National Guidelines for Hand Hygiene in
Irish Health Care Settings were introduced in 2005. All staff members
should be familiar with this document and use as an adjunct to MUH
Guidelines.
It is available
 In the Mercy Hospital Library
 From Health Protection Surveillance Centre,
25-27 Middle Gardiner Street, Dublin 1.
Tel. +353 1 876 5300
 Fax +353 1 856 1299
 Email info@hpsc.ie www.hpsc.ie
If any difficulties are encountered in obtaining a copy please contact
infection control.
Corporate responsibility for implementation of these guidelines lies with the
Chief Executive Officer (CEO) but Senior Health Care Workers (HWCs) such
as, Consultants, Nurse Managers and Managers in the Allied Health
Professional groups, Catering, Domestic and Technical Services must act as
role models and actively promote hand hygiene (Larson et al, 1982 & SARI,
2004).
All sinks throughout the Hospital MUST at all times be fitted with wall mounted
dispenser soap and paper towel dispensers. This also applies to bathrooms,
toilets, showers etc.
Sinks in clinical areas MUST be fitted with wall mounted dispenser soap,
paper towel dispensers, antiseptic hand wash ie. Hydrex, alcohol gel ie
Spirogel and Prometic XL Cream.
In addition all entrances to wards/other clinical areas should have wall
mounted alcohol gel ie Spirogel, at the disposal of staff and visitors.
Alcohol gel MUST always be available outside the door of isolation rooms
4.2 What Are Your Hands Carrying?
Micro-organisms found on the skin include two categories:
(A) Resident Micro-Organisms (normal flora)
These are usually deep seated in the epidermis, are not readily
removed and do not readily cause infections. However, during
surgery/invasive procedures, they may enter deep tissues and
establish an infection.
(B) Transient Micro-Organisms
These are organisms that are not part of the normal flora and represent
recent contamination, that usually survives for a limited period of time.
They are acquired during contact with the infected/colonized patient or
the environment and are easily removed by a good hand washing
technique. They include most of the organisms responsible for cross
infection, e.g. Gram-negative bacilli (E.coli, Klebsiella, Pseudomonas
spp, Salmonella spp.), Staph aureus, MRSA and viruses e.g.
rotaviruses (Damani, N.N. (1997)).
All members of Hospital staff and patients should wash their
hands:
 Immediately after using the toilet
 Immediately before a meal
 As soon as hands are visibly soiled
In addition, special groups of staff should wash their hands at other times also
– Clinicians/Nurses/Carers/Physiotherapists/Porters etc.
4.4 The Different Levels of Hand Hygiene
There are three recommended levels of Hand Hygiene to ensure that the
hand hygiene performed is suitable for the task being undertaken. The
efficacy of hand hygiene will depend on application of an adequate volume of
a suitable hand hygiene agent with good technique for the correct duration of
time, and finally ensuring that hands are dried properly.
(A) Social Hand Hygiene- Routine Hand Washing
The aim of social (routine) hand washing with soap and warm water is to
remove dirt and organic material, dead skin and most transient organisms. On
visibly clean hands it can be undertaken using an alcohol hand rub, and this
will remove transient organisms.
Social hand washing involves washing hands with a good quality liquid
dispenser soap and warm water for at least 15 seconds. The parts of the hand
that can be missed with improper hand washing are the thumbs, back of the
hands, back of the fingers, under the nails and the wrists (see table 4.4)
Social Hand Hygiene with soap and warm water, or an alcohol hand rub, which is
used on visibly clean hands- indications for use
 When hands are visibly contaminated with dirt, soil or organic materialalways wash hands when visibly contaminated.
 At the beginning and end of the shift
 Before/after each patient contact
 After moving from a contaminated to a clean area during care of an
individual patient
 Before/after wearing gloves.
 After handling contaminated equipment, material or contaminated
environment.
 Before preparing/handling food (soap only as alcohol may taint the food)
 After covering your mouth while coughing/sneezing.
 After blowing your nose
 After using the toilet
(B) Antiseptic Hand Hygiene
Antiseptic hand disinfection with an antiseptic hand wash agent ie Hydrex is
generally carried out for aseptic procedures on the ward and for areas of
Isolation. Hygienic hand disinfection will remove and kill most transient microorganisms- indications for use
 During outbreaks of infection where contact with blood/body fluids or
situations where microbial contamination is likely to occur.
 In “high” risk areas e.g. isolation, ICU etc.
 Before/after performing an invasive procedure
 Before/after wound care, urethral or IV catheters etc.
(C) Surgical Hand Hygiene
Surgical hand washing requires the removal and killing of transient microorganisms and substantial reduction and suppuration of the resident flora of
the surgical team for the duration of the operation, in case a surgical glove is
punctured/torn. Ensure that fingernails are kept short and clean. Wrist
watches and jewellery MUST be removed before surgical hand disinfection
(Bernthal E, 1997).
4.5 How to Wash Your Hands- Correct Technique
Hand washing with a good technique covering all surfaces of the hands at the
right time is more important than the agent used or the length of time of hand
washing. DO NOT use nailbrushes on the wards. Nailbrushes (soft, sterile)
used ONLY for Surgical Scrub.
(A) Preparation Check List
 Do keep nails short and pay special attention to them when washing
your hands – most bacteria on the hands come from beneath the finger
nails.
 Do not wear nail varnish or false nails. There is evidence that bacteria
may harbour in the subungual areas of the hands in high
concentrations, and that chipped nail varnish and artificial nails have
been epidemiologically linked to outbreaks (Hedderwick 2000). One
study found that 40% of staff wearing rings harboured gram negative
bacilli i.e. Acinetobacter, Klebsiella, e. clocae etc. under rings and that
some carried the same organisms for several months CDC (2002).
 Do not wear ridged/stoned rings- for safety reasons as well as the
Infection Control aspect of it. The total bacterial counts are higher
when rings are worn. Also, rings interfere with thorough hand washing
and may pierce gloves. It is also more difficult to put on gloves (ICNA,
1997). Studies have demonstrated that skin underneath rings is more
heavily colonized than comparable areas of skin on fingers without
rings. Ridged/stoned rings may also be a source of injury to the patient.
 Remove wrist watches and roll up or remove long sleeved clothing –
the wrists should also be included when washing the hands (Gould,
1994) and it may also be necessary to wash the forearms if they are
likely to have been contaminated.
(B) Sequence of Events
 Wet hands under running water
 Dispense soap/antiseptic (5mls approx) into a cupped hand
 Hand wash for 10-15 seconds vigorously and thoroughly without adding
more water.
 Rinse hands thoroughly under running water.
 Dry hands properly with a disposable towel. Drying is equally as
important as washing – bacteria thrive in moisture.
(C) Six step hand washing technique was devised by Ayliffe et
al. Each step consists of five strokes forward and five backward.
Remember to wash the wrists of both hands
(D) Areas most, less, not missed when hand washing.
(E) Alcohol Hand Rub Technique
Follow the six steps already described except instead of using water dispense
3mls of the gel into the palm of the hand. Remember to rub the wrists of
both hands.
Alcohol Gels
These are alternative methods of hand disinfection as already described
(section 4.5) They do not cleanse and, therefore it is important that hands
should first be cleaned with soap and water, in the presence of visible
contamination. They are particularly useful in areas where a wash hand basin
is not readily available, or when return to a wash hand basin is impractical e.g.
during a ward round, in between bed making ,during a dressing procedure or
if the previously washed hands touch the curtain trolley etc. They are also
particularly useful outside the door of an isolation room/area and for individual
patient bed space in “high” risk areas and during outbreaks on the advice of
infection control.
(F) Prometics XL Cream
The use of Prometics XL Cream available from the Pharmacy Department
(project of the Microbiology Laboratory) is also encouraged in the hospital.
This cream can be used for the same purposes as alcohol rub and as it
contains natural emollients which help to moisturize the skin staff are
encouraged to use it 3-4 times daily.
The main active ingredient is a natural fatty acid present in small amounts in
the skin. This is particularly active against VRE and MRSA and a protective
shield against the organisms remains in the skin when Prometics is used
unlike alcohol based products where the protective effect evaporates within
seconds.
NB: Only a very minute amount is required to be efficient. Surplus may
cause the hands to become greasy.
(G) Surgical Hand Disinfection
Surgical Hand antisepsis should be performed prior to all surgical procedures.
It involves thorough washing and disinfection of hands, subungual areas and
forearms. The agent used must have broad spectrum microbial activity, act
rapidly and persist on the skin over several hours
Betadine is the agent used in the MUH- See Theatre Policies for full
guidelines – available in the theatre and on the H Drive of the hospital
network.
4.6 Skin Care- Look After Your Hands
Bacterial counts increase when skin is damaged.
 Maintain an intact skin in as far as possible.
 Always wet hands before applying soap or medicated agents
 Always rinse and dry hands thoroughly- drying is particularly important
during the winter months when the hands have a tendency to become
chapped.
 DO NOT use communal pots of hand cream.
 Always cover cuts and abrasions with an impermeable waterproof .plaster
 Always wear disposable gloves when handling blood/body substances
 If you suspect sensitivity or allergy to disposable gloves, seek advice from
the Occupational Health Department.
 Always wash your hands after glove removal.
4.7 General Comments and Practical Points
 Only Liquid soap from a dispenser (disposable cartridge) is
recommended in a Hospital setting, but the container itself/nozzle must
be regularly cleaned. Bar soap is only allowed for patients own
personal use.
 Never use open topped jars of hand emollients ie. Atrixo etccommunal containers are a serious infection hazard.
 Any change of products can only be introduced by joint liaison
between Infection Control, Occupational Health and Supplies
Department.
 Gloves - Remember gloves are only a barrier when intact. They
should never be regarded as a substitute for hand washing. Hands
MUST be washed before/after wearing gloves.
 Ensure that all sinks are equipped with soap/paper towel, alcohol and
where necessary Hydrex. NB. Towel in the holder NOT lying on top.
 NEVER discard disposable towels in the toilet bowl, bed pan washer or
macerator. Such items cause blockage of the system and have
enormous implications for the Hospital, particularly the Maintenance
Department.
 No need to use several sheets of disposable paper.
NB: Patients should be made aware of these implications.
NOTE!
Your 10 Fingers
AreThe 10 most important
carriers of Cross - Infection
LET US ASK OURSELVES
WHO DID WE INFECT TODAY?
THE FUTURE IS IN YOUR HANDS
YOU CAN PREVENT THE SPREAD OF INFECTION
YOU CAN REDUCE THE FINANCIAL BURDEN ON
THE HOSPITAL
YOU CAN REDUCE HUMAN SUFFERING
THE RISE OF RESISTANT MICRO-ORGANISMS
IS THE CONTINUING THREAT OF THE FUTURE
YOU CAN PREVENT THE SPREAD
YOU MUST EDUCATE OTHERS
REMEMBER HAND WASHING
SAVES LIVES
Semmelweiss is as relevant to-day as he was a century ago
5. Mercy University Hospital
Colour Coding System
5.1 MUH Colour Coding for Cleaning Cloths,
Brushes & Buckets
Ward Kitchen
White Cloth
Clean Utility/Clean Clinical/Other Clean Areas
Pink Cloth
Dirty Utility/Bathrooms/Toilets etc.
Blue Cloth
Isolation Rooms/Areas
Yellow Sign
Yellow Cloth
Green Sign
Green Cloth
Note: It applies to all wards/areas and to the Contract
Cleaners
5.2 Colour Coding for Isolation Rooms/Areas
Specifically prepared colour coded cards, restricting visitors are placed on the
patient’s door. The different categories are assigned the following colour
codes.
Yellow Transmission Based Precautions
(for infection)
Green Protective Isolation
(for immunosuppressed)
Red In reserve for extremely high risk infection i.e. Multi
Drug Resistant Tuberculosis, Lassa Fever,
Marburg Disease, SARS etc. If required, sign is
available from Infection Control.
5.3 “Special Risk” Infection Coding System
“High Risk” Category Infection
 HIV positive of presumed positive
 Hepatitis B/C or presumed positive
 Leptospirosis (Weils Disease)
 Typhoid/Paratyphoid/Dysentery
 Other Infections – Any other unusual infection where the risk of
contagion is high.
Any of the above mentioned should have a special “Yellow” Luminous
Sticker with B.H. written in red.
(a) Outside of Case Notes
(b) Inside of Nursing Kardex
(c) Request forms to X-Ray, Physiotherapy, Occupational Therapy, E.E.G.
Dept. etc.
In order to preserve confidentiality, it is not regarded as essential to note the
precise infection in the case notes. Neither is it essential to write it on the
sticker. All staff should recognise this sticker and thereby that the necessary
“Blood/Body Substance” precautions.
MRSA Small Circular Purple Sticker
ESBLS Small Circular Red Sticker
R.STREPTOCOCCI Small Circular Dark Blue Sticker
These stickers must be placed:
(a) Outside of Case Notes
(b) Inside of Nursing Kardex
(c) Front page of Drug Chart
(d) On all Request Forms to X-Ray, Physiotherapy, Occupational Therapy,
E.E.G. Dept. etc.
Do not write the particular infection on the stickers; insert only the date of
isolation on or alongside the sticker (to observe confidentiality)
These stickers act as an alert.
B.H.
6. Principles of Asepsis/Aseptic
Technique
6.1 Introduction
The terms asepsis and aseptic technique are used to describe methods which
have been developed to prevent contamination of wounds or other
susceptible sites (e.g. the urinary tract) in the Operating Theatre, the Ward
and other treatment areas, by ensuring that only sterile objects and fluids will
make contact with these sites and that the risks of airborne contamination are
minimized.
Any procedure that involves penetration of the skin, exposure of wounds or
instrumentation should be carried out with sterile instruments and materials
from CSSD, using a non touch technique with forceps or gloves (Ayliffe,
Lowbury, Geddes, Williams, 1993).
The hand washing principle must be adhered to (see Section 4 – Hand
Washing). Following the first hand wash, Prometics XL cream or alcohol rub
should be available at any time during aseptic procedures, particularly when
non-sterile articles have been touched.
Aim
 To minimize the risk of introducing pathogenic organisms into a wound
or other susceptible site and to prevent the transfer of pathogens from
the wound to other patients or staff.
Indications
 Wounds healing by primary intention (before surface skin has healed).
 Intravenous cannulation.
 Urinary Catheterisation.
 Suturing.
 Vaginal examination during labour.
 Medical invasive procedures.
Principles
 Ensure that all equipment required is readily available and there is a
clear field in which to carry out the procedure.
 Wash hands or disinfect clean hands with Prometic XL Cream or an
alcohol gel.
 Open the pack carefully to prevent contamination of contents
 Wear sterile gloves for the procedure
 Use aseptic principles to ensure that:
(a) Only sterile items come into contact with the susceptible site
(b) Sterile items do not come into contact with non sterile object.
 After completion, discard waste contaminated with body substance into
a yellow waste bag and sharps into a sharps container.
 Discard protective clothing and wash hands to prevent cross infection
to other (Wilson, 2002).
6.2 Preparation of Trolley for Aseptic
Technique
Trolleys used for Aseptic Procedures should not be used for any other
purpose and must be well maintained (free from surface cracks/chips).
 Wash trolley with detergent (wash up liquid) and water and dry
thoroughly with a disposable towel.
 Disinfect with alcohol (70%) using a disposable towel and leave to dry
for two minutes. In the case of a dressing round, disinfecting with
alcohol suffices between each individual dressing, unless physically
contaminated.
 Place everything for one procedure on the bottom shelf of the trolley
including pack, scissors, normal saline sachets, extra dressings or any
other material which may be determined by the nature of the
dressing/other procedure. NB: The top shelf MUST be kept clear.
 NB: Place also a receptacle containing a swish of washing up liquid
on lower shelf for discarded instruments (non-disposable). This
prevents adherence of blood, tissue etc. to the instruments.
Instruments should be placed in the container according as they are
used. Apart from the contaminating aspect there is a risk that the
instruments may be discarded with the used wrappings and dressings
if left on the trolley.
 Attach pack holder to the side of the trolley, below the level of the top
shelf, so that any contaminated materials lie below the level of the
sterile field.
6.3 Preparation of the Environment for Aseptic
Procedures
These preparatory precautions apply to all aseptic
procedures, but with most reference to “wound care”.
General Precautions
 The procedure should be carried out in as clean an environment as
possible.
 Bed making, cleaning, dusting etc. should be completed ideally a half
an hour before dressings/other procedures are carried out.
 Windows/doors should be closed and ward movement restricted to a
minimum.
 Ambulent patients should be requested to sit quietly during the
procedure. Where possible curtains should be drawn well in advance.
 In the case of wound dressings, only one wound should be uncovered
at a time and wounds should be exposed only for the least possible
time.
 Clean dressings/procedures should be placed first on the list – i.e.
before colostomies, infected wounds, wounds of HIV/Hepatitis B/C etc.
 Staff with respiratory infection, sore throat, hand /finger infection should
refrain from dressings/other aseptic procedures.
 A greater reduction of droplet dispersion of organisms can be achieved
by staff/patient not talking unnecessarily during the procedure (Ayliffe,
Lowbury, Geddes, 1993; Royal Marsden, 1990).
These are general Infection Control principles – For further details refer
to the Mercy University Hospital Guideline booklet for management of
wounds.
7. Prevention of Hospital Acquired
Infection
7.1 Wound Care
These Guidelines are general Infection Control principles for Wound Care.
For extensive researched details, see Guidelines for Wound Management
available on all wards.
Introduction
The cost of post-operative wound infection can be high, both for the patient
and the Hospital. At the least, the patients may be inconvenienced by a
prolonged period of hospitalization; at worst the patient my die from
Septicaemia. All too often wound infections nullify the potentially, beneficial
effects of the operations preceding them. It is, therefore, highly desirable that
the incidence of wound infection should be reduced for humanitarian as well
as economic reasons.
Aims of Wound Care
 To promote healing.
 To minimize the risk of exogenous infection.
Broad Principles
 Apply principles of asepsis (See Section 6.1 and 6.2).
 The wound dressing should be removed carefully to prevent dispersion
of organisms (Ayliffe et al, 1993).
 If the wound is clean and dry, it is better to leave it alone (Thomlinson,
1987).
 Avoid unecessary prolonged exposure of wounds during dressing
changes.
 Wounds should be cleaned using normal saline. The use of antiseptics
can be injurious to tissues.
 Accurate recording of the condition of the wound and skin should be
made at each dressing change. This will aid the early detection of
wound infection (Morrisson, 1987).
 If “strike through” occurs, e.g. leakage reaching the surface of the
dressing, the dressing should be removed and a new one applied.
Extra padding should NEVER be applied over the soaked dressing
(Ayliffe et al, 1992).
Exceptions to this are:
 Wounds on day of surgery. If strike through is evident, the area is
marked and re-enforced if necessary.
 Leg ulcer patients with compression bandaging (in the Out Patients
Department). This bandaging is left inset for one week and it is
possible that strike through may occur. If so, the patient is advised to
reinforce with some more similar bandaging (this is actually given to
the patient by the OPD clinic).
Dressing of Wounds
Preparation of the Dressing Trolley See Section 6.1
Preparation of the Environment See Section 6.2
Procedure for Wound Dressing See Guidelines for Wound
Management – available on all
Departments.
For wounds with Resistant Organisms e.g. MRSA (See Section 10.
7.2 Urinary Incontinence/Catheter Care
Introduction
These Guidelines are general Infection Control principles for Catheter
Insertion/Catheter care. For extensive researched details on Urinary
Incontinence/Urinary Catheterisation – see booklet available on all wards in
the Mercy University Hospital and also seek advice from the Urology Team.
The National Prevalence Study (Meers et al, 1981) revealed that 10% of
patients in hospitals visited developed nosocomial infection; 30% of these
were urinary tract infection. Data provided by the National Nosocomial Study
in America revealed that 40% of all hospital acquired infections affected the
urinary tract. Hence the need to apply extreme Infection Control measures in
the field of catheter care.
General Principles
 The use of urinary catheters should be limited to clinical needs that
cannot be met by other needs. This may include, but not limited to,
relief of urinary tract obstruction, urinary drainage in patients with
neurogenic bladder dysfunction and urinary retention in urologic
surgery or other surgery on contiguous structures, accurate
measurement of output in critically ill patients and radiological
investigations.
 Catheter insertion and maintenance should be undertaken by people
who are adequately trained in the procedures.
 Hands MUST be washed and sterile gloves worn for catheter insertion.
Non sterile gloves should be worn for emptying of catheter bags.
Remember to wash hands before and after wearing gloves.
 The system of urine drainage should be sterile and continuously
closed, with an outlet designed to avoid contamination and a sampling
port. The drainage system should be appropriate to individual patient
need.
 The closed system should only be broken for limited, clearly defined
clinical reasons. Bladder washouts should only be for specific clinical
reasons and not as part of routine practice.
 The catheter should be changed according to clinical need, and not a
fixed regime, and with regard to the manufacturers instructions.
 All procedures involving the catheter and drainage system should be
clearly documented in the nursing notes. At a minimum, this should
include the name of the person inserting the catheter, the date, the
type and size of the catheter and the volume of water in the balloon.
Insertion of a Urethral Catheter
 The catheter should be of material suitable for the anticipated duration
of catheterization.
 The smallest balloon size should be used, unless the Urologist advises
otherwise, and inflated with the correct amount of sterile water.
 The smallest gauge catheter consistent with good drainage should be
used. The length will depend on the sex of the patient. If regular or
continuous irrigation is anticipated, a 3-way catheter should be used.
 The clinical needs of patients will determine whether an assistant is
required.
 Where possible, the patient should have a shower before the
procedure, if not, the genitalia should be washed with non-scented
soap and water. Sterile saline sachets to be used for swabbing the
vulva.
NB: Do not use Hibidil, as it may cause allergy and in turn irritation
leading to infection (See Section 5.2 for Preparation of Trolley).
 The urethra should be lubricated with sterile, single use, anaesthetic
gel.
 The catheter should be inserted using an aseptic technique and sterile
equipment. A second pair of sterile gloves should be available, should
contamination occur.
Maintenance of the Drainage System
 Drainage systems should be simple to operate with one hand, close
securely and be easy to position. Where feasible, offer the patient a
choice of drainage systems.
 The position and integrity of the system should be maintained in a
manner whereby it is compatible with patient comfort.
 The drainage bag must be kept below the level of the bladder at all
times to maintain an unobstructed flow of urine. It should be emptied
into a disinfected or single use container. Contamination of the outlet
should be avoided (wipe with an impregnated alcohol swab before/after
emptying).
 When urine samples are aspirated from the sampling port, an aseptic
technique and sterile equipment must be used and the port disinfected
with an alcohol impregnated swab before/after use.
 The drainage bag must be changed at catheter change, if it is
damaged, leaking, when there is an accumulation of sediment, or if
there is an odour, rather than on a fixed regime.
 Meatal care should be performed at intervals appropriate for keeping
the meatus free of encrustations and contamination. Showering or the
use of a gentle bidet is preferable. If the patient uses a bath it must be
cleaned before/after. The drainage bag should be emptied and the tap
closed before the patient enters the bath.
 Waste should be disposed of as per Hospital Policy.
Storage of Catheters
Proper care/storage of catheters is very important. The British Standard BS
states that because of deterioration that may occur, under certain conditions
of storage, catheters should be used as soon as possible after manufacture.
As soon as a catheter shows any modification of material characteristics, it
should be destroyed.
 Catheters should be stored away from direct sunlight.
 Catheters should be stored at room temperature, preferably at about
15 degrees centigrade.
 Limit the number of catheters in each container or box, to avoid
damaging the package.
 Observe the expiry date of the catheter.
 Never place elastic bands around catheter.
7.3 Prevention of Infection Associated with
Intravenous Therapy
These Guidelines are only general principles for Prevention of Infection
associated with Intravenous Therapy. For full details, see Guidelines for
Registered General Nurses on the Administration of IV Drugs.
Introduction
An intravenous catheter is a foreign body which produces a reaction in the
host consisting of a film of fibrinous material (biofilm) on the inner and outer
surfaces of the catheter. This biofilm may be colonized by micro-organisms
and will be protected from host defence mechanisms. Infection usually
follows colonization of the biofilm, causing local sepsis, septic
thrombophlebitis or in some cases systemic infection, e.g. bacteraemia or
septicaemia (Damani, 1997).
Intravascular (IV) devices are now widely used in medical care for the
administration of fluids, blood products, nutritional support and haemodynamic
monitoring. Infections associated with IV devices are often life threatening,
particularly in the critically ill, immunocompromised or neonates and can
largely be prevented by good infection control practice (Wilson, 1995).
Sources of infection may be:
(A) Intrinsic
This is due to contamination or faulty sterilization of fluids during
manufacture. It is usually due to gram negative organisms growing in
the infusate, such as klebsiella, Enterobacter or Pseudomonas spp.
(B) Extrinsic
This is due to contamination of the IV catheter during the insertion,
administration of the fluid or from the hands of the operator. However,
the most important reservoirs of pathogens causing catheter-related
infection are the insertion site and the hub. It is mainly due to microorganisms residing on the patient’s skin, e.g. Staph epidemidis, Staph
aureus and diptheroids.
Key Points
Peripheral Cannulae
 Ensure that the patient is in a comfortable position and aware of the
nature of the procedure as this will reduce anxiety.
 Place some protection under the patient’s arm to protect the
bedclothes.
 Principles of proper hand washing and strict aseptic technique must be
adhered to. The person cannulating should ideally have an assistant,
as otherwise complete sterility is not guaranteed.
 The vena puncture site should NOT be touched once the vein has
been selected and the skin prepared; avoid touching the shaft of the
catheter with fingers during insertion.
 Upper extremity site in preference to a lower extremity site. In
paediatric patients, insert catheters into a scalp, hand or foot site in
preference to a leg, arm or anticubital fossa site.
 Allowing the site to dry properly after disinfection is very important.
 Select a catheter that will fit properly into the vein. The correct size
catheter reduces trauma and congestion of the vein. Insert the
catheter as swiftly as possible using “non touch” technique. Do NOT
attempt repeated insertions with the same catheter. If the first insertion
is not successful, the procedure should be repeated with a new
cathether.
 Look out for flash back of blood and advance the catheter slowly.
Secure the catheter to prevent movement (as per booklet).
 Check the site hourly, when the cannula is in use and four hourly, when
not in use.
 Change the giving set every 48 hours routinely. For medicated giving
sets, every 24 hours and for blood giving sets, with alternate blood
units.
Central Venous Cannulae
The insertion of Central Venous Cannulae should ideally be carried out
in the Operating Theatre or in Ward Treatment Rooms. However, there
is no reason why it may not be carried out in an open ward if very
stringent measures of asepsis are adhered to.
 When carried out in the Ward setting, it MUST be carried out under
strict, operating theatre aseptic technique, requiring the use of sterile
packs, sterile gloves, sterile gowns, sterile drapes etc.
 NB: Proper skin disinfection is absolutely necessary and the sterile
field should only be prepared when ready to commence the procedure,
to avoid excess exposure to the atmosphere.
 The doctor MUST be assisted by a Nurse/s while carrying out the
procedure.
Additional Practical Points
 Stringent adherence to aseptic technique during insertion (already
mentioned) and later catheter manipulation significantly reduces the
risk of infection and is cost effective.
NB: Any manipulation of a Central Line requires the use of sterile
gloves, preceded by proper hand washing (Greene, 1990).
 In as far as possible it is recommended that administration set
changing, drug administration, blood taking and dressing change
should be carried out at the one interruption of catheter integrity.
 Hickman line dressings should be routinely changed weekly; Central
line dressings should also be changed weekly, or more frequently, if
the dressing is wet/loose or if the site is inflamed/painful.
 Connections should be reduced to a minimum. The risk of infection is
increased by the use of three-way taps and injection ports but the use
of protective caps and swabbing with 70% alcohol (medi-swab) before
the injection reduces the hazard.
 It is recommended when a heplock is removed that it is replaced with a
sterile heplock.
 Remove any intravascular device as soon as its use is no longer
clinically indicated, as the risk of infection increases with the length of
time of catheterization. Therefore, all patients with intravenous
catheters should be evaluated on a daily basis for evidence of catheter
related complications, e.g. tenderness, thrombosis, swelling or signs of
inflammation or infection. The insertion site should be palpated daily
for tenderness through intact dressing.
 The catheter should NOT be inserted into an area of inflammation or
infection and MUST be removed and re-sited if required.
 Use subclavian rather than jugular or femoral sites fo central venous
catheter placement, unless medically contraindicated.
 Wipe the outer hub of the catheter with 70% alcohol (medi swab)
before attaching the administration set. The luer lock should be kept
as clean and as dry as possible.
 Antibiotic prophylaxis before or during catheter insertion is NOT
recommended to prevent catheter colonization or blood stream
infection. Routine use of topical antimicrobial ointments is also NOT
recommended at the site of catheter insertion.
 NB: Blood cultures should be taken from the line ports as well as the
peripheral vein site when infected. If line infection is confirmed a
decision on the removal of the line will now need to be made by the
medical team.
 In cases of proven catheter related sepsis, appropriate antibiotics
should be given before fresh catheter insertion to prevent recolonization of new IV Lines. The choice of antibiotic will depend on
the sensitivity of the micro-organism; for blind therapy the
Microbiologist should be contacted for advice (Damani, 1997).
Air Lock – Intravenous Infusions
Prevention
Observing principles of strict aseptic technique, including proper hand
washing and the wearing of disposable gloves –
(A) Prime the administration set with the infusion fluid, so that it is ready for
use once the cannula is in position. Check that the fluid is running
freely and that all the air is expelled from the system. This prevents the
danger of embolous occurring.
NB: The equipment should only be primed immediately prior to the
infusion to minimise the risk of infection.
(B) Preparation for changing a container of intravenous fluid should begin
while a small amount of fluid remains in the container, thus preventing
the formation of air bubbles in the system.
(C) Ensure that any connections used are secure.
Air in Line Detection Pumps
Pump Alarming
Observing strict principles of aseptic technique including proper hand washing
and the wearing of disposable gloves.
(A) Place a sterile clinical sheet on the work area.
(B) Clamp the T Connector.
(C) Disconnect the system and remove any air from the giving set by
running through (on the sterile, clinical sheet) taking care to avoid
touching any non-sterile surface/equipment.
NB: Do not use a syringe/needle to extract air via the rubber bung
(D) Remove clamp and quickly reconnect/re-start infusion.
(E) Check that the set is loaded correctly/re-load if necessary.
7.4 Management of Parenteral Nutrition (TPN)
Parenteral nutrition is administered via a central venous catheter where the
high blood flow reduces the risk of thrombophlebitic effects of glucose.
Bacteria can multiply easily in parenteral fluid – gram negative bacilli and
particularly yeast, so infection is a frequent complication of PN therapy.
Particular care MUST therefore be taken to avoid contamination of IV devices
used to administer TPN.
 Prevention of infection depends on scrupulous aseptic technique both
in cannula insertion/subsequent daily care (Ayliffe et al, 1993).
 Ideally designate the cannula for TPN only, avoid using multi lument
catheters and do not add drugs or withdraw blood from the line.
 Do not connect ports, stop cocks or taps. It should be preferably a
single lumen line.
 Change the infusion fluid and administration set every 24 hours, using
sterile gloves and non-touch technique.
 Inspect the insertion site daily for signs of infection.
 Record temperature and pulse chart 4 hourly to detect early signs of
sepsis.
 Take blood cultures through the line and from a peripheral vein if the
patient becomes pyrexial.
See Mercy University Hospital Nutritional Policy for full details
Further Reading – Guidelines for Preventing Intravascular
Catheter related Infection.
7.5 Prevention of Infection Associated with
Epidural Therapy
Introduction
“Whilst insertion of an epidural catheter has similarities with intravascular
cannula placement, the consequences of infection include potentially fatal
meningitis and epidural abscess” (Catchpole, 1996).
Clearly, very strict principles of full aseptic technique are crucial to the
prevention of these infections, at the time of insertion/care/removal of the
epidural catheter. Infections involving any spinal delivery system must be
treated aggressively with removal of the infected system, culture and
immediate antimicrobial treatment (Doyle et al, 1996).
Key Points
The insertion of an epidural catheter is an aseptic procedure and should be
carried out in a ventilated operating theatre. In an ICU setting it may be
necessary in certain circumstances to perform this procedure in the
Department, if so; it MUST be carried out under strict operating theatre
aseptic technique, requiring the use of sterile packs, sterile gowns, sterile
drapes, sterile gloves etc.
NB: Proper skin disinfection (as per theatre scrub policy) and the sterile
field should only be prepared when ready to commence the procedure, to
avoid excess exposure to the atmosphere.
Close observation of the site is important and the dressing changed (dry
Mepore dressing) ONLY if necessary. Leave covered for 12 hours post
removal of catheter. Do NOT use disinfectant if dressing needs changing or
post removal of catheter. Only with evidence of infection should an epidural
site be treated with a disinfectant – Betadine is suggested and it is advisable
to wait for 1 hour post removal of the catheter to allow sealing of the site.
ALWAYS send the catheter tip, labelled Epidural Catheter Tip (in a sterile
universal container) to the Bacteriology Department for analysis on removal of
the catheter whether infected or non-infected. It is advisable for two people to
check the tip to ensure it is intact. To avoid false analysis, take care to avoid
touching the skin with the catheter.
8. Blood/Body Substance Isolation
8.1 Background to Blood/Body Substance
Isolation
The emergence of the blood-borne human immunodeficiency virus (HIV) and
the associated acquired immune deficiency syndrome (AIDs) pandemic
highlighted the risk to health care workers of acquiring blood borne viruses
through contact with blood and other body substances. It has been
acknowledged that, because individuals infected with blood borne viruses
cannot be readily identified, precautions to minimise the risk of transmission
should be used in the care of all patients. The concept became known as
“Universal Blood and Body Fluid Precautions”. The recommendations
were first published by the Centres for Disease Control, Atlanta, in 1985.
These precautions applied to blood, blood products and the following
body substances:
 Semen
 Vaginal fluid/Cerebrospinal fluid
 Pleural/Pericardial/Peritoneal fluid
 Saliva in association with Dentistry/Oral procedures
 Synovial fluid
 Amniotic fluid
These precautions applied to the following, if contaminated with visible blood:
 Urine
 Faeces
 Vomit
 Nasal secretions
 Sweat
 Tears
These precautions were reviewed in 1987 – adopting an approach whereby
all human blood and all body substances are treated as if they are known to
be infectious for HIV/Hepatitis B or C/other blood borne pathogens. This
approach was described as “Body Substance Isolation” (BSI) (Ward,
Wilson, Taylor, Glynn, 1997).
Again reviewed in 1996 by CDC (HICPAC) – Update by Hospital Infection
Control Practices Advisory Committee and described as Standard
Precautions Garner Julie S (1996) (See Section 7.1).
8.2 Standard Precautions
All health care workers should follow these guidelines at all times irrespective
of the infectious status of the patient.
General Principles
 Prevent blood/body substance contact with non-intact skin and mucous
membranes.
 Minimise blood/body substance contact with intact skin.
 Prevent sharp injuries.
 Immunise staff against Hepatitis B.
 Prevent contaminated items being used between patients.
 Before performing a procedure the risk of exposure should be
assessed and protective clothing selected accordingly.
 Gloves should be worn for touching blood/body substances, mucous
membrane, e.g. vaginal/dental examinations and non-intact skin e.g.
wounds. Gloves should be changed after contact with each patient
and at the end of each procedure. Hands must be washed before and
after wearing gloves.
 Plastic aprons should be worn if contamination of clothing with
blood/body substance is anticipated. They should be used for one
procedure and then discarded.
 Water-repellent gowns should be worn during procedures likely to
cause extensive splashing onto the body e.g. major surgical
procedures, endoscopy etc. Eye protection (or face visors) should be
worn during procedures likely to cause splashing of body substances
into the eyes, mouth or nose e.g. major surgical procedures, scrubbing
instruments etc. They should be available during procedures where
splashing is possible but unlikely.
 Additional protective clothing, such as boots and headgear may be
necessary for major surgical procedures.
 Mouthpieces, resuscitation bags or other ventilation devices should be
available in all clinical areas (in the resuscitation trolley) for when the
need to resuscitate arises.
 Hands should be washed immediately and thoroughly before/after
wearing gloves. Cuts and abrasions in any area of exposed skin
should be covered with a secure, waterproof plaster. Health care
workers with exudative lesions/weeping, dermatitis should seek advice
from Occupational Health. They should avoid all direct patient care,
food handling or handling of patient care equipment until the condition
resolves.
 Management of Sharps – Extreme care must be exercised during the
use and disposal of sharps (See Policies for Safe Use and Disposal of
Sharps/Needle Stick Injury/Hepatitis B. Vaccination Policy).
 Spillage of Blood/Body Substances – Spillage of blood/body
substances (with the exception of urine) should be dealt with
immediately (using gloves) by covering with hypochlorite granules e.g.
Presept Granules.
Cover with disposable paper towels and leave for a few minutes – the
debris treated as clinical waste (yellow bag); wash the area with
detergent and water.
 Spillage of Urine – Unfortunately, acidic solutions such as urine may
react with the hypochlorite and cause release of chlorine vapour.
Hypochlorite granules should NOT, therefore, be used on large spills of
urine.
o Put on disposable gloves and plastic apron if very large spill.
o Soak up spill with disposable paper towels.
o Discard into a yellow refuse bag.
o Wash area with detergent and water.
o Hypochlorite solution may be used afterwards.
o Disposal of Waste Material – Waste material contaminated with
blood/body substances should be discarded into yellow clinical
waste bags. Excreta can be safely discarded into the sewage
system. Linen should be placed in an “Alginate” bag (See
Guidelines for Disposal of Waste for details).
Decontamination of Equipment
Before decontamination, all equipment should be thoroughly cleaned with
detergent and water. Gloves should be worn and depending on the extent of
contamination, a plastic apron may be worn. Proper cleaning is essential to
remove blood/body substances, which may otherwise adhere to the surface
and enable micro-organisms to survive the decontamination process.
See: Cleaning/Disinfection Guidelines
Local Policies are available for specialist Departments, e.g. Theatre,
Endoscopy Unit, Urology Unit, Outpatient Department etc., on the
Departments. (Ward, Wilson, Taylor, Glynn; 1997)
Note: Before returning equipment, on loan from other Departments/other
Hospitals, rental equipment/equipment for repairs etc., it MUST be
properly cleaned and where necessary disinfected (as per Hospital
Policy).
In some instances it may be necessary to furnish an Equipment Cleaning/Decontamination Certificate available to print from the
Infection Control folder on the H Drive. If any problems are
encountered contact Infection Control.
9. Isolation
9.1 Introduction
The spread of infection to patients in hospital can be controlled by physical
protection (isolation); the extent of this control varies with the methods used
(Bagshaw et al, 1978). Isolation becomes necessary when a person presents
an infection risk to others and vice versa. The term isolation is generally used
in the sense of segregation of the patient in a single room, but it must also
include other methods by which the patient is protected, including barrier
nursing in an open ward or cohort nursing in a side ward or open ward, as a
single room may not always be available. Single room isolation is the
preferred method. Depending on the causative organism, isolation does not
always mean isolating the whole person e.g. a bacteria impermeable dressing
may isolate a wound, (Ayliffe, Collins, Taylor, 1982).
Risk Assessment
A well thought out plan finds the balance. The first stage is to diagnose the
infection, recognise the casual organism and determine its route of spread.
With this information, it is possible to decide on the most appropriate form of
isolation. It is important that patients with known/suspected “high risk”
infection are isolated at the time of admission. If a separate room is not
available seek advice from the Infection Control Team. Appropriate infection
precautions must commence on clinical suspicion; laboratory confirmation is
not necessary. The extent of this control varies with the methods used,
(Damani, N.N., 1997).
The consequent restrictions on freedom of movement and ability to
communicate can be disturbing for patients in isolation. They can experience
sensory deprivation, (Moore, 1991). To plan and deliver holistic care in these
circumstances, health care workers need to understand what the experience
means to each patient and use that awareness to deliver sensitive,
appropriate and effective care (Oldham T, 1998).
NB: It is important to emphasize that isolation precautions can protect only
if they are used consistently and appropriately. In some patients e.g.
those with extensive burns, combined Transmission Based and
Protective is desirable to protect patients already infected with one
pathogen against infection with other pathogens (Ayliffe, Lowbury,
Geddes, Williams, 1993).
Dedicate equipment to those in isolation i.e. stethoscope, sphygmomonoter
etc.
NB: Only mercury thermometers should be used for patients in isolation,
particularly Neutropenia and “high risk” infection (stock in Infection
Control)
9.2 Guidelines for Isolation in the Mercy
University Hospital.
Two Tier System of Precautions
Standard precautions for all patients (See Section 7.1)
In addition to:
Transmission Based Precautions (for infected patients)
↓ ↓ ↓
Airborne Droplet Contact
The revised guideline contains two tiers of precautions. The first, “Standard
Precautions”, synthesizes the major features of Universal Precautions and
Body Substance Isolation, into a single set of precautions to be used for the
care of all patients in hospital regardless of their presumed infection status. In
many instances, the risk of nosocomial transmission of infection may be
highest before a definite diagnosis can be made and before precautions
based on that diagnosis can be implemented. The routine use of Standard
Precautions for all patients should reduce greatly the risk for conditions other
than those requiring Airborne, Droplet or Contact Precautions.
In the second tier, are precautions designed only for the care of specified
patients. These additional “Transmission Based Precautions” are used for
patients known or suspected of being infected or colonized with
epidemiologically important pathogens that can be transmitted by airborne or
droplet transmission or by contact with dry skin or contaminated surfaces.
NB: Isolation of patients with infection – Negative Pressure Room
YELLOW COLOUR CODING SYSTEM – cloths, scrub, buckets
etc.
Isolation of neutropenic patients – Positive Pressure Room
GREEN COLOUR CODING SYSTEM – cloths, scrub, buckets
etc.
Ideally a room having positive air pressure should be kept
unoccupied but, as this is not always possible it must be
ensured that
Transmission Based Precautions are based on routes of transmission for a
smaller number of specified patients known or suspected to be infected or
colonized with highly transmissible or epidemiologically important pathogens.
These Transmission Based Precautions, designed to reduce the risk of
Airborne, Droplet and Contact transmission in hospital are to be used in
conjunction with Standard Precautions (CDC Guidelines, 1996)
9.3 Rationale for Transmission Based
Precautions
Transmission of infection within a hospital requires three elements
(A) A source of infecting organisms
(B) A susceptible host
(C) A means of transmitting the organisms
Airborne Transmission
It occurs by dissemination of either airborne droplet nuclei of evaporated
droplets containing micro-organisms that remain suspended in the air for long
periods of time or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and
may become inhaled by a susceptible host within the same room or over a
longer distance from the source patient, depending on the environmental
factors. Air handling and ventilation are required – Negative Pressure.
Droplet Transmission
Theoretically a form of contact transmission. However, the mechanism of
transfer of the organism is quite distinct from either direct or indirect contact
transmission. Droplets are generated from the patient primarily during
coughing, sneezing and during the performance of certain procedures such as
suctioning and bronchoscopy. Transmission occurs when droplets containing
micro-organisms generated from the infected person are propelled a short
distance through the air and deposited on the host’s conjunctivae, nasal
mucosa or mouth. Because droplets do not remain suspended in the air,
special air handling and ventilation are not required.
Contact Transmission
(a) Direct Contact Transmission
This involves a direct body surface – to – body surface contact and physical
transfer of organisms between a susceptible host and an infected or colonized
patient, i.e. on turning a patient, bathing a patient, other patient care activities
requiring direct personal contact. Direct contact can also occur between two
patients, with one serving as the source and the other the susceptible host.
(b) Indirect Contact Transmission
Involves contact of susceptible host with a contaminated object, usually
gloves that are not changed between patients etc
9.4 Synopsis of Types of Precautions and
Patients Requiring the Precautions
Note: These precautions are in addition to Standard Precautions
(See Section 7.1 for Standard Precautions)
Airborne Droplet Contact
 Measles
 Varicella (including
Zoster)
 Tuberculosis
 MRSA
 Multi Drug Resistant
TB
 SARS
 Influenza Pandemic
 Viral Haemorrhagic
Fevers
 Ebola
 Lassa
 Marburg etc.
NB: These demand
very strict isolation
 Invasive
Haemophilus
Influenza Type B
 Invasive Neisseria
Meningitis
 Other Bacterial
Respiratory
Infections:
- Diptheria
- Pertussis
- Streprococcal
Pharyngitis
- Pneumonia or Scarlet
Fever in Infants &
Young children
 Other Viral
Infections:
- Adenovirus
- Small Round Viruses
 Multin Drug
Resistant Gram
Negatives
 Clostridium difficile
 E.Coli 0157:h7
 Shigela
 Hepatitis A
 Rota Virus
 MRSA
 Highly Contagious
Skin Infections:
- Diptheria (cutaneous)
- Herpes Zoster
-Impetigo
-Major non-contained
abscesses, cellulites or
decubiti
- Influenza
- Mumps
- Parovirus
- Rubella
-Pediculosis
-Scabies
-Staphlococcal
furunculosis in Infants
& Young Children
-Viral Haemorrhagic
Conjunctivitis
(A) Airborne Precautions
(in addition to Standard Precautions)
Patient Placement
Single Room - Negative air pressure. Keep the door closed
Respiratory Protection
Heavy duty N95 or N97 masks for Open Pulmonary Tuberculosis or
suspected Pulmonary Tuberculosis, Green Surgical Mask for Meningococcal
or suspected Meningococcal Meningitis. Non immune or pregnant staff
should not enter the room of patients known or suspected to have Rubella or
varicella. Persons with immunity to varicella and rubella do not require
masks.
Patient Transport
Limit movement/transport of patient from the room to essential purposes only.
If transport/movement is necessary, minimize patient dispersal of organisms.
(B) Droplet Precautions
(in addition to Standard Precautions)
Patient Placement
Single Room. Special air handling/ventilation not necessary. Only cohort with
patient/patients who are infected with the same organism.
Mask
Wear a mask when working within three feet of the patient for Meningitis –
See Disease Specific Sections for other necessities or on the advice of
Infection Control.
Patient Transport
Limit the movement and transport of the patient from the room to essential
purposes only. If transport or movement is necessary minimize patient
dispersal of droplets.
Patient Care Equipment
Where possible, dedicate the use of patient care equipment to a single
patient. Otherwise, ensure that all items are adequately cleaned/disinfected.
(C) Contact Precautions
(in addition to Standard Precautions)
In addition to Standard Precautions, use contact precautions for specified
patients known or suspected to be infected or colonized with epidemiologically
important micro-organisms that can be transmitted by direct contat with the
patient or patient care items.
Patient Placement
Single room preferably. Cohort only with patients who are affected by the
same organism.
Patient Transport
Limit the movement and transport of the patient from the room to essential
purposes only. Where necessary ensure that adequate precautions are taken
to minimize the risk of transmission to others and contamination of
environmental surfaces or equipment.
Patient Care Equipment
Where possible dedicate the use of patient care equipment to a single patient.
Otherwise, ensure that all items are adequately cleaned/disinfected before
use for another patient.
The following are general Isolation Guidelines and MUST always be
incorporated into the Airborne, Droplet or Contact Precautions
forementioned.
Where possible Infection Control should be notified when transmission based
precautions are instituted.
1. Staff – Always strive to select staff that are immune to the patient’s
infection
2. Location – Place the relevant colour coded sign on the outside of the
door (see Section 8.4 below) indicating restricted entry to the room.
Door should be kept closed.
3. Charts – Patients charts should be kept outside of the room as paper
cannot be decontaminated.
4. Visitors – Visitors must report to Sister/Nurse in charge before
entering the room and instructions given as to any precautions that
should be taken. Visitors should be kept to a minimum and visiting for
children (except in certain circumstances) is not allowed/recommended
(see Visiting Policy)
5. Equipment – Only essential equipment should be brought into the
room and the equipment used should be easy to decontaminate.
Mercury thermometer is recommended.
6. Protective Clothing
 Ensure an adequate supply of protective clothing (gloves,
aprons, masks) whatever is necessary for the particular
category is available (outside) the door.
 Eensure that the alcohol gel is replaced as necessary and
encourage visitors to use the gel on entering/leaving the area.
 Ensure the yellow bag is available (inside) the room for disposal
of gloves, aprons etc. before leaving the room.
7. Linen – to be placed in “Alginate” bags and securely tied before
leaving the room. Ideally arrange for immediate transport to laundry.
8. Crockery/Cutlery – Machine wash with rinse cycle above 80 degrees
centigrade and allow to dry thoroughly. For patients with smear
positive pulmonary tuberculosis/Hepatitis B or HIV, who are bleeding
from the mouth or respiratory tract, use disposable crockery.
9. Environmental Cleaning – daily/terminal
(see Hospital Cleaning/Disinfection Protocols – Section 12)- Yellow
Colour Coding
NOTE
DO NOT overstock an isolation room/area with i.e. nutrient drinks,
nappies, dressings, disinfectant, refuse bags etc. (only what is required
at the time). This leads to considerable wastage, as everything within
the infected zone has to be discarded at terminal cleaning of the room.
9.5 Protective Isolation
Indications
Following diseases, lesions or therapy associated with an increased
susceptibility to infection and in which patients need special protection from
the hospital environment. Isolation requirements vary with the degree of
immunodeficiency, but to date are ill defined by the literature (Ayliffe et al,
2000) following chemotherapy, patients, especially Leukaemic patients ban
develop neutropenia, other immunodeficient states, severe dermatitis, burns
etc.
Precautions for Protective Isolation
Where possible Infection Control should be notified when Isolation is
instituted. Also, seek the advice of the Haematologist/Oncologist.
Location
 Single room with positive air pressure, GREEN SIGN on the door.
The room and equipment must be very thoroughly cleaned before the
patient enters.
 Staff with infection, skin lesions, eczema etc. or those having had
recent vaccinations or exposed to a communicable disease should not
attend to the patient. Nurses attending on patients with infection
should not care for those in Protective Isolation.
 Visitors must report to the Ward Sister/Nurse in charge before
entering the room. With regard to visitors and infection see
immediately above.
Protective Clothing
 Gloves – Proper hand washing/gloves for physical contact with patient.
Sterile gloves must be worn for any manipulation of IV Lines, catheter
care, dressings etc.
 Aprons – Recommended for staff members in contact with patient.
 Masks – According to some literature masks are rarely required, the
emphasis is on proper hand washing and non-infectious staff attending
to the patient but the Mercy University Hospital’s policy is to wear a
mask – NOT a white paper mask – a surgical mask.
 Equipment – It may be necessary to disinfect some items of
equipment before use. The Sphymomanometer, stethoscope etc. must
be disinfected and dedicated to the patient. Disinfect the thermometer
each time before/after use.
 Flora - No plants/cut flowers should be allowed in the room as they
may harbour bacteria/insects.
 Refuse – No specific precautions but do not let accumulate in the
room.
 Crockery – No specific precautions – machine wash.
 Food – Only cooked and processed foods should be given to
profoundly immunodeficient patients i.e. no salads or raw food, which
may be contaminated with gram negative bacilli. If in doubt, contact
the dietician.
NB: Extreme hygienic precautions should be exercised if giving ice
to the patient – single sachet ice cubes are recommended and
in the case of severe immunodeficiency, sterile water is
recommended.
 Interdepartmental Visits – Ideally should be avoided. If necessary it
should be arranged that the patient is seen immediately to avoid
contact with other patients who may have infectious condition.
Environmental Cleaning – daily/terminal – Green Colour Coding See Hospital Cleaning Protocols
9.6 Protective Isolation in St. Anne’s
Leukaemia Unit
Rationale
Infection is a major cause of death in children whose immune system is
compromised by leukaemia, cancer, other blood disorders and its treatment.
These children are vulnerable to infection from –
 Their own endogenous micro-organisms.
 Opportunistic micro-organisms.
 A much small dose of micro-organisms than would be a problem for a
non immunocompromised child. They generally are at increased risk
from bacterial, fungal, parasitic and viral infections.
It is not always possible to prevent infection from the patient’s own body flora
but, certain measures can be used to eliminate or minimise the risk from
endogenous organisms (Wilson, J., 2002, Infection Control in Clinical
Practice). These measures will be incorporated in the following Guidelines.
See Infection Control Manual – Section 8 for full details of the revised Mercy
University Hospital Isolation Policy, as adopted from the CDC Infection
Control Practices Advisory Committee, (Garner, J.S., 1996). These
Guidelines however, do not fully clarify Protective Isolation for the Leukaemia
Unit.
NB: It must be remembered that the Leukaemia Unit is
actually individual Protective Isolation within an
Isolation Unit.
Entrance to the Leukaemia Unit
 A GREEN SIGN denoting Protective Isolation (as per MUH Policy)
should be placed on the outside of the entrance doors.
 A door bell should be fitted on the outside to facilitate handing over of
supplies/meal trays/monitoring of visitors to the children etc. (see
section on visiting).
 The entrance doors should remain closed at all times
 In as far as possible only dedicated medical/nursing parents/guardians
should enter the unit.
 A wash hand basin should be positioned immediately inside the
entrance doors.
 Treatment Room – this room is not be used for any therapeutic or
diagnostic clinical testing of patients from the general side and children
from the general side MUST go to the operating theatre for General
Anaesthesia.
 In the event of an outbreak of infection in the general paediatric unit
leukaemic children should be admitted via Private Corridor 2 and via
the rear entrance to the Leukaemic Unit. This should be based on risk
assessment and if necessary following consultation with the
Haematologist/Microbiologist or Infection Control.
NB: Strictly No through traffic
Accommodation
Isolation requirements vary with the degree of immunodeficiency but this is
still ill defined in the literature (CDC Guidelines, 1996). Most infections
acquired by immunosuppressed patients are endogenous and the value of
single room isolation is often doubtful but cross infection can be a hazard.
These patients generally are at increased risk for bacterial, fungal, parasitic
and viral infections (as described above) from endogenous and exogenous
sources.
 Each child should be individually nursed in their own room with
protective isolation precautions in place and the door closed. Ideally in
a self contained unit (with shower and toilet) and a positive air
ventilation system (8-10 changes per hour is advised) Ayliffe et al,
1993.
 NB: Where available, and on a regular basis, the proper functioning
of the Mechanical Air Filtration System must be checked/cleaned, and
recorded by the Maintenance Engineering Department. In addition, a
mobile Hepa Filter Unit should be dedicated/not removed from the
area. This must be cleaned as part of the environmental equipment
and filters changed on a regular basis (by Maintenance).
 These children should remain confined to the area (with the exception
of necessary visits to i.e. the X-Ray Department or the Operating
Theatre). They should, in as far as possible, remain in their rooms and
should not at any time visit the “outside” play room.
 On entering and leaving hand washing is a MUST.
NB: Remember to open the windows throughout when any
rooms/areas are vacant.
Staffing
 The unit should have its own compliment of haematology/oncology
skilled staff
 These staff should be dedicated to the area and should not be reallocated during a quiet period/s, to the general paediatric unit/other
units.
 While not advisable, occasionally it may be necessary to assign a staff
member from the general Paediatric Section (i.e. in the event of an
increased work load) to the Leukaemia Unit. NB: It is important to
always have some staff member on hand who has no communication
with known infection on the ward.
 Staff must ensure that they maintain all of their own necessary
stock/supplies and should not have to borrow from the general
paediatric ward/other units and vice versa
 Staff with any serious infections, serious skin lesions etc. or those
having had recent vaccinations with live organisms i.e. BCG or Polio
Vaccine, or those who may be incubating an infectious disease should
not attend to these patients (if in doubt, contact Infection Control).
 Staff attending to patients with infection in the unit itself should refrain
from attending to the other non-infected patients in so far as possible.
Again, if in doubt contact Infection Control.
NB: NO staff meals/beverages to taken in the Leukaemia Unit. This
applies to both day/night shifts.
Visitors
 Ideally, strictly for parents or guardians – others, i.e. siblings, only on
prior consultation with staff.
 ONLY necessary staff (as already outlined).
 With regard to visitors having infections/feeling unwell – the same
restrictions as for staff (above) apply.
 All persons entering the unit MUST wash their hands and depending
on the risk assessment, the nurse will advise re any other precautions
to be taken i.e. the wearing of gloves, masks or aprons. These should
be available immediately inside the door and it is also recommended to
have an alcohol wipe, hand gel and/or Promethic XL Cream in the
vicinity for both staff and visitors.
Hand Hygiene
 Hand washing is regarded as one of the most important factors in
preventing spread of infection. Consultants, Nurse Managers and
Ward Managers must insist on good hand washing procedures.
 Routine hand washing with soap and water will render the hands
socially clean but in “high” risk areas, including Leukaemia Units, an
antiseptic hand wash preparation is also necessary – Hibiscrub.
 The use of Prometic XL Cream is also encouraged. It is
recommended that it is applied 3-4 times during the day or when rapid
disinfection is necessary. Remember it does not replace hand washing
but has quite a good inhibitory effect on MRSA etc.
 Even when gloves are worn remember that hand washing is mandatory
– before and after.
 Advise hand cleansing by the patient, before eating, after using the
bathroom, handling equipment etc.
NB: Alcohol Gel (i.e. Spirigel) to be placed at each
Individual Bed Side /Door
Protective Wear
Gloves/Aprons/Gowns/Masks
High standards of hygiene to prevent contact spread are important.
Gloves are indicated for:
 Contact/anticipated contact with blood/body substance
(Standard Precautions).
 If the patient has an infection.
 If the patient has a very low neutrophil count.
 When administering/handling chemotherapy drugs.
 Sterile gloves for aseptic procedures.
 Sterile gloves for any manipulation of Central Venous Lines (both in the
hospital and in the home setting).
Plastic Aprons are indicated for:
 Contact/anticipated contact with blood/body substance.
 Close contact with the neutropenic patient.
 Visitors having close contact with the patient.
 Use by cleaning staff.
Masks
(still ill - defined in the literature – CDC Guidelines, 1996)
 Not routinely necessary, only for those attending to/visiting the
patient if they have a sore throat, cough etc. In as far as possible, such
individuals should refrain from entering the room.
 Inter departmental visits, in as far as possible, should be avoided, but if
necessary, it should be pre-arranged that the patient is seen
immediately, to avoid contact with other patients, i.e. a visit to the XRay Department. Ideally, and where possible, first on the days list. In
such instances an N95 Mask should be worn by the patient (due to
presence of patients in large numbers in these areas.
 N95 masks for staff handling/administering chemotherapy drugs.
 No need for patients to wear masks either on their way in/out of the
hospital.
Equipment
 Immediately before/on admission of the patient, ensure that the room is
spotlessly clean and that the bed frame/bed table, locker or any other
equipment is wiped over with 1:80 Milton.
 Dedicate equipment, i.e. sphygmomanometer, stethoscope,
thermometer etc. These items must be disinfected with an alcohol
wipe before use.
 Daily damp cleaning of equipment in the room, including IV stands, IV
pumps, etc.
Food/Food Hygiene
 Only cooked and processed food should be given to
immunosuppressed patients. Uncooked food, particularly salads, may
be contaminated with Gram-negative bacilli or listeria and also soft
cheeses.
 If food from outside is brought in by parents, it is vital that this food is
handled properly and NEVER to be reused. Avoid re-heated food at all
times.
 Ensure that the kitchen work tops, fridge, microwave etc. are clean and
wiped over with Milton 1:80.
NB: Avoid giving ice to leukaemia patients. If it is absolutely
necessary, use only cubes made from sterile water, i.e.
boiled water, in separate ice bag sachets.
Toys/Play Area
 Leukaemic children should not have access to the play area attached
to the general ward.
 In addition (on their own unit) plastic toys are the type recommended,
in preference to soft toys. Plastic toys can be easily washed and
decontaminated by wiping over with Milton 1:80 (for general
disinfection) 1:10 (for blood spillage or high risk infection). Remember
to rinse off.
NB: It may be advisable when purchasing toys that they are
made of heat tolerant material that withstand machine
washing.
Cleaning
The Leukaemia Unit requires extraordinary cleaning measures
 Ideally, dedicated cleaning staff who are familiar with the requirements
for the specific area.
 Dedicated equipment – hoover, washing equipment, cleaning agents
etc.
 These items must not be moved/stored outside of the unit.
 It is the responsibility of the unit staff to ensure that the cleaners are
aware of any special requirements, i.e. if a patient has infection then
that patients room/area must be last on the days cleaning list.
 A clean supply of cloths/disposable cloths, scrub heads, buckets etc.
(as per colour coding system) should be available for each cleaning
session. Heavy duty cloths must be removed from the area after each
schedule and machine washed.
 As rooms/areas become vacant, a thorough clean of those areas
should be arranged/undertaken.
NB: Cleaning of televisions, videos, window blinds etc. –
these screens harbour a lot of dust and tend to attract
bacteria.
Refuse
 No special precautions (see Waste Management Guidelines/Infection
Control Manual) for disposal of refuse and linen but it must never
accumulate in the unit.
Crockery
 No special requirements - Wash in the automatic dish washer.
NB: No Plants/Cut flowers should be allowed in the unit
as they may harbour bacteria/insects
Construction/Demolition/Renovations in or near the
Leukaemia Unit
Nosocomial outbreaks of invasive Aspergillosis have become a well
recognised complication of construction/demolition/renovation activities in or
near hospital wards accommodating immunocompromised patients.
Nosocomial Asperigillosis can cause sever systemic infection in these
patients (Manuel & Kibbler, 1998). Outbreaks of infection in susceptible
patients are often associated with high spore levels in the air derived from
environmental sources, i.e. building sites, rather than person to person
spread, (Humphries et al, 1991).
 Where construction/demolition/renovation projects are planned in
Leukaemia Units, a multi-disciplinary team comprising of Hospital
Administrators, Nursing Directors, Technical Services, Designers,
Infection Control Staff, Relevant Clinicians, Medical & Nursing staff
should be established to develop, monitor the implementation of risk
management and Infection Control Guidelines.
 Clear lines of communication, among all personnel involved, must be
established at the planning phase. The protection of vulnerable
patients will depend on the acceptance and effectiveness of
implementing Infection Control measures, which will require high level
of commitment, understanding and co-operation from all personnel
involved in the construction project.
Construction/Demolition/Renovation activities in close
proximity to the hospital
 It should be noticed that similar risks are present in the context of large
scale construction/demolition/renovation activities external to but
proximal to the hospital.
 Hospital Managers should ensure that they are aware of such activities
i.e. by liaising with the Planning Authorities and receive notification of
planning decisions in the locality and institute precautionary measures
to protect a risk patients where appropriate, based on the findings of
the risk assessment (NDSC Guidelines for the Prevention of
Nosocomial Aspergillosis during construction/renovation activities).
Screening for MRSA etc.
 Monthly screening of staff (all grades).
 Screening of holiday locum staff or any new staff, prior to commencing
duty (Infection Control to be timely notified).
 Screening of staff post presence of MRSA on the unit.
 Screening of patients on the advice of the Microbiologist.
 Infection Control to carry out the procedure.
Liaison Staff & Patients own Home
Increasingly, patients with leukaemia requiring specialist treatment and
invasive devices are being cared for in their own homes. Preparation will
have started whilst still in hospital and continuing education by the Oncology
Liaison Nurse
 The organisms found in the home may be different from and not as
virulent as those in hospitals, but clinical practices need to be
underpinned by basic hygiene and infection control principles.
 Family members and anyone associated with the care of the patient
need a basic knowledge of safe practice.
 A basic understanding of routes of transmission of the micro-organisms
likely to be met and the methods of care of medical devices and
procedures to prevent their spread must remain the cornerstone of
practice (Horton et al, 2002).
 The use of alcohol gel and/or Prometic XL Cream are encouraged for
use in the home both by the patient, family and the nurse.
 The patient/family should be advised regarding the risk of Pasteurella
attached to “licking” of line by dogs/cats.
Weekly Return Clinics
These clinics/any other return visits for bloods etc. ideally should be dealt with
in an out patients setting as the unit is not large enough to accommodate both
in/out patient children and parents.
 In an out patient setting, it is important that the patients do not pass
through the general waiting area or sit in the general waiting area – a
separate entrance is advised.
 These rooms/areas should have some form of clean air.
 Priority should be given to these children to be accommodated for the
first clinic of the day.
For further Guidelines on Cleaning/Disinfection, Isolation etc. see
Section 8 and Section 9 and 12 of this Manual.
For detailed Guidelines for care of Central Venous Lines etc. refer to
Guidelines for Administration of Medical Preparations.
Strict adherence to the principles of asepsis, as outlined in the
Guidelines, must be adhered to for any intervention of the Central Line
in the unit or in the home setting.
9.7 Strict Isolation
Strict Isolation is stringent, high security isolation (in a single room/negative
pressure/ante room with wash hand basin and en suite toilet facilities). It is
used for patients with highly transmissible and dangerous infections, rarely
encountered in this area. However, due to the increase in foreign travel etc.,
it could be encountered. Ideally, these patients should be transferred to a
Regional Infectious Diseases Unit in an ambulance with special precautions.
Arrangements for such transfers should be made under the direct supervision
of the Microbiologist. However, as there is a lack of such facilities in this
country it may be necessary to deal with such situations in this hospital.
(Refer to Mercy University Hospital Guidelines for dealing with SARS – these
guidelines form a good basis for dealing with any “high” risk infection.
Location
 Single Room (purpose built) with RED card on the door.
Indications for Strict Isolation
 Lassa Fever
 Marburg
 Ebola
 Plague, Anthrax
 Rabies
 Sars
 Influenza Pandemic
 Othe deemed very “high” risk.
Precautions for Strict Isolation
Infection Control MUST be notified and the following precautions (in addition
to those already outlined) applied whilst awaiting transfer to Isolation
Unit/Designated Hospital.
 Single Room under negative pressure is essential. RED SIGN on the
door, which must be strictly closed.
 Staff – Restrict the number of staff having access to the patient and
the Department Head must maintain a list of all staff in contact with the
patient in strict isolation.
 Protective Clothing – Only disposable non-permeable, long sleeved
gowns must be worn and gloves must cover the cuffs of the gown.
Masks of high filtration (N95) which covers the nose and mouth must
be worn.
 Equipment – Use disposable equipment wherever possible. Non
disposable equipment must be kept inside the room and do not
circulate for communal use without consulting the Microbiologist.
 Linen – Use disposable linen if available. Non disposable linen should
be autoclaved before processing in the laundry. Otherwise destroy.
 Laboratory Specimens – In addition to placing specimens in a “bio
hazard” bag, the laboratory MUST be notified of the danger.
Specimens MUST be transported in a closed, robust container
(available from Bacteriology, with necessary equipment etc.)
Last Offices
 See Guidelines for Laying out of “High Risk” bodies (Section 11).
See also –
 Hospital Cleaning/Disinfection Protocols (Section 12).
 Hospital Detailed Guidelines for SARS – See Mercy University
Hospital Major Incident Plan, Pages 62-81. These Guidelines may be
referred to for any “very high risk” situation. They are particularly
specific to any “high risk” situation in the Emergency Department.
9.8 Isolation Methods for Individual Diseases
This section lists infections in alphabetical order, the category of
isolation and special nursing procedures. Some infections may not
require isolation e.g. Leptospirosis, but require excretion precautions
(urine). Examples are included in this table.
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Acquired Immune
Deficiency
Syndrome (AIDS)
Standard Precautions
Infectious Material –
Blood/Body
Substances
Isolation not
necessary – only if
there is profuse
bleeding – then
Contact Isolation
YELLOW SIGN
ONLY while the
profuse bleeding
persists
Anthrax
Cutaneous
Standard Precautions Contact Isolation Isolation for duration
of hospitalisation
(until off antibiotics &
cultures negative)
Laboratory must be
informed
(a) Pulmonary or
Systematic
Standard Precautions
Infectious Material Spores entering
abrasions on skin
Lung inhalation of
spores
Strict Airborne &
Contact Isolation
RED SIGN
The Laboratory
MUST be notified
Isolate for length of
illness/completion of
drug therapy
Note:
Standard Precautions must be taken with all patients and isolation
when needed is always in addition to Standard Precautions.
Ideally “High Risk” infections requiring strict isolation (Red Sign)
should be transferred directly to an Infectious Disease
Hospital/Centre (if available).
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Aspergillus Standard Precautions Isolation not
necessary
Not transmitted from
person to person.
Fungi causing
opportunistic
infections in
immunocompromised. It
occurs widely in the
environment –
particularly during
renovations.
Brucellosis Standard Precautions Isolation not
required.
Campylobacter Standard Precautions
Infectious Material Diarrhoea
Isolation not
necessary.
Not usually spread
from person to
person.
Never drink from
milk bottles whose
corks have been
“picked” by birds.
Candida
(Moniliasis
Thrush)
Standard Precautions Isolation not usually
necessary.
If necessary i.e. neo
natal and leukaemia
units – Contact
Isolation
Precautions.
YELLOW SIGN
Isolate for duration of
illness.
Spread is rare,
except in high
dependency units,
ICU, Leukaemia,
Neo Natal Units etc.
Careful use of
antibiotics should be
considered.
Chicken Pox
(Varicella Zoster
Virus)
Discharge home if
clinically fit.
Standard Precautions.
Infectious Material –
Respiratory droplets &
vesicle fluid.
Droplet & Contact
Isolation
Precautions.
YELLOW SIGN
Infectivity from 7
days/ until vesicles
are dry/crusted.
Non-immune staff,
particularly if
pregnant, should
refrain from
attending to these
patients.
NB All staff are
encouraged to know
their immune status.
Cold Sore Herpes
(Simplex Virus)
Standard Precautions
Isolation not
necessary but avoid
Encourage good
basic hygiene.
Infectious Material –
Saliva, Vesicles
contact with the
infectious material.
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Cholera Infectious Material –
Stools
Strict Contact
Isolation
RED SIGN
Length of illness
Clostridium
Difficile
(Spore forming)
Standard Precautions.
Infectious Material –
Diarrhoea
Single Rooms or
Cohort Nursing in
one room/area
YELLOW SIGN
(See Section 9.1 for
further details)
Isolation while
diarrhoea persists.
NB: Continue flagyl
for 4-5 days after
diarrhoea has
stopped.
Conjunctivitis Standard Precautions
Infectious Material –
Eyes/ Eye Secretions
Isolation not
necessary.
Crytosporidosis Standard Precautions Isolation not
necessary
Encourage good
hygiene.
Investigate source.
Exclude food
handlers.
Cytomegalovirus Standard Precautions.
Pregnant women
should be very careful
to avoid contact with
patients’ urine.
Isolation not
necessary.
Diptheria Standard Precautions.
Infectious Material –
Nasal/oral secretions.
Usually spread by
aerosol.
Strict Contact &
Airborne Isolation
RED SIGN
Isolation for duration
of hospital stay.
Focus of infection
may be the throat,
nasopharynx or skin.
Dysentary
(Shigellala
species)
Standard Precautions
Infectious Material –
Stools
Contact Isolation
YELLOW SIGN
Isolate until 3
consecutive negative
stools after acute
phase & free of
symptoms with
normal stool.
Spread faecal/oral
route (direct/indirect)
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Enteric Parasites
e.g. Ascaris,
Hookworm,
Tapeworm,
Threadworm
Standard Precautions
Infectious Material Stools
No isolation needed. Extreme care with
general/hand
hygiene.
Enteric Fever
Typhoid
Paratyphoid
Standard Precautions Strict Contact
Isolation
RED SIGN
ESBL’s
(Extended
Spectrum Beta
Lactams)
Gram negatives
i.e.
Klebsiella
Serratia
Proteus
Enterobacter
Pseudomonas
aerogenosa
Standard Precautions Contact Isolation
YELLOW SIGN
Isolation until clear
Detailed cleaning of
sinks, door handles,
general environment
etc. by Contract
Cleaners and, in
between, clean by
Ward Staff.
Recommend –
Alcohol Gel
Prometic XL at bed
side/ entry sink etc.
Fungal Infection
Systemic i.e.
Cryptococcosis
Histoplasmosis
Standard Precautions Isolation not
necessary
See Section on
Ringworm
German Measles
(Rubella)
Standard Precautions
Infectious Material
Droplets Urine of
infants and congenital
infection.
Droplet & Contact
Isolation.
YELLOW SIGN
Discharge patient
home if clinical
condition permits.
Exclude non immune
staff/visitors of child
bearing age or those
pregnant.
Gonococcal
- Opthalmia
Neonatorum
- Genital Infection
Standard Precautions
Infectious Material –
Genital tract
membranes
Contact Isolation –
single room
May be nursed in
open ward.
Isolate while there is
still discharge
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Hepatitis - Types
Type A Standard Precautions.
Infectious Material –
Faeces
Faecael/oral spread &
food water cont.
Contact Isolation
YELLOW SIGN
Considered
infectious 1/52 prior
to onset of jaundice
& usually for a few
days afterwards.
Type B Standard Precautions
(See Aids/Hepatitis B
Guidelines)
Isolation not
necessary unless
there is very profuse
bleeding/ other
complications which
may exist then –
YELLOW SIGN
Type C As Type B As Type B
Type D As Type B As Type B
HIV
(See AIDs)
Standard Precautions
Blood/Body Substance
Isolation
Do not require
isolation unless there
is very profuse
bleeding then –
YELLOW SIGN
Single Room is
required for
immunosuppressed
patients.
Isolation only for
duration of bleeding
(if profuse).
NB: Staff who have
cold sores should
not attend to
immuno-s patients.
Herpes Simplex Standard Precautions
Infectious Material –
Exudate, Saliva,
Lesions.
Contact Isolation
YELLOW SIGN
Isolate for duration.
Herpes Zoster Standard Precautions Contact Isolation
YELLOW SIGN
Isolated during the
length of the acute
phase – until
vesicles dry.
As Herpes Zoster
may lead to Chicken
Pox susceptible
individuals and
pregnant staff who
are not immune
should be excluded
from these patients.
Visitors who have
not had Chicken Pox
should be warned of
the risks.
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Herpes Zoster
….. cont.
NB: Staff with
herpes should not
attend to immuno –
compromised
patients.
Impetigo Standard Precautions
Infectious Material –
Lesions
Contact Isolation
YELLOW SIGN
Isolate until swabs
are negative – after
successful course of
antibiotics.
Influenza Standard Precautions Standard Droplet &
Airborne Isolation (if
admitted with the
disease)
YELLOW SIGN
For 5 days after
onset.
Isolation is of
doubtful value if
acquired in hospital
or if others are
suffering from the
illness.
Immunisation can be
offered to a selected
group.
Lassa Fever
VHF
Standard Precautions Strict Contact
Isolation
RED SIGN
Legionnaires
Disease
Standard Precautions Isolation not
necessary
Not transmitted from
person to person.
Regular flushing of
toilets/running of
hot/cold taps/
shower is
recommended.
Leptospirosis
Leoptospirosis
(Weil’s Disease)
Standard Precautions
Infectious Materail –
Urine
Isolation not
necessary
Not transmitted from
person to person.
Lyme Disease Standard Precautions Isolation not required No person to person
spread.
Transmitted to
humans by hard
ticks found on
bracken and in
undergrowth.
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Malaria Standard Precautions Isolation
unnecessary
Caused by female
mosquito bite.
No person to person
spread.
Rarely blood
transfusion spread.
Marburg Virus
Disease VHF
Standard Precautions Strict Contact
Isolation.
RED SIGN
Isolate for duration of
time in hospital.
Measles Discharge home if
clinical condition
permits.
Standard Precautions
Contact & Droplet
Isolation.
YELLOW SIGN
Infectious for 5 days
after start of rash
except in immunocompromised
patients with whom
precautions should
be taken for the
duration of illness.
Immunoglobulin for
exposed immuno –
compromised
patients.
If outbreak in
Paediatric Ward, do
not admit nonimmune children
until 14 days after
the last contact has
been discharged
home.
Meningitis
Coliforms
Standard Precaution Isolation
unnecessary
Neisseria
Meningitis
(Meningococcal)
Standard Precautions Droplet & Contact
Isolation
YELLOW SIGN
Isolate for 48 hours
after start of effective
antibiotic therapy
and patient has
received
chemoprophylaxis.
Children should not
visit.
Close contacts
should be given
Rifampicin
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Pneumococcal
Meningitis
Standard Precautions Isolation not
necessary
Viral Meningitis Standard Precautions Isolation not
necessary.
Meningocococcal
Septicaemia
Standard Precautions Droplet & Contact
Isolation
YELLOW SIGN
Isolation for 48 hours
after start of effective
antibiotic therapy
and patient has
received
chemophrophylaxis
MRSA Standard Precautions Contact & Airborne
Isolation
YELLOW SIGN
Isolate until negative
swabs (3)
See MRSA Section
for details
Mumps Standard Precautions
Exclude non-immune
staff.
Inform visitors who are
not immune
Droplet & Contact
Isolation
YELLOW SIGN
7 days before to 9
days after onset of
Parotid swelling.
Persons with
subclinical infection
may be infectious.
Norovirus (Winter
Vomiting)
Standard Precautions Contact + Airborne
YELLOW SIGN
Pneumonia Standard Precautions Usually no isolation
required but
Airborne Isolation
is required for
Streptococcal
Pneumonia resistant
to penicillin
YELLOW SIGN
Poliomyelitis Standard Precautions
Faecal/oral route
contaminated water
Strict Droplet &
Contact Isolation
Droplet spread
during the first week
– Masks should be
worn. Subsequently
faecal excretion is
Isolate while virus
persists in stools –
may be present for
weeks.
NB: Virus shedding
may follow
vaccination with a
live polio vaccine for
more important.
RED SIGN
several weeks –
careful with nappy
changes.
Visitors and staff
should be
immunized.
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Poliomyelitis …..
cont.
Gamma globulin for
non-immune
contacts.
Contacts. Booster
for immune contacts.
Psittacosis
(Q Fever)
Standard Precautions
Infectious material –
secretion precautions
Airborne Isolation
YELLOW SIGN
Isolate for 7 days
after onset. Spread
by airborne
dissemination of
rickettsiae in dust
and direct and
indirect contact with
infected animals and
other contaminated
materials.
Rabies Standard Precautions
Infectious Material
Secretions
Gloves/Gowns/
Goggles etc. Minimum
of staff involvement.
Staff with any lesions
should not attend to
the patient. Pregnant
staff should not attend
to the patient. Staff
should be offered
Gamma
globulin/immunization
Strict Contact
Isolation
RED SIGN
Isolate for duration of
illness.
It is spread via a bite
from infected
cat/dog/bat via
saliva.
Person to person
transmission has not
been documented,
however it is
theoretically possible
since the saliva of
the infected person
may contain virus.
Ringworm Standard Precautions
Infectious material –
Infected skin scales.
Depending on the
extent of the
Ringworm, isolation
in a cubicle is
advisable, especially
in a Paediatric ward.
If isolated Contact
Isolation
YELLOW SIGN
Salmonella (not
Typhoid
Paratyphoid)
Standard Precautions
Infectious Agent –
Faeces
Faecal/Oral spread
Contact Isolation
YELLOW SIGN
Until 3 stools
negative or
cessation of
symptoms. The
organism may be
present in the gut for
several weeks.
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Scabies Standard Precautions Not necessary to
isolate except in the
case of Norwegian
Scabies – in this
case, Contact
Isolation
YELLOW SIGN
Isolate until
successfully treated.
Norwegian Scabies
are very highly
contagious.
Streptococcal
Infection (including
Scarlet Fever &
Erysipelas)
Standard Precautions
Infectious material –
exudates and
secretions exudates
Contact & Droplet
Isolation
YELLOW SIGN
Isolate until
organism is no
longer isolated
(following drug
therapy)
Tape Worm Standard Precautions
Intestinal infection.
Infectious material –
Intestinal Excretion
No isolation needed.
Thread Worms Standard Precautions
Infectious material –
Intestinal Excretion
No Isolation
necessary
Attention to proper
hand hygiene. Give
patient their own
toilet roll etc.
Toxocara Standard Precautions
Infectious Material –
Excretion
No Isolation
necessary.
Toxoplasmosis Standard Precautions No Isolation needed.
Tuberculosis
Pulmonary (open)
Standard Precautions
Infectious Material –
Secretion & Exudate
Precautions
Airborne Isolation
Negative Pressure
Room
YELLOW SIGN
2 Weeks after start
of effective treatment
and sputum negative
for AFB.
See Section 8.1 for
details.
Multi Resistant
Tuberculosis
Standard Precautions
Strict Airborne
Isolation
RED SIGN
Isolate while in
Hospital.
Arrange monitoring
of compliance on
discharge.
Closed
Tuberculosis
Standard Precautions No Isolation needed.
Typhoid
Paratyphoid
Standard Precautions Strict Contact
Isolation
RED SIGN
Refer to Special
Unit.
DISEASE PRECAUTIONS
INFECTIOUS
MATERIALS
CATEGORY OF
ISOLATION &
COLOUR CODE (IN
ADDITION TO
STANDARD
PRECAUTIONS)
PERIOD OF
ISOLATION WHILE
IN HOSPITAL
OTHER
COMMENTS
Viral
Haemorrhagic
Fevers (some, e.g.
Lassa Fever, are
already mentioned
Standard Precautions Strict Isolation
RED SIGN
Vancomycin
Resistant
Enterococci
VRE
Standard Precautions
Infectious Material –
Exudate & Secretions
Contact Isolation
YELLOW SIGN
Patients can remain
colonized for a long
time after leaving
hospital. They
should be promptly
identified on readmission.
Extra cleaning,
wiping over door &
toilet handles, hand
washing facilities,
nozzles etc. as an
adjunct to the
contract cleaning.
The use of alcohol
gel/Prometic XL
encouraged.
Whooping Cough
(Pertussis)
Standard Precautions
Discharge patient
home is clinical
condition allows
Infectious Material Secretions
Airborne & Contact
Isolation
YELLOW SIGN
Isolate until 3 weeks
after start of
paroxysmal cough or
7 days after start of
effective antibiotic
treatment.
Visiting by children
should be restricted
to those who are
immune.
Prophylactic
erythromycin to
close contacts as
advised by MicroBiologist.
Ayliffe et al (2000)
Horton, Parker (2002)
NDSC & NHS Guidelines
10. Precautions with Specific Infections
10.1 Infectious Diarrhoea
These precautions are to be carried out in conjunction with Standard Isolation
Precautions (Yellow) – (see Section 9.2). They apply to single room/open
ward or cohort. They apply to all patients with diarrhoea/vomiting as all cases
of gastroenteritis should be regarded as potentially infectious until appropriate
investigations are completed (Damani. N.N., 1997).
Precautions
Send a specimen of faeces to the laboratory immediately when diarrhoea
occurs and where possible single room isolation (with toilet facilities) until
results are available. Ideally such patients should not use general washing
facilities/toilets. Where possible, only if clinical condition allows, patients with
enteric infection should be discharged home.
If food poisoning is suspected, a dietary history of infected patients/staff and
of non-infected controls should be investigated.
Samples of suspected foods should be collected from the kitchen. Catering
staff should be questioned for symptoms and samples of stools collected if
necessary. Affected Catering staff should not handle food until three negative
samples of stools are obtained (Ayliffe, Lowbury, Geddes, Williams, 1993).
Patients should be instructed to wash their hands thoroughly after using the
toilet/commode/bed pan or urinal (these should be for the patients own use)
and these patients should also have their own toilet paper/towel etc.
Excreta to be disposed of at once using “Standard Precautions” approach of
wearing plastic apron/gloves. Remember to wash hands before and after.
Staff dealing with excreta of patients with infectious diarrhoea/vomiting should
not, as far as possible, undertake feeding of other patients or attend highly
susceptible patients e.g. immunosuppressed.
Cleaning of the room – if infection is present the Ward Sister/Nurse in charge
must inform the cleaner and advise on the precautions to be taken e.g.
wearing plastic apron/gloves. The room/area should be last on the cleaning
schedule and separate (YELLOW) cleaning cloths; buckets etc. to be used
(See Cleaning/Disinfection Protocols – Section 12). If in doubt seek the
advice of the Infection Control for advice on cleaning/terminal
cleaning/disinfection etc.
Commode seat to be cleaned each time after use and disinfected with the
appropriate disinfectant, usually Milton 1:10 depending on the organism (see
Cleaning/Disinfection – Table 12.7).
Specimens to the laboratory should be securely fastened and placed in a
“Bio-Hazard” bag and remember to insert Bio-Hazard on the request form.
Also remember to inform all other Departments as necessary.
In the Paediatric Ward, staff attending to children with infectious diarrhoea
should not feed babies or prepare feeds. Gloves/aprons must be worn when
changing nappies of babies with known/suspect diarrhoea. Mothers who tend
their own babies should be instructed in the importance of hand washing and
should not handle other cots/babies.
Depending on the type of diarrhoeal infection, see Table 8.3 for type specific
isolation and precautions to be taken.
10.2 Tuberculosis
Open Pulmonary Tuberculosis
Droplet/Airborne Precautions in addition to Standard Precautions
(See Section 8.1) CDC 1996.
Location
 Patients who are sputum smear (AFB) positive, including those
previously negative who became smear positive on/after bronchoscopy
should be admitted to a single room. A room with negative air pressure
and en suite facilities is the recommended (Ayliffe et al 2003).
 NB: Remember to contact the maintenance department to ensure
correct pressure (on/before admission of the patient).
Protective Wear (immediately outside the door)
 N95 or 97 high filtration type (PINK or YELLOW)
 Plastic aprons, gloves
 Alcohol Gel
 Prometic XL Cream
 Alcohol Wipes (for door handles etc.)
 YELLOW Isolation Sign on the door.
Visitors
 Visitors should be restricted to those who have been in close contact
before the diagnosis and should be limited. They must wear a mask.
 Hand washing or the use of an alcohol gel as for all isolation areas is
all that is necessary.
Staffing
 Staff having immunity to Tuberculosis
 Keep to a minimum without compromising patient care. Allocated
person/persons should carry out as many tasks as possible at the
one intervention, for the patient i.e. present meal trays to the
patient and collect when partaking in some other intervention. No
need for kitchen staff to enter the room.
Equipment
 Dedicate equipment
o Mercury thermometer
o Blood pressure cuff etc.
o Single use disposable respiratory equipment and accessories
should be used where possible.
o If items are re-usable then they should be thoroughly cleaned
and disinfected or sterilized.
Chart
 All charts should be left outside of the door.
Refuse
 YELLOW bag placed immediately inside the door.
Linen
 All linen to be placed in a water soluble bag (alginate), securely tie
immediately.
Crockery/Cutlery
 Machine wash
Infection Sticker
 Place a YELLOW sticker with B.H. written in red on all request
forms to the Laboratory X-Ray, Physiotherapy, Pulmonary Function
etc. Also place a sticker on the outside of the patients case
notes/inside the Nursing Kardex.
Last Offices
 Standard Precautions
Cleaning
 Rooms occupied by patients with Tuberculosis should be last on the
day’s schedule.
 Any surfaces/equipment contaminated with saliva/sputum should be
cleaned immediately using a disposable towel washed with
detergent and water and wiped over with Milton 1:10.
 Terminal cleaning (see Hospital Cleaning Protocols – Section 12)
Toys
 Toys should be washed/wiped over with Milton 1:10 or autoclaved
Inter-Departmental Visits
 Limit the movement/transport of the patient to essential purposes
only.
 Seek advice from the Infection Control team.
Termination of Isolation
 The Microbiologist in conjunction with the Consultant should decide
when to terminate isolation. Uncomplicated sputum positive
tuberculosis will usually be non-infectious after two weeks
compliance with multi-drug therapy (Ayliffe, Lowbury, Geddes,
Williams, 1992).
 Adult patients with pulmonary TB having three negative smear
samples and patients with non-pulmonary TB (with the exception of
those with infected discharging wounds) should be regarded as
non-infectious and nursed in an open ward.
 NO patient with suspected/confirmed respiratory tuberculosis,
whatever the sputum status, should be admitted to an open ward
containing immunosuppressed patients, such as HIV infected or
Oncology patients (Damani, N.N., 1997).
NB: Cough inducing procedures for production of sputum etc. should never
be performed in an open ward.
Patients with Smear Negative Sputum
 They are not infectious. Routine infection control measures will be
adequate. They may be nursed in a general ward. Safe disposal of
used tissues etc. into clinical waste (YELLOW) bag.
 They are not infectious provided that drainage/dressings etc. are
handled with care. Immediate safe disposal of dressings etc. into
clinical waste (YELLOW) bag is essential to prevent cross infection.
10.3 Guidelines for Bronchoscopy in Patients
with possible Pulmonary Tuberculosis
– in the Mercy University Hospital, 2005
Possible tuberculosis is a common reason for admission for bronchoscopy in
our hospital.
1. Mycobacterium Tuberculosis is discovered in the laboratory by
one of two methods:
(a) Acid and alcohol fast bacilli stain (also called AFB or smear) –
this is done by directly looking at the specimen under the
microscope and identifying the organism. TB specimens which
contain a lot of TB organisms are often acid and alcohol fast
stain positive (AFB positive or smear positive).
(b) Tuberculosis culture – this is done by growing the organism in
culture. TB is very slow growing so, unlike bacterial infections, it
may be 10-12 weeks before the results are reported. TB
specimens which contain very few TB organisms are often acid
and alcohol fast stain negative (AFB negative or smear negative
but culture positive.
2. Pulmonary Tuberculosis is diagnosed in one of three ways at
present:
(a) Positive sputum, AFB or smear. The patient is coughing up
sputum that is AFB or smear positive. These patients are open
or infectious, but are usually diagnosed as having pulmonary
tuberculosis without the need for bronchoscopy and are started
on treatment. Tuberculosis culture will usually confirm the
diagnosis and identify the subtype organism.
(b) Negative sputum, AFB or smear negative. The patient is not
coughing up sputum or the sputum that the patient is coughing
is AFB or smear negative. These patients are closed or not
infectious and will usually proceed to bronchoscopy to obtain
bronchial washings. Bronchial washings or tuberculosis culture
will then determine whether the organism can be found.
(c) Clinically based on a high index of suspicion, after the above
investigations have proven negative.
3. Therefore, the critical determinant of whether a patient is infectious or
not is whether their sputum is AFB or smear positive (see algorithm
below).
For patients with suspected tuberculosis, surgical facemasks do not provide
adequate protection during bronchoscopy and should be replaced by
disposable particulate respirators e.g. N95 Respirator
Guidelines for staff in preparing the patient with
possible pulmonary TB for Bronchoscopy
In most case if the Bronchoscopy is being performed to look for pulmonary
TB, the sputum will be AFB or smear negative and thus the patient should
managed as any other patient on the ward, except that all patients with
suspected tuberculosis should undergo bronchoscopy at the end of the list.
In rare cases, or when a patient with AFB or smear positive pulmonary TB is
having a bronchoscopy for another reason, the following infection control
guidelines apply:
 Isolate the patient if possible.
 If this is impossible, the patient must wear a mask at all times.
 Wear a disposable particulate respirators e.g. N95 respirator, gown
and gloves when dealing with the patient in close contact (nurses,
not adjacent patients).
Guidelines for staff in the Endoscopy Suite
Patients with suspected tuberculosis should undergo bronchoscopy at the end
of the list.
(a) All staff in the endoscopy suite should wear a facemask, gown and
gloves during bronchoscopy, irrespective of whether the patient is an
“open” or “closed” case.
(b) If a patient has suspected pulmonary tuberculosis, all staff should wear
a disposable particulate respirator e.g. N95 Respirator.
Dr. Terry O’Connor
Dr. Neil Brennan
CNS Nellie Bambury
Dr. Jim Clair
10.4 Meningococcal Meningitis
Introduction
Person to person contact is mainly by droplet spread from the upper
respiratory tract and no reservoir other than humans and the organism dies
quickly outside of the host. The incubation period is 2-10 days but most
invasive disease normally develops within seven days of acquisition.
Therefore, for practical purposes a one-week period is considered sufficient to
identify the close contacts for prophylaxis (Damani, N.N., 1997). Urgent
admission to the Hospital is a priority and early treatment with benzylpenicillin
is important and saves life (PHLS Meningococcal Infection Working Group –
1995). It is now the policy of the HSE that all suspect cases are given such,
by the General Practitioner (if seen by the GP) prior to admission (Southern
Health Board Guidelines for Meningococcal Chemoprophylaxis).
Management in Hospital
Location
All cases of suspected Meningococcal disease should be placed in Single
Room – Standard Isolation (YELLOW) – Respiratory Precautions. Some
books state isolation for 48 hours after therapy but penicillin does not get rid
of the carrier status. The acceptable practice now is to give all patients
Rifampicin for 48 hours before going to an open ward.
Notification
All suspected/confirmed cases of Meningococcal illness should be urgently
reported to the Public Health Department, Abbey Court House, by the
Clinician/Microbiologist.
Chemoprophylaxis of Contacts
Close contacts have an increased risk – 750 times more than others (B.M.J.)
of developing Meningitis/Septicaemia. This risk is greater in the first few
days. Rifampicin should be offered as soon as possible to all close contacts
(UK Guidelines).
Outside the Southern Health Boards hours (9.00 am to 5.00 pm, Monday to
Friday), chemophrophylaxis is provided by the Hospital. Remember it must
still be notified when working hours resume. NB: As there are side effects
to Rifampicin, a leaflet regarding it must be given to those receiving the
drug (Such leaflets are available on each Department).
Close contacts deemed at risk are:
 Household contacts – all those sharing living accommodation with the
case in the ten days prior to admission.
 Kissing contacts – all kissing contacts of the case in the 10 days prior
to admission.
 Nursery school/day care centre contacts – school contacts are not
usually considered to require chemoprophylaxis unless more than one
related case occurs in school.
 Health care workers are not considered at risk and do not require
prophylaxis unless involved in mouth to mouth resuscitation.
NOTE: It is important to emphasize that chemophrophylaxis is effective
in reducing the naso-pharyngeal carriage rates after treatment but does
not completely eliminate transmission between household members.
Contacts should be reminded of the persisting risk of disease, and of
the need to contact their G.P. urgently if they develop any symptoms.
10.4A Viral Meningitis
If in doubt as to the viral or bacterial aetiology of a clinical case of meningitis it
is desirable that the patients should be isolated in a single room, as quickly as
possible – Standard Isolation Precautions -YELLOW
In the case of Viral Meningitis the following must be taken into consideration
on admission.
1. Viral Meningitis is spread in two ways:
- Hand to Mouth.
- Droplet Spread.
2. It may not be always practical to isolate a diagnosed case of viral
meningitis but it is still desirable. If this is not feasible, please ensure
that the patient is kept away from babies, as babies are the most
vulnerable to the virus. Affected children should be restricted to their
own room/area and should not be allowed to roam the
corridors/department etc.
Should more than one child present with viral meningitis they may be
cohort nursed.
NB: Remember proper hand washing at all times and the use of Alcohol
gel and Prometic XL Cream – other precautions as in Section 10.3
(previous section).
3. All cases of Viral Meningitis must be reported to:
- Infection Control Dr. Clair/Infection Control Nurses
- Microbiology Secretary (if unavailable) Ext 5716.
10.5 Clostridium Difficile Infection
Introduction
In the last two decades, Clostridium Difficile has been recognised as a major
cause of diarrhoea, particularly in the elderly and debilitated patients and
patients who have had antibiotic treatment (Damani, N. N. 1997). The
majority of cases that have been reported have occurred in people over fifty
(Professional Nurse, 1997). Whilst being associated with a number of enteric
diseases (Viscidi et al, 1981), it is significantly the most common cause of
pseudomembranous colitis (antibiotic associated colitis), (Bartlett et al, 1980).
All suspected cases should be investigated by sending faecal specimens to
the Microbiology laboratory for detection of Clostridia toxin (Tabaqchali S,
Jumaap P., 1995). Clostridia Difficile has the ability form spores that survive
in the environment for months. They are highly resistant to most disinfectants
and therefore in order to minimize environmental contamination the emphasis
needs to be on standards of cleaning rather than chemical disinfection but
however, Milton 1:10 is highly recommended. The following infection control
precautions should be taken.
These precautions are to be carried out in conjunction with Standard
Isolation Precaution YELLOW – Section 8.1
Precautions
Location
 Infected patients should be segregated from non-infected patients in a
single room with en suite toilet facilities, where possible, or if more than
one is affected cohort in one room – yellow card on door.
Staff
 Where possible designated staff should care for these patients.
Charts
 Patient’s charts should be kept outside of the room, as paper cannot be
decontaminated.
Visitors
 Visitors must report to Ward Sister/Nurse in charge before entering the
room to receive instructions on protective clothing/precautions to be
taken. They should be kept to a minimum and visiting for children is
not recommended.
Refuse
 All refuse to be treated as infectious and placed in yellow bag for
incineration. This bag should be kept on a stand inside the door of the
room, tied securely before leaving the room. Arrange for prompt
transport to the Compound.
Linen
 All linen to be treated as infectious and placed in “alginate” bags, tied
securely before sending to the laundry.
Crockery/Cutlery
 Machine wash with rinse cycle above 80 degrees C and dry
thoroughly. Do NOT over stock the Isolation room with supplies e.g.
nappies, bags, dressings etc. This leads to considerable wastage, as
everything within the infected zone has to be discarded at terminal
cleaning of the room.
Hand Hygiene
 Hands can become contaminated by direct contact with patients who
are colonized/infected with Clostridium Difficile, or by contact with
spores contaminating the environmental surfaces. Therefore, strict
hand washing and wearing non sterile disposable gloves before/after
contact with the patient remains the most effective infection control
measure in preventing person to person spread of this infection.
 Hands must also be washed after removing gloves. Remember to
repeat this procedure between each patient.
Plastic aprons must also be worn. No masks.
Environmental Cleaning – Daily
 The patients immediate environment/other areas where spores may
accumulate e.g. sluice, commodes, toilets, bedpans, sinks, floors and
other soiled areas must be cleaned frequently and thoroughly with
warm water and detergent .
 The room must be cleaned daily and the cleaner advised of the
requirements and precautions to take.
 Separate equipment must be reserved for this purpose and kept within
the area.
 Single use disposable cloths must be used and discarded into the
yellow bag (within the room) after use.
 Milton 1:10 should be used for disinfection. Note: Door handles
should be wiped frequently during the day/night (an alcowipe).
Termination of Isolation
 The patient may be discharged home/to the open ward when the
diarrhoea no longer persists or the Clostridia toxins are not longer
present in the stools
 NB: In the case of patient discharge or transfer the medical
practitioner should be informed about the patient’s diagnosis.
Terminal Cleaning
 All refuse, linen (including curtains) in alginate bags, should, when
properly closed be removed from the room.
 All equipment must be cleaned with detergent and water and
disinfected with Milton 1:10 before removing from the room.
 Likewise for fixed equipment e.g. Oxygen fittings, lampshades,
switches, walls, floors, windows, ledges, beds etc.
 NB: Remember after using Milton, delicate surfaces such as
mattresses should again be washed over with plain water.
 When clean/disinfected as for any infection open windows fully and
leave vacant for as long as possible. However if the room is needed
urgently as it is not airborn it may be used. Proper cleaning/disinfection
is what is necessary.
10.6 Hepatitis B, C/HIV Infections
Introduction
Health care workers are known to be at risk of acquiring blood-borne
pathogens through exposure to infected blood/body substances. Worldwide,
at least sixty four health care workers have acquired HIV through exposure at
work, many have acquired Hepatitis B. Virus and there is evidence of
Hepatitis C transmission. The greatest risk of transmission is following
inoculation injuries, but it is also known to have occurred following splashing
of blood on to mucous membranes or broken skin.
Individuals infected with blood borne pathogens cannot be reliably detected
and although some activities are known to increase the risk, e.g. sharing of
intravenous drug users equipment/sexually promiscuous medical staff are not
always aware of “high risk” behaviour practiced by their patients, so
blood/body substance precautions must be consistently used for all patients,
(Ward, Wilson, Taylor, Cookson, Glynn, 1997) and (Alter M.J., 1994).
Measures of Control
Standard Precautions – Section 7.1 must be strictly adhered to and, in
addition to this approach, the following specific measures:
“High Risk” Infection Sticker
Hepatitis B/C, HIV positive or presumed positive should have a special
YELLOW luminous sticker with “B.H.” written in red (in line with other “high
risk” infections) attached to:
(a) Outside of case notes
(b) Inside of Nursing Kardex
(c) All request forms to the Laboratory Department, Physiotherapy
Department, X-Ray Department, Pulmonary Function Department,
EEG Department etc.
(d) In order to preserve confidentiality, it is not regarded as essential to
note the precise infection risk in the case notes or on the sticker.
All grades of staff should recognise the sticker and thereby take the
necessary Blood/Body Substance Precautions.
Location
The Hepatitis B/C, HIV patient can be nursed in the open ward and other than
observing blood/body substance precautions do not require any restrictions.
However, if they are bleeding, have diarrhoea, are psychotic or require
isolation for other reasons (e.g. open tuberculosis) then single room
accommodation is indicated (Ayliffe, Lowbury, Geddes, Williams, 1993).
Laboratory Specimens
 Specimens to the Laboratory should be placed in special “bio-hazard”
bags.
 Do not overfill specimen containers, by doing so it will cause leakage
and become an infection hazard.
 For the same reason ensure that caps are tightly secured.
 Any specimen container having evidence of blood/body fluids are not
acceptable in the Laboratory. The same applies to request forms.
Inter-Departmental Visits
 If it is necessary to transfer patients to other departments the receiving
department must be informed of the risk so that the appropriate
precautions can be taken.
 If the patient is likely to bleed/vomit, the accompanying nurse should
bring along some tissues, bowl etc. and provisions for self protection.
 NB: Always notify Theatre, Endoscopy Unit etc. of “high risk” and these
patients in as far as possible should be placed last on the day’s list.
Refuse Disposal
 Disposal of clinical waste as per usual (yellow bag). All non-clinical
acceptable in clear bags for the City Council.
 There are no restrictions for food disposal.
 Sharps – Extraordinary care must be exercised, to avoid injury with
needles/sharps (Viral Hepatitis Prevention Board, 1994). See Section
13.4 – Guidelines for Safe Use/Disposal of Sharps.
Crockery/Cutlery
 No special precautions are necessary other than the usual machine
washing at 80 degrees centigrade. In some situations where there is
bleeding from the mouth or Respiratory Tract, disposables should be
used.
Laying Out of Bodies
See Section 11 – Guidelines for Laying out “High Risk” bodies.
Terminal Cleaning of Room
See Section 12 – Cleaning/Disinfection Policy
See: Local Guidelines pertinent to Operating Theatre, Endoscopy Unit etc.
are available on these specific units.
10.7 Viral Haemorrhagic Fevers
Introduction
The Viral Haemorrhagic Fevers are endemic in west and central Africa.
Although never seen in this country, there is nevertheless (due to travel
abroad) the possibility that such provisional diagnosis might first be made in a
Casualty Department or in a patient already in a general ward. The following
action must be taken:
This is an emergency. A team to direct the emergency must be assembled
immediately.
The patient must be isolated in a Single Room – Strict Isolation (RED). See
Section 8.2 for details.
As a matter of urgency contact the Microbiologist and the Infectious Disease
Consultant, who will arrange immediate transfer to a “Special” Unit.
The absolute minimum of staff may have contact with the patient e.g. one
doctor and one nurse. The doctor involved in making the initial decision
should only seek advice from the Microbiologist. In such circumstances no
other medical staff should be invited to assist in confirming suspicions, to
minimize the risk to health care workers.
Staff already involved in the case must not resume other professional duties
and should remain, as far as possible, within the department, using a
designated staff room. Instruments dressings, documents, clothing or any
other item must not be removed from the area.
In consultation with Infection Control/Occupational Health arrange any
necessary continuing isolation for those that have been in contact with the
patient. Also, determine patient contacts and decontamination measures of
room and equipment (Damani, N.N., 1997).
For full Guidelines see: NDSC Management of Viral Haemorrhagic
Fevers in Ireland – NDSC Website – www.ndsc.ie.
10.8 Antibiotic Resistant Infections
Introduction
The problem of resistance to antibiotics has been aggravated by the misuse
and overuse of antibiotics worldwide in the treatment of humans and animals
and in agriculture. The effect of such usage is a general ecological selection
of those bacteria that survive. In some parts of the world where there are
inadequate supplies of antibiotics, partial treatments may be given. This fails
to cure the disease and instead aids the emergence and spread of resistant
bacteria (Journal of Infection Control Nursing, 1996).
The most effective way to prevent and curb resistance is prudent use of
antibiotics appropriately and for the designated periods (as short as needed),
thereby reducing their overall selective effects. This, to- gether with good
professional practice and routine infection control precautions such as hand
hygiene, constitute the major measures in controlling and preventing health
care associated infection ie MRSA. Both in the hospital and the community
(SARI) Topical antibiotics and unjustifiably prolonged courses of treatment
and prophylaxis should be avoided (Sanderson, P.J., 1984). Equally
important is the early detection of resistant organisms and prevention of cross
infection.
Of this complex group this section will cover one of the more common
resistant infections in this area.
10.9 Methicillin Resistant Staphylococcus
Aureus (MRSA)
Staphylococcus aureus is one of the most common pathogens well known for
causing skin/soft tissue infections. Up to 30% of healthy people carry Staph.
Aureus in their nose/other moist areas. The majority of these are sensitive to
antibiotics. MRSA is resistant to flucloxacillin and erythromycin, the most
commonly used antibiotics to treat Staph. Aureus infection, but they are also
resistant to other antibiotics, leaving only antibiotics which are very expensive.
The consequences of not controlling MRSA in hospital leads to increased cost
because of increased length of stay of patients in hospital/increased antibiotic
costs (Damani, N.N., 1997).
As part of the remit under SARI National Guidelines- Control and
Prevention of MRSA in Hospitals and in the Community were introduced
in 2005. All staff members should be familiar with this document and use as
an adjunct to MUH Guidelines which have been modified to suit the MUH.
The document is available
 In the Mercy Hospital Library
 From Health Protection Surveillance Centre,
25-27 Middle Gardiner Street, Dublin 1.
Tel. +353 1 876 5300
 Fax +353 1 856 1299
 Email info@hpsc.ie www.hpsc.ie
If any difficulties are encountered in obtaining a copy please contact
infection control.
Measures of Control
Standard and Transmission Based Precautions. MRSA is spread by both
airborne and contact routes.
YELLOW Isolation sign on the door.
1st Choice Isolate in a singe room where possible
2nd Choice Nurse together in a room specifically assigned to MRSA
3rd Choice On an open ward, placed together in a specifically
assigned area (cohort) adjacent to an open window if
possible and a Hepa Filter Unit to segregate. (This is not
an ideal location).
NOTE: For non-ventilated rooms, the use of the mobile Hepa Filter Unit is
always recommended.
Keep the door closed at all times. Open the windows – if it is a room with a
fan, open the window on the opposite side of the fan, not directly next to the
fan.
An MRSA patient must NOT under any circumstances be placed near an
immunocompromised patient.
The patient should be promptly discharged from the hospital if the clinical
condition allows.
Routine Screening – Nasal Swabs on:
 All patients previously colonised.
 Transfers from other hospitals/nursing homes/long stay institutions.
 All international hospital transfers.
 All patients scheduled for open surgery.
 Repeated admissions for:
Chronic Chest
Leukaemia
Cytotoxic Treatment
 All patients with leg ulcers/suprapubic catheters.
 Long stay patients – swab every three weeks.
 Screening during outbreaks is on the advice of Infection Control.
 Screening of staff will be carried out by Infection Control on the advice
of the Microbiologist.
As soon as MRSA is identified, place small PURPLE sticker on:
 Outside of case notes
 Inside of the Nursing Kardex
 Front of Drug Sheet
 All department requests (as already outline in Section 5.1)
Do NOT write MRSA on sticker – insert only the date of isolation of MRSA on
or alongside the sticker.
Staff
 The number of staff attending to the patient should kept to a minimum,
if possible. Staff with skin lesions, eczema etc. should be excluded.
Sharing of Information
 The onus is on the referring Doctor to inform the admitting hospital of
the patients MRSA status.
 Inform the Microbiologist/Infection Control Sister when a previously
known MRSA patient is admitted to the ward.
 Staff including Care Attendants, Ward Porter, Physiotherapists,
Phlebotomists, ECG Technicians, and Cleaners etc. should be
informed by Department heads of the patients status. This particularly
important at change of shifts – night shift included.
 Theatre staff, Endoscopy staff etc. should be informed and is so far as
possible, these patients should be placed at the end of the days list.
 See Section above for tagging of charts.
Visitors
 Visitors should be advised regarding not sitting on beds and avoiding
visiting other patients. Visitors must wash their hands on
entering/leaving the room/area. Where possible restrict.
Gloves
 Gloves must be worn when in close contact with the
patient/environment.
 Hands must be washed and dried properly before/after attending to an
MRSA patient and always on leaving an affected area. An antiseptic
e.g. “Hydrex” and/or the use of Mercy XL Cream. Hand washing is
mandatory even when gloves are worn. Alcohol hand rub should also
be on hand.
NB: Proper hand washing in addition to good antibiotic control is regarded as
one of the most important means of preventing spread of MRSA and should
be strictly adhered to by all grades of staff (Taylor L., 1978) (Reybrough G.,
1986).
Aprons
 Plastic aprons should be worn where a lot of physical contact is
involved. If used, they must be changed between patients.
Masks
 Not routinely necessary- do use for close chest physiotherapy, cough
induced procedures, suctioning of ventilated patients.
 NB: Remember to dispose of protective wear in the “yellow” bag
before leaving the affected area.
Environment/Equipment
 Where possible, keep all equipment in the patient’s room/area for their
sole use – Stethoscope, Blood Pressure Devices etc.
 Where possible, an MRSA patient should be allotted their own
commode (if in room without bathroom) of if communal remember to
clean after use.
NB: As in the case of any isolation - Do NOT overstock the room. Only
take what is necessary to the bedside/room.
Charts
 Case notes/Prescription Charts/Temperature Charts etc. should be
kept outside of the room – paper cannot be decontaminated.
Refuse
 All refuse must be disposed of as clinical waste (yellow bag). Bags
must be sealed before leaving the room/area.
 NB: The yellow bag MUST be kept within the room to confine the
infection.
Linen
 “Used” linen must be handled gently to avoid scattering bacteria. Linen
must be placed in an “alginate” bag, at the bedside, tied securely and
removed promptly to the dirty utility area.
Crockery/Cutlery
 Do not require segregation – Machine Wash (80 Degrees C).
Cleaning
 Department Head/Senior Nurse should inform cleaning staff each
morning/evening of the room/area needing special attention – separate
cleaning cloths/equipment etc. These areas should be placed last on
the day’s schedule.
 Good housekeeping is what is necessary – furniture i.e. bed frames,
lockers, bed tables, curtain rails etc. to be cleaned daily with detergent
and water or with a hypochlorite e.g. Ajax.
 Particular attention should be paid Monitors, TV screens( screens
seem to attract bacteria) drip stands, pumps, sinks, taps,
shelves/ledges, lamp shades, refuse stands, hibiscrub/soap dispenser
nozzles etc. Door handles/surrounds should be cleaned a few times
and wiped over with an alcohol wipe on leaving the area.
 During the presence of MRSA particular attention should be paid to
toilets/showers – this should be the case at all times.
 Frequent changing of patients clothing, towels, linen is recommended.
 Stethoscopes should be cleaned after each use with 70% alcohol
wipes or ideally dedicate stethoscope.
Terminal Cleaning
 Disposable equipment and other refuse MUST be placed in a
YELLOW bag, secured and removed from the area.
Linen and curtains to be placed in an “alginate” bag and sent to the laundry.
 Any equipment to be removed from the room MUST be washed before
removing. Wash with detergent and hot water.
 NB: Remember to clean the Hepa Filter Unit. A Hydrogen Peroxide
Decontamination Unit is desirable if possible.
NB: OPEN THE WINDOWS
For further details see Cleaning/Disinfection Protocol – Section 12. If in
doubt, seek the advice of Infection Control.
Transfer of Patients with MRSA
Within the Hospital
 Keep to a minimum – only if necessary
 Notify receiving area of patient’s status
 Ensure that transferring staff are aware that the patient is MRSA
positive. Avoid close contact as much as possible with the patient. No
need to wear gloves/aprons etc. when transferring MRSA on trollies
/wheelchairs unless there is risk of bleeding/other leakage of body
fluids. Hand washing is essential.
 Precautions for going to Theatre etc. (as already mentioned).
 Prompt attention in Out Patients/Casualty etc.
Discharge/Transfer to other Acute Hospitals/
Institutions/Nursing Homes /Community
 Notify the relevant Health Care Professionals when a patient is/was
colonized/infected with MRSA is being discharged/transferred. It is not
a reason to delay transfer but the discharge letter should include
details of the status/treatment regime.
 MRSA is not a reason for refusing to accept a patient back to the
referring hospital.
Death (of patient having MRSA)
 Usual precautions.
Health Care Personnel
 Screening programme ongoing (on the instruction of the
Microbiologist).
 Staff with nasal carriage may continue to work in low risk areas. They
will be treated with nasal Bactroban (t.i.d.) completing the tube and reswab 3 to 4 days after completion of treatment. Ideally they should not
work in ICU, Leukaemia Unit, Oncology or other high-risk areas, until a
until at least having two days of the cream. They should not, even in
low risk areas perform dressings/aseptic procedures until 24 hours
after commencing treatment.
 Staff with hand carriage (if known must adhere to strict hand washing
principles- soap. Alcohol gel, Prometic XL. Gloves should be worn and
again affected staff should not perform dressings/aseptic procedures
until rid of carriage.
 Repeat swabs should be sent to the laboratory after consultation with
Infection Control.
Dressing Procedure for Infected Wounds
This includes all infected wounds but particularly wounds infected with
resistant organisms.
 A separate dressing trolley should be used or otherwise these wounds
should be placed last on the day’s list.
 Do not uncover the wound until ready to carry out the dressing
procedure.
 Ideally the person dressing infected wounds should refrain from
dressing clean wounds.
 Gloves and plastic aprons should be worn.
 Prompt sealing of the pack containing the soiled dressings is important.
 Immerse the soiled instruments in the usual quix solution before
transfer to CSSD.
 On completion, ensure thorough cleaning of the trolley with quix
solution. Leave to dry and wipe over with alcohol – 70%.
NB: For patients – Do not apply Bactroban to wounds, tracheostomy sites
etc. or do not treat nasal carriage of MRSA with Bactroban cream. Seek the
advice of the Microbiologist.
10.9 (A) Mercy University Hospital Patient
Decontamination Protocol for MRSA
Patients colonised with MRSA who are to undergo an elective procedure,
have a prosthesis in situ or are in a clinical area where there is high risk of
colonisation leading to invasive infection, eg ICU should undergo
decolonisation. A risk assessment of other patients such as long stay patients
or patients with chronic nasal colonisation should be carried out to determine
if nasal decolonisation should be attempted in these patients. However,
excessive use of nasal decolonisation agents should be avoided as this may
select for resistance to these agents (SARI (2005) p.19).
This regimen should be commenced on the advice of the Infection
Control Team only and in consultation with the Consultant. It is not a
prescription.
Guidelines for administration of
Prometic Body Wash & Shampoo
Guidelines for the administration
of Mupirocin Nasal Ointment 2%
(Bactroban) as prescribed on drug
chart
Patients should bathe daily for 5
days with special attention to the
known possible carriage s
 Wash skin thoroughly
 Apply body wash using clean
cloth
 Wash whole body paying
particular attention to the
hairline, axillae, perineum,
groin, feet and any patch of
damaged skin. These should
be at least 1 minute contact.
 Rinse skin thoroughly
 Wash hair with the agent twice
during the 5 days
 After washing patient should
have fresh change of clothes &
bed linen
Apply Bactroban 2% Nasal
Ointment to the nose three times
daily for seven days
 Encourage patient to blow the
nose to clear away secretions
 Unscrew cap & squeeze a
small amount (pea size) of
ointment onto a cotton bud
 Apply to the inside of both
nares
 Close nostrils by pressing the
sides of the nose together
 Use Nasal Ointment only as prescribed
 Re- screen with swabs for MRSA after 24 hrs, 3 days and 5
days unless the patient is being discharged.
 Records should be kept of swabbing results
Reference- Strategy for Control of Antimicrobial Resistance (SARI) 2005,
Section B1. 24, P19.
10.10 Multiple Resistant Gram Negative Rods
(ESBLs)
Introduction
Q. What does ESBL stand for?
A. Extended Spectrum Betalactamase
These are Gram-negative rods including Klebsiella, Citrobacter, Serratia,
Enterobacter, Proteus spp, Pseudomonas aerogenosa etc and they have the
power to become very resistant. These organisms can cause hospital wide
problems because of their ability to acquire resistance to antibiotics. They are
more widespread in the hospital environment as a result of broad-spectrum
antibiotic usage/invasive techniques (Damani, N.N., 1997).
Wet environments in the hospital are the major reservoir of these organisms.
They are spread between patients on the hands of health care workers
(Loomes S, 1989).
Measures of Control (these measures to carry out in conjunction with
Standard Isolation Precautions – See Section 8.2 for details).
If the infected patient is in a special unit e.g. ICU, Oncology, and Leukaemia
etc. the patient should be isolated in a single room with Contact Isolation.
Precautions to prevent cross-infection to the highly susceptible patients
(Ayliffe, Lowbury, Geddes, Williams, 1993).
 Compliance to hand washing procedures/wearing of gloves is
essential. Patients should not be transferred between wards/hospitals
unless absolutely essential. If essential, Infection Control should be
contacted.
 Extreme care should be exercised with the handling of bed pans,
commodes, urinals etc. Disposable are recommended, otherwise
ensure proper cleaning/disinfection.
 Communal equipment may act as a source for these organisms,
therefore ward equipment must be stored dry and soaking of
instruments in disinfectant must be avoided. Ward equipment, where
possible, should be sterilized.
 Insertion of urinary catheters should be carried out as an aseptic
procedure. Urine drainage bags must be emptied by the tap, for which
single use disposable gloves should be used and hands should be
washed before/after the procedure. Do not break the circuit and
reconnect. A separate jug/container should be used for each patient
when emptying urinary drainage bags (see Catheter Care Booklet for
further details).
NB: Excessive use of broad-spectrum antibiotics should be avoided.
Antimicrobial prophylaxis for surgery should be restricted to a maximum of 24
hours (Damani, N.N., 1997).
Cleaning
 Extraordinary detail to cleaning is necessary in the presence of ESBLsparticularly sinks, taps, door handles, toilets etc.
 Ensure that then cleaners are made aware of the requirements.
 Cleaning in between usual schedules is necessary and staff
themselves are encouraged to wipe over the environment with an
alcohol wipe as often as possible.
“Infection Risk “Sticker-Highlight the outside of the case notes, inside of the
nursing kardex and the drug sheet with a small round red sticker.
10.11 Vanocomycin Resistant Enterococci
(V.R.E.)
Introduction
The incidence of nosocomial colonization/infections due to Enterococci spp
(E. faecalis/faecium) has been rising steadily since the 1980’s. At the same
time these bacteria have acquired resistance to ampicillin, amoxicillin,
aminoglycides, vancomycin and teicoplanin. Enterococci are founds in the
gastrointestinal tract and female genital tracts and most enterococcal
infections have been attributed to endogenous sources within the individual
patient. However, recently it has been indicated that patient to patient
transmission of VRE can occur either through direct/indirect contact via hands
of personnel or contaminated patient care equipment/environmental surfaces
(Damani, N.N., 1997).
Measures of Control
These measures are carried out in conjunction with Standard Isolation
(YELLOW) Precautions (see Section 8.2 for details).
`
Isolate infected/colonized patients in a single room or if more than one cohort
them with other patients.
Dedicated instruments should be used e.g. stethoscope, sphygmomanometer
etc. Adequate cleaning/disinfection should be carried out.
 Extraordinary detail to cleaning is necessary in the presence of VRE
particularly sinks, taps, door handles, toilets etc.
 Ensure that then cleaners are made aware of the requirements.
 Cleaning in between usual schedules is necessary and staff
themselves are encouraged to wipe over the environment with an
alcohol wipe as often as possible.
 Surfaces when cleaned should be disinfected with Milton 1:10.
Remember to rinse off afterwards as Milton corrodes.
Protective Wear
Gloves
 Wear non sterile disposable gloves when entering the room of a VRE
infected/colonized patient because VRE can extensively contaminate
such an environment.
 When caring for a patient, a change of gloves may be necessary after
contact with material that could contain high concentrations of VRE e.g.
stools.
Aprons
 Wear a plastic, disposable apron on entering the room of an infected
patient if substantial contact with the patient or environmental surfaces
in the patient’s room is anticipated.
 If the patient is incontinent/has an ileostomy of colostomy or wound
drainage.
NB: Remove gloves/apron before leaving the room and place in YELLOW
bag within the room.
Hand washing is mandatory before/after wearing gloves/aprons.
Subsequently disinfect with Prometic XL Cream or an alcohol gel.
Additional Precautions
 Obtain a stool specimen or rectal swabs from roommates of patients
newly diagnosed and apply isolation precautions as necessary.
 It is thought that stringent criteria should apply to duration of isolation
because VRE colonization can persist indefinitely. Consult the
Microbiologist.
 Because VRE patients can remain colonized for long periods it is
important to highlight the case notes for identification/isolation on
readmission (Boyce M., Maki G. Weinstein, R.A., 1996).- Small round
Dark Blue Sticker
10.11 Norovirus (Winter Vomiting)
Introduction
Infection due to Norovirus is extremely common in the community.
Noroviruses are highly infectious agents, capable of being spread directly
from person to person by food, water and through the air. The virus is very
resilient and can survive for long periods in the environment and on surfaces
such as door handles, soap dispensers, towel fittings, toilets, lockers, curtains
etc. Because of these features, noroviruses can cause widespread and
intractable outbreaks especially where people are gathered closely together.
Since it is a community infection, outbreaks in congregate settings such as
hospitals are simply a reflection and a gauge of what is happening in the
community.
Modes of Transmission
Person to Person spread by:
 Vomiting due to widespread aerosols
 Environmental contamination with subsequent indirect person to
person spread.
 Faecal-oral route
 Vomit spread
Foodborne
 Any food can be a potential source if in contact with an infected food
handler, particularly cold meats, salads, sandwiches etc.
Waterborne
 Water and Ice
Clinical Features
 Characterised by acute, rapid onset of nausea, vomiting and abdominal
cramps. Vomiting is generally the principal symptom (although it may
be reduced or absent).
 Prolonged diarrhoea may also be a feature, especially in children.
 May of other symptoms i.e. headache, muscle aches, chills and fevers.
Control Measures
Early control measures are vitally important principle methods being:
Location
 Contact/Droplet and Airborne Isolation Precautions in single rooms if
available or, in an outbreak situation and depending on numbers
affected cohort isolation in designated ward/area.
 Closure of the entire department and discontinuation of isolation will be
on the advice of the Microbiologist and Infection Control Team.
Main Entrance to the Department
 Keep doors closed.
 Isolation Notice on the door.
 Place Protective Gear (as outlined below) at the door.
 Encourage the use of alcohol gel/Prometic XL Cream at entrances
Limitation of movement of staff and patients
 Designate staff to the affected patients and those designated staff
should attend to all those patients needs i.e. receive/hand back meal
trays etc at the door.
 When an area/department is in isolation, staff should be confined, in as
far as possible, only to those working in the area and only to the
necessary medical/other facilities.
 Likewise staff from affected areas should confine themselves to those
areas. Visiting other departments should be restricted.
X-Ray, Physiotherapy, Speech Therapy etc.
 Patients affected/from affected areas should not be taken outside of
these areas. The Medical Team should be contacted and if absolutely
necessary, the X-Ray/other procedures should be carried out in the
area itself.
Protective Wear
Outside the door place –
o Aprons
o Gloves
o Masks (green)
o Alcohol Gel
Inside the door a YELLOW Bag for disposal of protective wear
Hand Hygiene
NB: Proper hand washing and the use Prometic XL Cream and alcohol
gel is encouraged.
Refuse
 Treat all waste as Clinical – YELLOW bag placed immediately inside
the door and in the case of an outbreak, all refuse should be handed to
the Maintenance transporter at the entrance door.
Linen
 Alginate Bag.
Visitors
 During an outbreak, all visiting should be restricted (this includes
company representatives, medical students, etc. However this will be
reviewed daily and will be at the discretion of the Microbiologist but, it
will always take into account in certain circumstances the human
element.
 Children should, where possible, not visit during an outbreak.
 Visitors with a history of vomiting or diarrhoea should not visit a
hospital (whether during an outbreak or otherwise) until at least 48
hours after their last episode of vomiting and/or diarrhoea.
Cleaning
 Immediate cleaning and decontamination of soiling is vitally important.
 Frequency of cleaning should be increased.
 Dedicated cleaning staff to the area.
 Clear instructions should be given to the cleaners by the Department
heads.
 Milton 1:10 for disinfection.
Speaking to the Press
 Only Hospital Management.
Exclusion of ill staff for 48 hours after their last episode of vomiting
or diarrhoea.
See NDSC Guidelines for further details, available on www.ndsc.ie.
11. Laying Out of Bodies with
Communicable Diseases
Introduction
If a person known or suspected to be carrying a “high risk” pathogen dies in
hospital, it is the duty of those with knowledge of the case to ensure that those
who handle the body should be aware that there is a potential risk of infection,
so that they may be protected by using the appropriate control methods.
Making a known or suspected hazard known to those concerned is a statutory
duty under the Health and Safety at Work Act, 1974 (Damani, N.N., 1997).
The precautions already described for handling infected patients do not
become unnecessary with the patient’s death, (Ayliffe, Lowbury, Geddes,
Williams, 1993).
Precautions to be taken
Blood/Body Substance Precautions
See Section 7.1 and in addition to this approach, the following specific
measures:
The Ward Sister/Senior Staff Nurse on duty must take responsibility to inform
the Porter and Undertaker that the patient has died of an infectious disease.
The details of the actual disease are not disclosed. As a matter of courtesy,
the relatives should be informed that the undertaker has been notified.
Usual “laying out” procedure, as described in “Care of the Dying
Guidelines, Hospital Policy Book, but the following specific measures
must be taken:
 Staff who perform last offices should wear the appropriate protective
clothing.
A special “Cadaver Pack” is in readiness in Infection Control CNS office
(opposite the Bacteriology Department) containing  Long sleeved gowns.
 Heavy duty gloves.
 Masks.
 Visors (if splashing with blood/body substances is anticipated).
 An inner lining bag (full length clear plastic bag) and an outer
“Cadaver” bag.
This pack will be replaced by Infection Control as necessary.
 Do not handle the body unnecessarily.
 Do not pack any orifices – place a nappy securely underneath the
body.
 Do not remove IV cannulae – cover the sites securely. Do not remove
urinary catheters - place a nappy underneath the body and secure the
catheter.
 When the usual laying out procedure has been carried out, place the
body in the inner lining bag, bringing the bag from below upwards.
Family and close friends should be encouraged to view the body at this
stage. If this is so, for humanitarian reasons, leave the face exposed,
remembering to cover the body. When relatives have left, secure the
inner bag (this must now be left closed) and then place in the outer “zip
up” Cadaver bag.
Post mortems should be avoided but, if necessary, a consultation is
necessary between the Pathologist and Microbiologist.
For Terminal Cleaning/Decontamination of equipment etc. – See Cleaning/
Disinfection Guidelines, Section 12.
12. Cleaning and Disinfection Policy
12.1 Introduction
Inadequate decontamination has frequently been responsible for outbreaks of
infection in hospital (Cefai et al, 1990 – Kolmos et al, 1993). Therefore, it is
important that all hospitals should have a cleaning/disinfection policy. The
aim of this policy is to remove visible soil/dirt and invisible organisms, making
patients items/equipment safe, to prevent cross-infection and to protect
personnel from the infected items and equipment (Damani, N.N., 1993). It is
important to have a clear understanding of the terms and classification used in
this process and to choose the most appropriate procedure for the items or
surfaces in question.
Patient and Staff Expectations
The apparent level of cleanliness of the hospital environment is very important
to patients and visitors perception of the general level of care. Patients
expect to be cared for in an environment free from dirt and dust and if a ward
is untidy or dirty, patients and relatives may regard this as poor quality care.
Staff too, have a right to a clean environment in which to work, to ensure their
health and safety and maintain morale. Cleanliness is now the domain of the
domestic services staff but Department heads and nursing staff have a
professional responsibility and a vital role to play in ensuring a hygienic
environment for their patients. Cleaning today, due to levels of resistant
bacteria in hospitals/institutions is now more important than ever before.
Team Approach
There are several ways in which nurses can contribute both directly and
indirectly to the cleanliness of the care environment
 An environment that is tidy is much easier to clean.
 Careful planning of available storage space, so that equipment is put
away and surfaces kept clear, facilitates the work of contract cleaners
and care attendants.
Let us, as Nurses, have a look at our work area, for example, the utility
or clinical room where much equipment and supplies are stored.
 Is it an easy area to clean, or could tidiness or storage be improved?
 Do we inform the cleaning staff of changes in the function of a room
and are we aware of our own responsibilities for cleaning equipment
such as drip stands, IV pumps etc.?
 Do we inspect the shower, toilets, commodes etc. or delegate
responsibility to guarantee maximum hygiene (Nursing Times, 1997).
 Do we record our actions?
12.2 Methods of Decontamination
Cleaning
Disinfection/Sterilization should always begin with cleaning. Cleaning is a
process which removes soil e.g. dust, dirt and organic matter, along with a
large proportion of micro-organisms; a further reduction will occur on drying,
as micro-organisms do not multiply on a clean dry surface. Thorough
cleaning with soap/detergent and water is adequate for most surfaces in the
hospital environment and is a prerequisite before disinfection and sterilization
is commenced (Ayliffe, Coates, Hoffman, 1993).
Disinfection
Disinfection will destroy micro-organisms but not bacterial spores. Chemical
disinfection does not necessarily kill all micro-organisms present but will
reduce them to a level not harmful to health. Chemical disinfection should
only be used if heat treatment is impractical or may cause damage to the
equipment. Chemical disinfectants can be classified as chemical sterilants if
they are used to kill bacterial spores as well as other viable organisms (which
normally require prolonged exposure time). Disinfectants are normally used
or inanimate objects only and not on living tissue. Chemicals used to kill
micro-organisms on skin or living tissue are know as antiseptics (Damani,
N.N., 1997).
Disinfection may be performed in three ways:
A. Cleaning (See Section 12.6 and 12.7).
B. Heat Disinfection
a. Boiling in water at 100 degrees C for 5 minutes can be used to
disinfect medium risk equipment. Instruments should be
completely immersed and timing starts after the water has
returned to boiling point. Boiling is not commonly used in
Hospitals.
b. Pasteurisation – items are heated to between 65 and 80
degrees C to eliminate harmful pathogens, e.g. bed pan
washer/dishwasher. Linen is also disinfected by machine
laundering at temperatures of 65 degrees C for not less than 10
minutes or preferably 71 degrees C for not less than 3 minutes.
With both options mixing times must be added to ensure heat
penetration and assured disinfection. (Health Service
Guidelines (95, 18)).
C. Chemicals (See Chemical Disinfection – Section 12.2).
Sterilization
Sterilization is a process that achieves the complete destruction or
removal of all micro-organisms, including bacterial spores. Equipment and
materials used in procedures involving a break in the skin or mucous
membranes should be sterilized e.g. surgical instruments and products
intended for parenteral use or for instillation into sterile body cavities.
Requirements include routine biological, mechanical and chemical
monitoring to ensure that all parameters of sterilization are met before
using the instrument on or in the patient. Steam sterilization – 134
degrees C for 3-5 minutes or 121 degrees C for 15 minutes (Steam under
15lbs/sq inch pressure).
The choice of method of decontamination depends mainly on the type of
material to be disinfected, level of decontamination required for the
procedure and micro-organisms involved, (Damani, N.N., 1993).
12.3 Chemical Disinfectants
Before dealing with chemical disinfection, the following points should be
emphasized:
 The Purchasing Officer/Hotel Services should consult with the Infection
Control Team before ordering any new chemical disinfectants or
cleaning agents that contain chemical disinfectants for the hospital (in
turn the Health/Safety Officer).
 Before buying equipment, it should be known:
 How the equipment may be cleaned (equipment which cannot
be cleaned is unsuitable for hospital use).
 How it may be sterilized, if needed (if there are doubts about
sterilization, Infection Control should be consulted).
Users of Disinfectants should note:
 The correct disinfectant and concentration for particular tasks.
 The shelf life of the disinfectant when diluted.
 Materials which may neutralize the disinfectant.
 Materials which may be corroded by the disinfectant e.g. hypochlorite
can be damaging to all materials, especially metals, if not careful. It
should always be rinsed with water and the surface or equipment dried.
Use and Dilution of Disinfectants
There are a number of important factors that must be considered when using
disinfectants:
 The correct volume of disinfectant and the correct volume of water
must be carefully measured (as per manufacturer instructions). Pump
dispensers are available from pharmacy for measuring of Hypochlorite
solution. Containers or jugs used dilution must be washed well with
soap and water, dried and inverted.
 Chemical disinfectant solutions must not be mixed or detergents added
unless they are compatible. Always follow the manufacturer’s
instructions.
 All chemical disinfectants must be clearly labelled and used within the
expiry date. They should be freshly prepared and stored in an
appropriate container. Under no circumstances should they be
prepared and stored in multi-use containers. Solutions stored in this
manner may easily become contaminated with micro-organisms; using
such solutions will therefore readily contaminate a surface rather than
clean it, (Damani, N.N., 1993).
12.4 Control of Substances Hazardous to
Health (COSHH) Regulations
COSHH Regulations, 1999, require employers to assess the risks presented
by the use of hazardous substances in the workplace and to determine the
control measures required to ensure they are handled safely. The COSHH
Regulations incorporate codes of practice on general substances hazardous
to health, carcinogenic substances and biological agents. Therefore, all users
of chemical disinfectants must be aware of the correct way to use chemicals
to protect them from injury. For chemical disinfection, the greater risk is from
undiluted disinfectants. Concentrated disinfectants should be stored/handled
with care and appropriate protective clothing such as gloves, aprons,
respiratory and eye protection etc. should be used, where appropriate. For
certain chemical disinfectants, proper ventilation is required and where
necessary, the exposure of employees should be monitored (e.g. with
Gluteraldehyde).
 Equipment used for sterilization/disinfection must be commissioned on
installation, regularly serviced, maintained and tested in accordance
with the manufacturer’s instructions. Records must be kept to ensure
that accepted standards of safety are achieved.
 Should chemical disinfectant come in contact with eyes/skin/mucous
membrane, wash well with running water, report to Occupational
Health (Bleep 6626 – Mon-Fri – 8 am – 5 pm). Out of hours report to
the Casualty Department. Complete Accident/Incident Form as per
Hospital Policy
12.5 Selection of Disinfectants
Where compatible with other requirements, disinfectants used should be
bactericidal, active against a wide range of microbes and not readily
inactivated. The manufacturer can supply information on the properties of the
disinfectant, but independent antimicrobial tests by the laboratory are also
required. As well as the antibacterial activity, the properties of the disinfectant
should be considered in terms of acceptability. The Pharmacist, with the aid
of relevant information should assess stability, toxicity and corrosiveness.
Acceptability and cleaning properties should be assessed by the user. In
conclusion, a few good disinfectants is all that is necessary for any
Disinfection Policy (Ayliffe et al, 1993).
Detergents/Antiseptics/Disinfectants of choice in the
Mercy University Hospital
Detergent (includes Wash Up Liquid, Cream Cleansers i.e. Jif etc., powder,
i.e. Ajax)
If any other brand is introduced it MUST be trialled/passed by Infection
Control. Detergent solution is used as a general purpose cleaner, to clean
various items/equipment/surfaces throughout the hospital, for general purpose
cleaning and to remove grease etc. pre dishwashing.
Ajax – highly recommended because of its hypochlorite content. Ajax is an
abrasive scouring powder containing hypochlorite and used as a general
purpose cleaner, in particular bathroom/toilet areas/wash basins/lockers/bed
tables etc. It is particularly useful for cleaning MRSA affected areas. Note: It
should not be used to clean mattresses, delicate chromes etc.
Jif – a scouring cream and suitable for general purpose cleaning.
Floor Cleansers
The Cleaning Supervisor recommends floor cleansers fro the different floor
surfaces, in accordance with Infection Control Guidelines for
cleaning/disinfection in the Cleaning Manual specific to the Contract Cleaners.
Soap
For social hand wash – Liquid soap dispensers (wall mounted) are
recommended with individual disposable replacement cartridges.
The use of Prometic Body Wash is recommended and available from
Pharmacy, particularly in instances of MRSA/other infections
Remember
 To frequently clean the nozzle
 Soap should never be added a partially empty soap dispenser – if
containers are refilled, wash and dry between refills.
NB: Soap dishes/bar soap are obsolete as the moisture harbours microorganisms and must not be used in the hospital.
Antiseptics
Hibiscrub (4% Chlorhexidine Gluconate) Hydrex (similar)
Hibiscrub is a rapid antimicrobial skin cleanser used as a disinfectant hand
wash prior to carrying out aseptic techniques etc. It has a good persistent
effect due to residue on the skin after rinsing and drying. It is recommended
for use during outbreaks and routinely in special units e.g. ICU, Paediatric
wards etc. It is particularly recommended in Isolation settings.
Savlon (Hibiset) contains Chlorhexidine 1.5% and Cetrimide 15%. It is an
antimicrobial preparation with cleansing properties for general antiseptic
properties.
Note: It is incompatible with soap. Its use in the hospital is limited to:
 Cleansing suction channels and outside of endoscopes.
 Adding to the bath water of patients with infected lesions to reduce
contamination of the water and reduce deposition of organisms on the
surface of the bath. Savlon should not be used with soap.
Remember: Cleaning of the bath is still necessary after an antiseptic bath
additive has been used.
Betadine (Providone – Iodine 7.5%) is used as pre-operative scrub.
Betadine is also used for pre-operative preparation of the skin at the operation
site. Iodine is the only antiseptic that has been shown to have a useful
sporicidal action on the skin.
Disinfectants
Alcohols
(Ethyl alcohol 70% (ethanol) and 60-70% isopropyl alcohol (isopropanol) are
effective and rapidly acting disinfectants and antiseptics with the additional
advantage that they evaporate leaving the surfaces dry, but they have poor
penetrative powers and should only be used on clean surfaces. They are active
against mycobacteria but not against spores. Alcohol may be used for the rapid
disinfection of smooth, clean surface e.g. trolley tops, probes and
electronic/electrical equipment which cannot be immersed in disinfectants. It is
commonly used for skin disinfection e.g. without additives for treating skin prior
to injection (alcohol impregnated swabs). Recommended also, for wiping door
handles on leaving an isolation room, after removing gloves. Remember it is
flammable- it should never be placed near to a naked flame or on a window
sill/other site in the sun.
Halogens (Chlorine releasing agents)
These are cheap and effective disinfectants which act by release of available
chlorine. They are rapidly effective against viruses, bacteria, fungi and spores.
They are particularly recommended for use where special hazards of viral
infection exist. Dilute Solutions lose their activity and should be freshly prepared
daily. They are readily inactivated by organic matter (e.g. pus, dirt, blood etc.)
and may damage certain materials (e.g. plastics, rubber, some metals and
fabrics). For that reason the manufacturer’s directions should be followed for
dilution and use. If used on surfaces that can be damaged ensure rinsing
afterwards with water.
Chlorine Releasing Agents include the following Domestos (Strong alkaline hypochlorite solution) - Concentrated solutions
are corrosive. Their use in the hospital is restricted to public toilets (used by
Contract Cleaners only, for that purpose).
Milton (Hypochlorite solution containing 1% (10 000 ppm av CI2) and
stabilized with sodium chloride. Chlorine releasing agents should not be
mixed with acid, including acidic body fluids such as urine, particularly in a
confined space - as it may result in the release of harmful chlorine gas. Milton
has a wide range of uses and is particularly recommended for catering
departments.
See Table 12.6 for recommended Milton Sterilizing Fluid
Presept Granules (NaDCC Granules are used to apply directly on spillage of
blood and are a convenient and effective alternative to solutions (Coates,
1988; Bloomfield and Miller, 1989)
See Section 7.1 - Procedure for dealing with spillage of blood/body fluids.
High Level Disinfectants
Cidex OPA
Cidex Ortho- phthalaldehyde Solution is Gluteraldehyde free and activity is
more rapid. It is active in 5 mins against a wide variety of bacteria, fungi,
viruses and mycobacteria. Cidex OPA requires no mixing, activation or
dilution and can be used directly from the bottle. It is virtually odourless and
non-irritant, e.g. Washer-disinfector St. Olivers and Operating Theatre for
disinfection of endoscopes.
Peracetic Acid
This is a peroxygen compound with a wide range of antimicrobial activity – and
better penetration of organic matter than glutaraldyhyde, although it is less
stable and more damaging to instruments. Peracetic acid kills bacteria, fungi and
viruses rapidly, mycobacteria in 20-60 mins, and spores in 3-10 hrs, depending
on the product. It has a strong smell, but is not currently listed as an irritant.
E.g. Perascope used in Theatre & St Johns for disinfection of endoscopes.
Peracetic Acid & Cidex OPA require the use of:
 Personal Protective Equipment, i.e. Nitrile gloves, gowns / aprons,
respiratory masks, goggles should be worn during its use and visors
should be worn when handling bulk solutions.
 Extraction
 Staff monitoring
Table 12.6 Summary of Methods for Cleaning &
Disinfection of Equipment or Environment
Routine Procedure
Detergents include: Washing Up Liquid i.e. Fairy/Quix, Cream/Powder
Cleaners i.e. Ajax, Jif, etc.
Washing up liquid is adequate in most situations but the use of Cream powder
cleaner, in particular Ajax, should be encouraged (particularly with the
upsurge in resistant organisms) as it contains hypochlorite. Its use is
encouraged for the cleaning of toilets, baths, showers etc. Careful with its use
on delicate chromes as it may tarnish.
Equipment for service/repair – must be cleaned/disinfected (if
necessary) & a decontamination certificate completed - see
decontamination certificate at end of this table
EQUIPMENT OR
SITE
ROUTINE OR
PREFERRED METHOD
ACCEPTABLE
ALTERNATIVE OR
ADDITIONAL
RECOMMENDATIONS
Airways
Bag- ValveMask Device
(a) Bag & Valve
(b) Masks
(c) Reservoir Bag
Disposable- Single use
ONLY
To the Operating Theatre for
low steam autoclaving
Laerdal- To Operating
Theatre for autoclaving in
Low Pressure Autoclave
King Systems- Disposable,
single use ONLY
External Surface- wash
with detergent & H20. Dry.
Wipe over with alcohol
wipes.
Babies Feeding
Bottles
Separate Milton container
for each baby
General Stock Pre made up
bottles
Wash separately in wash
up liquid & rinse in
readiness for collection.
These teats are disposable
 Wash, rinse & steam
sterilize on the ward
 Separate
Milton)container for
each baby.
 Milton dilution- 1:80
Baths
Clean after each use with
detergent and water.
NB. Taps and overflow.
Infected Patients
Patients with unhealed
wounds or
immunosuppressed
Patients – Wash well with
detergent and H20. Wipe
over with Milton 1:80. Rinse
NB. For the above patients
showering is the
recommendation
Bath water
Do not add an antiseptic
bath additive routinely.
ONLY for patients with
infected lesions or
staphylococcal dispersers
on the advice of the
Microbiologist or
Consultant.
Savlon is acceptable
Beds/Cots
Wash with detergent & H20
Dry properly.
Infected patients- such as
HIV/Hep B/Clostridia
Difficile After thoroughly washing
(as over) wipe over with
Milton 1:10 and leave for 3
minutes.
NB Remember to
afterwards rinse off with
clean water as Milton may
corrode the frame.
MRSA- Wash with
detergent & H20. Allow to
dry.
NB. DO NOT WASH
THE MATTRESS WITH
AJAX.
See Section 12.7-Cleaning
of Mattresses.
Bed Cradle
Wash with detergent &
water. Dry.
If used for an infectious
patient- wash with
detergent & water & wipe
over with Milton 1:80 (if
c.diff, ESBLs, or VRE etc.
Milton 1:10. Always
remember to wipe off
Bed Pans
Disposable
Non –
Disposable
Place in Macerator.
Close lid properly.
NB. No cotton wool, nappies
etc. as these damage the
machine.
Place in Bed Pan
Washer/disinfector.
Close lid properly.
Regular auditing of the
efficiency of the Machine
should be carried out by
staff on the dept.
If washer/disinfector is not
available bedpans should
be thoroughly cleaned with
Ajax & H20. Soaked in
Milton 1: 80 for 30mins.
Remember to rinse.
Bed-Pan Rack
Wash with detergent and
water part of routine daily
cleaning.
Bowls
(Washing)
Washer/
disinfector
Machine
Manual
Cleaning
Place in Washer/disinfector
for full cycle. Store dry and
inverted.
Wash well with detergent &
water. Dry thoroughly, store
inverted.
For Infected Patients In the absence of an
automatic washer, after
cleaning with detergent &
water, disinfect with Milton
1:80 or Milton 1:10 for c
diff, ESBLs, VRE etc. Rinse
with clean water and dry.
Individual bowl for infected
patient.
Buxton Chairs
Wash with detergent and
hot water. Dry thoroughly.
Use a disposable sheet for
protection.
After use on infected
patients – after cleaning
with detergent & water wipe
over with Milton Solution
1:80 or 1:10 for high risk
infections as already
outlined NB. Rinse off as
Milton is corrosive
Buckets
Never leave with stagnant
(even clean) water residue.
Wash with detergent and
water. Dry and store
inverted.
From infected areas- After
cleaning wipe over with
Milton 1: 10, leave for 3
minutes and store inverted.
Dedicate the bucket to
these areas.
Cleaning
Equipment
As above - See also page
- Section on Cleaning
recommendations for
Contract Cleaners.
(See colour coding section
for cleaning equipment) for
each area e.g. clinical, nonclinical, kitchen and
sanitary area.
Commodes
Wash daily with detergent &
H20.
After each use the seat of
the commode should be
cleaned with a large alcohol
impregnated.
If contamination has
occurred, remove soil with
tissue. Wash with detergent
& water and wipe over with
Milton 1:10. Rinse and dry.
Crockery and
Cutlery
Machine wash (dishwasher)
with temperature above 80
degrees Centigrade.
For dentals or patients who
are bleeding from the
mouth, use disposables
where possible.
Computer Key
boards
Clean with an alcohol
wipe/special computer wipe
on a regular basis.
Curtains
Curtains should be washed
every three months and
when visibly soiled.
Records should be kept.
They should also be
washed after change of
patients with MRSA (if
patient was heavily infected
or in for a considerable
period) Clostridia Difficile,
ESBLs, VRE , Winter
Vomiting etc. R.
Pneumococci etc.
(Remember to place in an
“alginate” bag in such
instances).
NB. Remember to remove
the hooks to avoid
damage to the machines).
Dental Cartons
Disposables only.
Where possible patients can
clean their own dentures.
NB. Label with patients full
name, DOB. etc. as
lockers, bed tables are
constantly being moved.
Likewise patients being
transferred.
Drainage
Bottles
Rinse & send to CSSD for
sterilization
Disposable are the
alternative
Drip Stands
Wash with detergent &
water. Dry
When a drip is discontinued
wash well with detergent
and water.
Store tidily in the
appropriate place and wipe
over if dusty before re-use.
Regular routine
checks/cleaning
Infection- Clean as over &
depending on the infection
wipe over with Milton 1;80
or 1:10. Remember to rinse
off promptly
Drains Inside Drains- The practice
of pouring disinfectant down
drains to destroy odours is
waste of money. Proper
cleaning around the outlet
with detergent and water is
sufficient.
Outside Drains- Drains
require regular cleaning to
remove fallen leaves and
litter. A clean drain will
rarely have a bad odour
Any problems- contact the
Maintenance department.
Duvets
Duvets and covers should
be laundered between each
patient.
Wipe Over Duvets
Clean with detergent &
water
In Recovery- as lack of
time is a factor- wipe over
with detergent wipes. This
is non- alcohol & will not
damage the material.
High risk Infection, Body
fluid contaminate- wipe
over with Milton 1:10
Ear Phones
Wipe with detergent solution
(wash up liquid) in between
patients and wipe over with
alcohol 70%. Change
earpieces as necessary.
Replace foam after use in
Isolation
E.C.G.
Electrodes
Disposable leads
Endoscopy –
See Policy local
to:
Endoscopes
(Gastroscopes)
Broncoscopes
Laproscopes
Cystoscopes
Endoscopy Unit and
Operating TheatreCleaning/Disinfection
See Endoscopy Policylocal to of Scopes
Floors
Wards/Clinical AreasVacuum only. Sweeping
Brushes/Dust Control Mops
should never be used in
wards/Clinical areas due to
their dispersal of dust.
Washing of Floors- Wash
with detergent (as per
policy) and clean hot water
Routine Chemical
disinfectants are not
necessary as microbes
return to original level quite
rapidly.
Disinfectants are only
necessary
for(a) Spillage of Blood Presept Granules
(b) Terminal Cleaning of
Infected Rooms/ Areas Flower Vases
Wash in hot detergent
solution- Dry/store dry.
NOTE - It is advisable to
change the water in flowers
fairly often as when water is
stagnant/topped up it may
encourage the growth of
Pseudomonas.
Ideally flowers are not
suitable for any patient
areas and their use is not
advocated in the hospital
Food
Preparation
Surfaces
Clean with detergent & hot
water. Wipe over with Milton
solution 1:100. If using
Milton on stainless steel it is
advisable to rinse over with
clean water, in case of
corrosion (after 3 minutes)
See Catering Manual for
further details.
Furniture &
Fittings/Ledges
Wash/damp dust with
detergent solution
Known infection -Wipe
over with disinfectant - See
Section 12.
Cleaning/Disinfection.
Food Bins
(waste)
Emptied and washed daily
with detergent solution.
Wash also the surrounding
area if spillage has
occurred. NB. Only food to
be put in these binsNO Papers etc.
Keep covered
Humidifiers
Single use disposable
Infant
Incubators
After use, wash all
removable parts and
thoroughly clean with
detergent solution (wash up
liquid) and hot water. Dry
thoroughly.
Infected Patients- After
cleaning wipe over with
Milton 1:80 or alcohol 70%
Aerate the incubator before
re-use.
Computer Key
Boards
Should be regularly cleaned
– evidence to denote the
presence of bacteria on
computer key boards in the
hospital setting.
Clean with an
alcohol/special wipe.
Linen
See Section 13, Table 13.2
Laundry Bag Coding
system.
Infected Linen- Alginate
Bags
Tea/coffee/mineral
stained linen – rinse under
running (cold) tap or soak
in cold water.
Mattresses
In between patients wash
with detergent solution wash up liquid ONLY- not
Ajax or other cleaning agent
as these agents will damage
the mattress. Do NOT over
wet, dry properly and leave
for a while before redressing (to allow further
drying.
MILTON 1:10 for Typhoid,
Dysentery, Clostridia
Difficile
Haemorrhagic Diseases,
ESBLs, SARS, blood etc.
Disinfection not necessary
after
MRSA.
NB. Do NOT use alcohol
on mattresses
A regular programme of
inspecting,
SEE SECTION 12.7
CARE/CLEANING OF
MATRESSES - for full
details of cleaning the
various types of
mattresses.
Medicine
dispensers/
spoons
Wash with detergent (wash
up liquid) & hot water. Place
in Milton 1:80. Remember to
change Milton solution daily
Medicine cups should not
be left lying on sinks,
lockers etc.
& record
Mops
Ideally not recommended
but if used must be
detachable mop heads ,
changed daily and machine
washed/dried.
Pillows
Treat as mattresses.
Pumps (IV
Feeding Pumps)
Clean regularly & as
necessary with detergent &
water, dry.
Razors
Patients should have their
own shaving equipment or
disposable razors ONLY.
Isolation – wipe over with
Milton 1:80. Use Milton
1:10 for Blood, c. diff,
ESBLs, SARS etc.
Receivers
Empty, rinse and
wash/disinfect in automatic
bed pan washer
In the absence of an
automatic disinfector, wash
in detergent and water.
Disinfect with Milton 1:10.
Rinse off.
Sluice /Slop
hoppers
Wash daily with detergent
(Ajax/Jif) and water, and as
necessary to keep waste
trap and overflow clean at
all times (wearing household
gloves).
Sputum
Containers
Use disposable ONLY.
Fitted lids.
Suction Bottles
Ideally use disposable
liners.
Infected patientsdisposable liners.
Glass Jars- Wash with
detergent and hot water,
taking care not to leave any
residue at the end of the jarleave to dry and send for
autoclaving. Remember to
wear disposable gloves.
Telephones The cleaning of telephones
is on the agenda of the
Contract Cleaners.
But, in addition should be
wiped regularly by ward
staff with an alcohol 70%
wipe/special wipe
Thermometers
Genuis Tympanic
ThermometersUse an individual disposable
probe for each patient. Wipe
over thermometer itself
regularly with an alcohol
swab.
DO NOT use alcohol on the
probe itself (manufacturer’s
instructions)
Isolated patients etc- use
an individual thermometer
for each patient and store
dry in the patient’s
individual container.
Before and after use wipe
with a sterile alcohol swab.
In between patients wash
in detergent (wash up
liquid) and water and
sterilize in Milton 1:20 for I
hour.
Toilets
Wash well with detergent
(Ajax or Jif etc.) and hot
water, using a toilet brush to
clean around the rim.
Particular attention should
be paid to the area
underneath the seat and the
pipes
Pouring disinfectant
routinely into the toilet bowl
is waste. For the purpose of
descaling particularly
casualty - Three Way Life
Guard, Domestos may be
used. Ensure surroundswalls/doors, floors etc. are
seen to.
High Risk Infections Wipe over with Milton 1:10,
rinse off with cold water.
Blood/Body fluid soilingWipe off using toilet tissue.
Clean as already
described. Disinfect as
described.
Ensure clean toilets,
equipped with toilet paper,
towels and soap at all
times. Report any faults to
Maintenance
NB. Scheduled
checks/tick records to be
in place
Toilet Brushes
See Brush Section
Toys Hard plastic- Wash with
detergent and hot water.
If infected wipe over with
alcohol 70% or Milton 1: 80.
Soft toys are not
recommended for
hospitals.
Treatment
Rooms
Clean all work surfaces daily
or as necessary with
Work – tops
Floors
Couches
detergent and hot water.
Disinfect work - top for
drawing up injections by
wiping with alcohol 70 %.
Vacuum only, sweeping
disperses too much dust.
Wash daily using detergent
and hot water. Disinfection
is only necessary if spillage
occurs and high risk
infections-seek advice of
Infection Control.
Clean daily and as
necessary, using detergent
and hot water. Change
sheets in between patients.
High Risk Infections- In
addition to cleaning wipe
over with Milton 1:10.
Leave for 3 minutes only
and rinse with clean water
to avoid corrosion.
Trolleys
Theatre
Trolleys Linen Trolleys
Trolleys for Aseptic
Technique
See Section 5.1.
All theatre trolleys should
be thoroughly cleaned using
detergent and hot water. Dry
Ensure that the first side of
the mattress is dry before
washing reverse side. NB.
If trolleys become dusty/
soiled at any time they
should be attended to
(outside of the weekly
clean).
Procedure as for Theatre
trolleys.
Remember to clean the
wheels and oil the wheels
on a regular schedule.
Blood - Should trolley or
mattress become
contaminated with blood
wipe off using paper
towelling. Wash with
detergent and water .Wipe
over with Milton 1: 10,
Leave for 3 minutes only
and rinse over the surface
with clean water to prevent
corrosion. NB. Remember
to wear gloves.
Risk Infections - Follow
the same procedure as
above.
Urine Collection
Jugs
Empty, rinse and
wash/disinfect in automatic
bed washer.
After emptying rinse well
under running water (in
sluice room).
Clean, using detergent and
hot water. Store dry and
inverted. Wipe with Milton
1: 10, leave for no longer
than 3 minutes, rinse under
running water (to prevent
corrosion). Infection- after
washing place in Milton 1:
80 – 30 mins. Rinse
Wash
Basins/Sinks
Wash with detergent
(preferably Ajax/Jif etc.) and
hot water, paying particular
attention to around the tap
area and drains.
Extraordinary attention to
the cleaning of
sinks/taps/outlets etc. cover the entire area. This
precaution is necessary
due to the upsurge in
Resistant Gram negative
bacteria.
Wheel Chairs
Weekly Routine- Wash with
detergent and hot water. Dry
properly. Oil the wheels
periodically and check that
all attachments are
safe/secure.
NB. - If soiled clean
immediately after use.
High Risk Infection or
blood spillage - wash as
already described and wipe
over with Milton Solution 1:
10, leave no longer than 2
minutes and rinse off with
clean water.
MRSA – normal cleaning
as described.
X- ray
Equipment
Switch off, Damp dust with
detergent solution (wash up
liquid) Do not over wet.
Allow to dry before use.
High Risk InfectionsWipe clean and disinfect
with Milton 1:10. Rinse off.
12.7 Guidelines for Cleaning of Mattresses/
Pillows/Pressure Redistributing Chair
Cushions
Introduction
 The importance of a clean, dry bed suited to the individual needs of the
patient is very important in terms of preventing Nosocomial infection
(Ndawula 1991).
 All mattress stock in the hospital are encased in washable covers. It is
important to note that whilst the proper cleaning of mattresses/pillows is
vitally important, the unnecessary use of chemical disinfectants, harsh
cleaning materials or even excessive water can shorten the life of the
mattress.
 Rough handling of mattresses/pillows during bed making should be
avoided. TEARS, DO NOT HAPPEN, THEY ARE USUALLY CAUSED.
Mattresses should be carefully placed and stored in a dry, well-ventilated
area.
 Auditing of mattresses/pillows will be carried out on a regular basis, but if
at any time a tear or other problem should occur, it should be reported to
the department head and/or Ms. M. Byron (CNS Wound Care)
Note:
 Phenolic disinfectants should NEVER be used on any type of mattress.
Phenol can damage the waterproofing and allow moisture to penetrate
leading to Pseudomonas aeruginosa etc. beneath the cover (Fugita, 1981).
 Likewise Alcohol can also damage the surface of all mattresses and for
that reason are NOT used.
The Aims of these Guidelines should be:
 To maintain the safety and integrity of these products
 To prevent cross infection between patient use
 To reduce harbourage of micro-organisms
Procedure for Cleaning
 It is always advisable to read the manufacturers instructions for
cleaning/disinfecting. This is particularly important, where from time to
time new types of mattress/pillow may be purchased. If in doubt contact
the company/Tissue Viability Nurse and/or Infection Control.
All Types of Mattress e.g.
Standard Mattress e.g. Medifoam/Thermocontour/Transfoam/other
Foam Support Overlay (Propad).
 These must be cleaned thoroughly (on both sides) on each change of
patient using detergent (Quix) and clean water. Likewise the bed frame
itself. NB: Dry properly.
 Only after cases of known/suspected infection e.g. Hepatitis B/C, HIV,
Typhoid, Dysentery, Resistant Group D. Streptococci, Clostridia Difficile
etc. or contamination with blood/body fluids wipe over with Milton
solution 1/10- Take care to rinse with clean water afterwards as Milton is
corrosive.
 Washable mattress covers should only be laundered if gross
contamination occurs - and hypochlorite added to the final rinse. Extreme
care should be exercised when removing/replacing covers to prevent
tearing.
NOTE - Leave the mattress/pillow to dry properly before dressing the bed.
Proper drying is as important as washing. Non adherence to this policy not only
encourages bacterial growth but will also ruin the mattress/pillow.
Alternating Pressure Overlays/Mattress Replacement
 Place in bag provided by company and store for collection.
 Gloves should be worn if known/suspect infection.
 Details of contamination should be issued to the company.
Autoexcell
 One Autoexcell mattress in the MUH. Clean according to standard
guidelines.
12.8 Guidelines for Cleaning of Manual
Handling Equipment
Cleaning/disinfection/laundering/maintenance of manual handling is the
responsibility of designated ward porters.
Saturday- is the allocated day, where possible, for general cleaning.
Tuesdays, Thursdays- for laundering, but if any sling etc. becomes visibly
soiled /contaminated send to the laundry at any time.
NB: Remember to clean/disinfect any equipment prior to investigation,
inspection, service or repair. See Safety Action Bulletin- San (NI), July 21,
1995).
Hoists
 Wash weekly with detergent and hot water. Dry properly, and wipe over
the entire surface with Alcohol 70%. Using disposable towels to apply.
Remember to pay particular attention to areas around joints, screws,
bolts, fixed straps etc.
 Immediate thorough cleaning with Ajax/detergent and water is
necessary where contamination with blood/body fluids occurs. Wash
and wipe over with Milton 1/10 and rinse off.
 Following use on i.e. Clostridia Difficile, ESBL, Resistant Vancomycin
patients etc. wipe over thoroughly with Milton 1:10 that is after washing
(as already outlined). Remember to immediately rinse off to avoid
corrosion. Where possible allocate a separate sling to infected patients.
Handling Slings
 All handling slings and storage bags should be sent to the laundry on a
weekly basis - half on Tuesdays and half on Thursdays. Wash at 60
degrees C. In the event of any sling becoming contaminated send to
the laundry immediately. Remember to remove all rods from the slings
prior to sending to the laundry and return the rods to the storage press.
 In the case of a known infectious patient/patients - where possible
allocate a sling to the particular patient/patients e.g. to MRSA patients.
Allocate a sling to MRSA cohort wards/areas and leave in the
ward/area. Remember to weekly launder this sling. Wipe over with
Alcohol 70% in between patients.
Blue Lifting Mats
 Where possible provide each patient with his or her own designated
lifting mat. This is a must in infection risk patients e.g. MRSA/other
resistant infections/Clostridia Difficile etc. Where this is not possible
(but only for non risk patients should it be allowed) wash and wipe over
with Alcohol 70%. Wash all mats thoroughly on a weekly basis.
 Follow the same procedure post discharge of a patient.
Pat Slide
Wash thoroughly on a weekly basis with detergent and water and wipe
over with Alcohol 70%, using a paper towel.
Maxi Slide
 As for Pat Slide
Rollboard
 Wash thoroughly on a weekly basis with detergent and hot water. Wipe
over with Alcohol 70% using a paper towel.
 In the case of infectious patients, encase the roller board in a plastic
cover before use. These are single use covers.
NB. Scheduled cleaning check/ticked lists to be recorded and
stored
12.9 Mercy University Hospital Interim Infection
Control Guidelines for Cleaning/ Changing
of- Nebulizers, Oxygen Face Masks, Nasal Prongs
Introduction
To date there are no established guidelines – National/European or other for
cleaning/replacement of the above mentioned respiratory appliances.
Guidelines are only in the process of being drafted.
Outbreaks of infection related to the use of respiratory- therapy equipment
have been associated with contaminated nebulizers, which are humidified
devices that produce large amounts of aerosols. When the fluid in the
reservoir of a nebulizer becomes contaminated with bacteria, the aerosol
produced may contain high concentrations of bacteria that can be deposited
deep in the patient’s lower respiratory tract (MMWR 1997). Pneumonias
caused by Legionella sp., Aspergillus sp and Influenza virus are sometimes
due to inhalation of contaminated aerosols (MMWR 1997). While aerosols are
not created by oxygen face masks and nasal prongs, these latter also require
scheduled cleaning and replacement.
Nebulizers
 SINGLE Patient use.
 Nebulizers should be rinsed daily (in the am) with sterile water- if
necessary wash in warm water and wash up liquid but, DO
REMEMBER to afterwards rinse with STERILE water (NDSC 2003)
and DO REMEMBER to properly dry with clean paper towel.
 Change on a weekly basis or more often if necessary.
Oxygen Face Masks
 SINGLE patient use.
 Oxygen masks should be rinsed daily with sterile water or if necessary
wash in warm water and wash up liquid. DO REMEMBER to
afterwards rinse with STERILE water. DO REMEMBER to properly dry
with clean paper towelling.
 Change on a weekly basis or more often if necessary.
Nasal Oxygen Prongs
 SINGLE patient use
 Not for washing or rinsing.
 Change three times weekly or more often if necessary.
Pulmonary Function Department and Intensive Care Unit have
Guidelines local to their own areas.
12.10 Guidelines for Dealing with Spillage
Introduction
In the interest of Health & Safety spillage must be dealt with as quickly as
possible and each staff member who discovers the spillage is obliged to take
responsibility /follow the guidelines (however in the event of not being able to
do so at the time, the relevant day/night nurse manager should be informed)
Depending on the nature of the spillage these guidelines vary, but, the
common denominator is the immediate placing of cones on either side of the
spill( or somebody to guard the area until they have been placed). The cones
should be left at the site until the area is completely dry/safe. Cones are
available in the cleaning stores on all departments and at reception for
spillages in the public areas- hall, stairwells, back offices, corridors etc.
Noonan Cleaning Services Ltd. are available on Bleep 6690
Monday - Friday 9 am – 8 pm
Saturday & Sunday 9 am – 11 am
Spillage of water, milk, tea, coffee etc.
These may be dealt with by any staff member
 Ensure the safety of patients/staff/visitors/at all times. Depending on
the area/size of spillage etc. it may be necessary to cordon off the area
in a ward setting or in a ward setting to move away from the site.
 Wipe up the spillage immediately using water and detergent and dry.
 If cones are in place do not remove until the area is completely dry.
Blood/Body Substance Spillage (With the exception of urine)
 Blood/Body fluid spillage should be dealt with immediately
 Cordon off the area-placing cones to the back and front of spillage
 Wearing disposable gloves, spread Presept Granules over the spillage
 Cover the area with disposable towelling and leave for a few minutes.
Final Cleaning
 Wearing gloves, apron, mask if large spill) dispose of the debris as
clinical waste (yellow bag).
 Wash the area thoroughly with detergent and water.
 Leave to dry before removing warning cones.
Spillage of Urine
Unfortunately acidic solutions such as urine may react with hypochlorite, as in
Prespt/Milton etc. and cause release of chlorine vapour.
 Put on disposable gloves, apron
 Soak up spill with disposable towels
 Discard into a yellow bag
 Wash the area with detergent and water
 Milton may be used afterwards
Mercury Spillage
 Cordon off the area as already described.
 Contact the Reception Desk (5201) and arrange for the Reception
porter to deal with the spillage.
A special kit is available at reception and the reception
porters have been trained accordingly. This applies to both
day/night spillages.
There are Local Guidelines relevant to specific areas and in the event of
discovering spillage in i.e. any of the under mentioned please contact the
relevant departments (who themselves will deal with the matter):
 X-Ray Dept – Radio Active Spillage
 Laboratories – Chemical Spillage
 Oncology – Urine spillage post radiotherapy etc.
 Maintenance Dept. – Chemical Spillage etc.
12.11 Infection Control
Mercy University Hospital, Cork
Equipment - Cleaning / Decontamination Certificate
Standard: All equipment for maintenance/service/repair either within the area or
transferred from the area is pre-cleaned, decontaminated
Dept___________________________________
Type of
Equipment__________________________________________________
Equipment Serial Number____________________________
Description of Cleaning _________________________________________
__________________________________________________________________
Type/strength of chemical disinfectant used (if used)
___________________________________________________________
Additional information/ details (if any)______________________________________
Signed _______________________________
Date ________________________
Copy of Decontamination Certificated MUST be kept on file
12.12 Mercy University Hospital Infection
Control Guidelines for Contract Cleaning of the
Hospital Environment
Introduction
A clean environment is necessary to provide the required background to good
standards of hygiene and asepsis and to maintain the confidence of patients and
the morale of staff. Wet surfaces and equipment are more likely to encourage the
growth of micro-organisms and to spread potential pathogens. Cleaning
equipment and used cleaning solutions may be heavily contaminated with
organisms and should be removed from patient treatment areas as soon as
cleaning is completed. Thorough cleaning and proper drying will remove microorganisms and the material on which they thrive. This will render most items
free of infection risk and safe to handle.
 Disinfectants should ONLY be used as part of the Hospital’s Disinfection
Policy and on the advice of the Ward Sister/Staff Nurse in charge, or
Infection Control.
 Disinfectants, when used, MUST be properly diluted (measured
accurately according to the manufacturer’s instructions) freshly prepared
for each task and disposed of promptly after use.
 Cleaning solutions and equipment MUST conform to Hospital Policy These are the recommended cleaning agents for this hospital (as per the
Disinfection Policy):
 Cleaning powder/cream- Ajax and Jif
 Hypochlorite (Milton) is the recommended disinfectant.
 Descaling agent (Domestos) is sometimes needed in toilets and
urinals.
 Floor Maintainers chosen by the Contract Cleaning Co. but cleared
with Infection Control in conjunction with Occupational Health.
From time to time some other agents may be required i.e. for the walls of the
Aseptic Room i.e. an alcohol based agent, instead of water, to facilitate drying
and prevent splashing. When agreed this will be incorporated into the area’s
own local policy.
Note: Changes/additions to any of the above MUST be cleared by Infection Control in
consultation with Occupational Health.
N.B. Cleaning Staff MUST report to the head of the department at the beginning of
each cleaning schedule to agree any special requirements e.g. the precautions to be
taken when infection is present - whether or not a disinfectant is to be used, if single
use cloths etc. are to be used and what precautions are necessary for the protection of
the cleaning staff themselves. If in doubt contact Infection Control.
Methods of Cleaning
Dry Cleaning
Sweeping brushes or Dust control mops re-disperse dust and bacteria into the air
and should NOT be used in patient areas or food preparation areas. To avoid
dispersal during use the head should remain in contact with the floor during
sweeping and should NOT be lifted at the end of each stroke. Vacuum cleaning is
the accepted method for floors and upholstery.
Wet Cleaning
 For cleaning of floors, furniture, ledges, lockers, bed tables etc.) NB.
Proper drying afterwards.
 After dry cleaning the sluice, bathroom, toilet floors should be wet
cleaned at least daily using detergent, hot water, using preferably the
“Flat” Mop system. This system is preferable to the deck scrub and cloth.
Where used both the cloth and deck scrub MUST be clean and water
changed frequently to prevent build up of bacteria. After vacuuming
utility floors, ward and corridor floors should be wet cleaned with
detergent & hot water again preferably using the “Flat” Mop system,
particularly in “high risk” areas i.e. ICU, Oncology Unit, Leukaemia
Unit, Pharmacy Aseptic Unit and Theatre.
 In the Theatre setting a mechanical washer may be used (in addition to
the “Flat” Mop system) i.e. weekly or as deemed necessary by the theatre
staff. This washer MUST be scrupulously cleaned and serviced.
 The use of disinfectants is reserved for terminal cleaning of rooms and
other areas, only as requested by staff (such as infected areas, terminal
cleaning of Furniture, ledges, shelves, pipes etc. MUST be damp dusted
with a cleaning agent as above (never dry dusted in wards/clinical areas).
If spray bottles are used solutions MUST be freshly prepared and spray
bottles should be stored clean and dry. A disinfectant is only necessary for
the same reasons as above.
Care/Maintenance of Cleaning Equipment
 The design and maintenance procedure for all cleaning equipment
should be cleared with Infection Control in conjunction with the
Household Services so that unforeseen problems of organism
dispersal will not be overlooked.
 Poorly designed or inadequately maintained mechanical cleaning
equipment may increase the bacterial count of the cleaned surface or
the surrounding air and should NOT be introduced into the hospital.
 All cleaning equipment should be examined at regular, scheduled
intervals and cleaned when soiled. Worn or damaged equipment
should be repaired or replaced.
 It may be permissible to use a “Flat” Mop System in more than one
area (non- “high risk” areas, but as a general rule equipment should
NOT be shared between wards.
 The Contract Cleaning Company MUST at all times supply their own
cleaning equipment, including cloths, buckets, cleaning agents,
disinfectant etc. The Company MUST provide household gloves and
under NO circumstances are hospital disposable gloves to be worn by
cleaning staff (with the exception of specific situations of infection risk,
when hospital staff will advise).
Vacuum Cleaners
 Vacuum cleaners should meet the requirements of BS 5415.
 The inner bag MUST be checked before use and discarded when half
full. NB. NEVER use a vacuum cleaner without using a bag and
NEVER empty and re-use the same bag.
 Bag exchange MUST be made away from patient treatment areas with
the minimum dispersal of dust.
 Filters MUST be checked at regular intervals (e.g. monthly) and
changed if dirty/blocked.
 Vacuums MUST be kept in a clean condition, stored tidily and regularly
serviced.
 “High Risk” areas e.g. ICU, Operating Theatre, Leukaemia Unit,
Oncology, Aseptic Room etc. MUST have their own vacuum cleaner
and should NOT under any circumstances be removed from the area.
Mechanical Washer
This MUST also meet the BS requirements. Its use MUST be confined to Theatre ONLY.
It MUST be properly cleaned/ maintained/ serviced.
Dust Attracting Mops/ Ordinary Mops
As already stated, if used, it should only be for areas removed from wards, ward
corridors, offices etc. and then only if absolutely necessary. Dust attracting mops
if used for a period without replacement, will fail to retain the dust and may
disperse it into the air. They should be replaced frequently. After use they should
be hoovered and laundered frequently. If ordinary mops are used (MUST be the
detachable type head), the mop head MUST be hoovered after use and
laundered.
Pads for Buffing
These pads MUST be washed with detergent and plenty of hot water after use
and left to dry. Ideally they should be laundered after use They MUST be
replaced as necessary.
Buckets
Buckets should be washed with detergent and hot water after use and stored dry
and inverted.
Cleaning Cloths
 A clean supply of cloths MUST be made available for each cleaning
session e.g. clean for morning schedule/clean for evening schedule.
NB. Cloths used MUST be removed from the Department on
completion of each cleaning schedule and laundered. Wet, crumpled
cloths lying around encourage the growth of bacteria.
 Cloths used for cleaning areas of infection MUST not be used in other
areas. Ideally they should be single use.
 Cloths MUST be renewed when worn.
 NB. Colour Code
Colour Coding
 Clean Utility/Clean Clinical/other clean areas -- Pink
 Dirty Utility/Bathrooms/Toilets etc.----------------- Blue
 Isolation Rooms/Areas- Yellow Sign-------------- Yellow
 Isolation Rooms/Areas-Green Sign----------------Green
 Kitchens-------------------------------------------------- WhiteWhit
These colour codes apply to cleaning cloths, buckets, scrubs, brushes/other
If “Flat” Mop buckets cannot be supplied in the specified colour coding then a
suitable alternative i.e. stamped in green or yellow is necessary and staff
educated accordingly.
Refuse
Clear Plastic Bags - For Corporation Waste (papers, flowers, plastic bottles etc.)
NO blood stained material, disposable gloves etc.
Yellow Bags Waste pertaining to hospitals. NO papers, wrappings,
plastic bottles, flowers etc.
Black Bags Cardboard only
.
 Do not over fill refuse sacks. Close when three- quarters full. On the
other hand do not waste bags by under filling or by placing an unfilled
bag or bags, within another bag.
 Secure with the special, purpose made, coded plastic tie, by placing
the serrated edge towards the bag and tie firmly. Replace the bag. The
bags should be handled by the neck only and kept upright. Do NOT
put your hand underneath refuse bags while lifting and bags should be
held away from the body at all times.
 Refuse bags should be stored in a neat fashion within the designated
area and the area should be cleaned regularly and kept dry.
NOTE - Should a syringe, needle/sharp of any type be noted on the floor, locker,
bed-table etc. by a member of the Cleaning Staff it MUST be immediately reported to
the Department Head. Under NO circumstances should the sharp be touched, or
disposed of by the Cleaning Staff.
Cleaning of Isolation Rooms/Areas
(A) Cleaning of Rooms occupied by Infectious Patients
Yellow Card on the Door
Remember to report to the Department Head on arrival who will make staff
aware of possible infection hazards, and will be instructed as to the procedure
required. The Infection Control team are always available for advice. Nursing
staff will, however, deal at once with contamination caused by infectious
material. Extensive cleaning should not be necessary during the stay of any one
patient, but the room must be cleaned daily and maintained scrupulously clean.
General Points
 The room/area should be last on the cleaning list.
 Separate cleaning equipment- “Yellow” coded bucket/separate
cloths or in the case of the ”Flat” Mop if yellow is not available,
stamped in yellow, as an alternative.
 All equipment must be kept for this room/area and all the equipment
used MUST be fully decontaminated after terminal cleaning of the
room.
 The cleaner will be advised by ward staff of the necessary protective
wear- i.e. plastic apron, disposable gloves, masks, etc. These together
with disposable cleaning cloths (if used) must be placed in the yellow
bag at the end of the cleaning before leaving the room/area. Nondisposable cloths MUST be placed in a bag and taken separately for
machine washing.
 Special attention MUST be given to washing of taps, handles, fittings,
phone and door handles etc.
 Hands must be washed before entering and leaving the room.
(B) Cleaning of Rooms occupied by patients who need to be protected
from infection
Green Card on the Door
It should be remembered that in these instances the aim is to protect the patient
from you and other patients. It is really the reverse to the immediate section
above. If cleaner has flu, sore throat, infected finger or indeed illness of any sort
they should NOT enter such rooms. Cleaning of such rooms should be first on the
cleaning list.
Specification for Cleaning Wards/Bathrooms/Toilets/Showers
General Points
Hands MUST be thoroughly washed before/after wearing gloves (clean,
disposable gloves MUST be worn. Plastic aprons MUST be worn and
sometimes masks may be required (on the advice of the Ward Sister/Infection
Control Sister.
Cleaning as already outlined above but scrupulous attention MUST be paid to
it, particularly the door handles.
Green colour coding – same principle as outlined for “Yellow” etc. (Green) It
must be used for that room alone and after use cleaned and stored in the
room. All equipment MUST be scrupulously clean before bringing into the
room.
Refuse can be removed from the room and disposed of as per usual policypapers, wrappings etc. in the clear plastic bag.
Door MUST be kept closed at all times.
NB: Refrain from talking too much to the patient, to avoid spreading bacteria in the
air.
Terminal Cleaning of Room/Area
Terminal Cleaning of a room is indicated when an infectious patient has
been discharged or transferred to another area. The Ward
Sister/Infection Control, who will list the requirements/precautions, will
request it. As a general rule the following procedure should be followed:
 Cleaning staff should wear a disposable plastic apron and disposable
gloves.
 Terminal cleaning should commence only after the patient and his/her
possessions have been removed from the room or the area. Ward staff
will have the room ready for cleaning. Refuse will be bagged/secured,
all items of equipment, linen, curtains etc. will be removed and the
cleaning of the bed/mattress will be attended to.
 All equipment, including bed table, locker, chairs, sink, television,
toilet/shower/bath etc. MUST be well cleaned with detergent or
cleaning powder and hot water. In conclusion every part/item of the
room including lower walls and (high wall washing on instruction of the
department head/Infection Control) floors, ledges, windows etc. must
be cleaned properly and disinfected with Milton on the instructions of
the Department Head/Infection Control.
 Open the windows, to facilitate thorough drying of surfaces.
NOTE - If the patient is isolated in an open ward near a sink or near a
window then the entire surrounding area up to the next bed, including the
curtain rail, window etc. if applicable should be cleaned.
Some areas i.e. Operating Theatre, Aseptic Room etc. have special
requirements and have specific guidelines local to their areas. These are
available on the Departments and the Department Heads will direct Cleaning
Supervisors accordingly.
If spillage of blood/urine/any body substance occurs inform the nursing staff
who will issue instructions to the cleaner before he/she proceeds to wash the
area.
In the interest of Health & Safety, where even spillage of i.e. ordinary water
occurs care MUST be exercised to drying the area properly.
REMEMBER!
 The placing of the cones for spillage.
 The removal of cones when spillage is dealt with
 The cleaning of cones
Additional Key Points for Cleaning of the Environment
 Outside of the normal time allocated for cleaning - for example an area
allocated for cleaning in the evening may be visibly soiled at 10am- Then
it should be attended to when noticed.
 Cleaners should be encouraged to seek out areas that need cleaning,
rather than following a routine, which concentrates, on areas that are
regularly cleaned. The floors of the toilets are usually cleaned but it is not
uncommon for faecal contamination of walls or doors to remain for
several weeks.
“High Risk” areas
“High Risk” areas e.g. ICU, Operating theatre, Leukaemia Unit, Isolation Units,
Aseptic Rooms etc. These are areas, which demand scrupulous cleaning. They
MUST at all times have their own equipment, cleaning cloths, cleaning agents
etc. Under NO circumstances should equipment be borrowed/loaned in these
areas…
Storage of Equipment
 Cleaning equipment must NOT be stored on the back stairway of the
hospital. These stairways serve as a fire escape. Neither should it obstruct
fire doors. Store Room MUST be kept, clean, neat, tidy at all times.
Vacuum all floor surfaces until visibly free of dust and debris. Pay particular
attention to underneath beds, corners etc. Where possible staff will assist
moving beds together to facilitate more thorough cleaning.
Bathrooms/Toilets/Showers
Particular attention should be paid to the cleaning of toilets, baths, showers,
bidets etc. They should be maintained scrupulously clean at all times to maintain
the good image of the hospital.
Areas RemovedIt is important that areas such as filing rooms, offices etc. are not forgotten.
Proper dusting/polishing of shelves, desks, cleaning behind computers, emptying
of bins etc. is carried out. This also applies to the Classrooms, Nurses Home, Out
Patient’s, Endoscopy, Physiotherapy, E.E.G, X-ray Departments etc.
Corridors/ Stairs
Proper attention to cleaning of all stairs in the hospital is very important,
particularly attention to the corners, edges etc. Regarding the front stairs
extreme care should be exercised in keeping in between banisters free from
dust/fluff. All entrances require 100% attention to detail.
Telephones, Statues etc
These are areas which tend to be neglected but must be remembered.
Mirrors/glass
Mirrors and glass should at all times be maintained spotless, particularly the
front hall mirrors, the glass in St. Anne’s Ward, Lifts and mirrors of lifts/other.
Placing of cones
Cones should be placed as an alert in areas where cleaning is in progress,
particularly when floors are being washed. It is advised that washing is carried
out on one side of a ward/corridor at the time, to allow for traffic on the other
side.
Flex, Plugs etc.
When vacuuming, scrubbing, buffing ensure that the flex of the machine is not
stretching across the ward/corridor as it may cause an accident. Always use plug
nearest the machine and on the same side if possible. If cleaning elevators
summon assistance to hold the lift.
Daily Service
REPORT to the Ward Sister/Department Head at the beginning of each
schedule to receive specific instructions regarding any special
requirements/precautions.
For general purpose cleaning Detergent/Ajax or Jif are acceptable cleaning
agents. There is no need for disinfectant unless specified by the Department
Head /Infection Control.
Empty bins and dispose of in the appropriate refuse bag (see Section on
refuse). Clean and dry.
Wash lockers, bed tables, wardrobes, chairs, tables etc. (paying particular
attention to the legs and underneath frames. Damp dust bed ledges.
NOTE- Take care when vacuuming not to bang paint work, wood etc. Do
not use sweeping brush in ward/clinical areas. Do not use dust control
mops in ward/clinical areas.
(See Section on Methods of Cleaning)
Wash floors with clean, hot water, preferably using “Flat” Mop system. Dry
properly. NOTE- Take care to wash corners/edges properly and dry off
properly, thus avoiding scum formation at the edges/corners.
When dry, spray buff floor areas using buffing machine and appropriate, clean
buffing pad.
Bathrooms/ Toilets/ Showers
 Clean sinks, baths, showers, toilets, with a cleaning powder preferably,
paying particular attention to area underneath seat covers and handles
of toilets DO NOT let dirt accumulate in these areas.
 If the seat is obviously contaminated disinfect with a hypochlorite
(made up according to the manufacturer’s instructions). If hypochlorite
is used the seat must afterward be rinsed with water and dried.
 Flush toilet and use toilet brush to clean inside of bowl. Pouring
disinfectants down the toilet is considered waste- flushing removes
bacteria more effectively than disinfectants. However, at times a descaling agent may be necessary i.e. a strong one for areas such as the
gent’s toilets, particularly the Casualty Department i.e. Domestos.
 Particular attention should also be paid to cleaning around taps, plug
holes etc.
 Wash toilet brush/holder and store dry. NEVER store in any type of
solution.
 Wash floors using detergent and hot water. If contaminated a
hypochlorite in its proper dilution may be used.
 Remember to clean towel cabinets, sanitary bin surfaces, light
switches,
 and chairs, spot wash walls, doors etc. if necessary.
 Empty bins. Clean.
NOTE:
Attention to detail is very important. Bathrooms, toilets, showers etc.
MUST never be neglected. Spot check walls, doors, skirting while
walking along corridors, stairways etc. Look out for the unexpected –
spots on walls, gum on floors, marks on floor, cobwebs at entrance
doors, cobwebs on lights etc. Seek out the hidden areas.
Report any broken tiles, wall cracks, non- functioning toilets etc. to
Domestic Service Department
This is a guideline document for the Contract Cleaners from an Infection Control
perspective. It is the responsibility of the firm to implement these guidelines, in
conjunction with Household Services Guidelines.
No alteration can be made to this document without prior consultation with the
Infection Control Team.
13. Waste Management
13.1 Introduction
The application of more stringent environmental standards and also the
recognition of the importance of improved Health & Safety standards have
placed renewed emphasis on the importance of proper management, handling,
storage, transportation, treatment and disposal of healthcare waste. The
Department of Health published a “Health Services Waste Policy” in 1994. The
policy outlines the different disposal methods available and provides guidance
for healthcare waste producers. Further studies showed that the best overall
option was the treatment of healthcare risk waste by the use of shredding and
disinfection at a small number of sites throughout the country.
The Joint Waste Management Board (JWMB) commenced in spring 2000 and
consists of a contractor- provided service for the collection, transportation,
treatment and final disposal of healthcare risk waste throughout Ireland. The
Department of Health and Children published the working draft on the
Segregation, packaging and storage guidelines for healthcare risk waste in 2002.
This document provides guidance for a uniform system of managing waste, with
the majority of healthcare risk waste now being processed using nonincineration disinfection technology.
The Mercy University Hospital prepared its own Health Care Waste
Management Plan. It was drawn up in conjunction with the Southern Health
Board document as the S.H.B. holds the contract for disposal of the Mercy
University Hospital Waste. The plan proposes that –
The minimization of waste is actively pursued, and increased emphasis put on
the use of greener products and recycling.
The criterion by which Health Care Waste is to be separated into Health Care
Risk / Health Care Non-Risk is described.
The need to provide a safe working environment for those engaged in
handling waste is addressed and ongoing training programs in place.
To facilitate the effective implementation of the plan and to comply with
statutory obligations, appropriate records will be maintained.
See: Mercy University Hospital Waste Management Plan
13.2 Categories of Waste
Segregation at the point of origin, aided by suitable and consistent packaging
is vital in enabling different forms of waste to be handled, transported and
disposed of in a manner which is safe and in keeping with the nature of the
waste. The first level of segregation involves the categorization of healthcare
waste into “risk” and “non-risk” healthcare waste. The second level is between
parts of the same waste stream which have distinctly different properties.
Segregation should be done at the point of generation where the nature of the
waste is best understood.
See Dept. of Health poster on the Segregation & Packaging of Healthcare risk and
non-risk waste
See STG (Sterile Technologies Group) Booklet and Health Care Risk Packaging 2005
Non Risk Waste
Non-risk or household waste – the majority of healthcare waste - is non-toxic,
non-infectious and unlikely to prove a health hazard or give offence. There are
no particular requirements for segregation, but recycling schemes may involve a
degree of segregation. It consists of:
Domestic waste – normal household and catering waste
Confidential material – shredded confidential waste documents
Medical equipment – assessed as non-infectious
Potentially offensive material – assessed as non-infectious
Healthcare Risk Waste (Clinical)
Infectious Waste:
(a) Blood and items visibly soiled with blood.
(b) Contaminated waste from patients with transmissible infectious diseases.
(c) Incontinence wear from patients with known or suspected enteric
pathogens/other infection.
(d) Other healthcare infectious waste.
Sharps:
Any object which has been used in the diagnosis, treatment or prevention of
disease, which could cause a puncture wound or cut to the skin.
Anatomical Waste:
Microbiological cultures: specimens and potentially infectious waste from
Microbiology, Biochemistry, Haematology, Pathology departments (Laboratory
and Post Mortem Room) or Research.
Toxic Waste/Chemical waste:
Discarded chemicals and medicines.
Radioactive Waste: Includes materials in excess of authorized clearance levels,
classified as radioactive under the General Control of Radioactive Substances
Order, 1993.
Table 13.3 Segregation of Healthcare waste – Non
risk waste, risk waste and laundry disposal
DESCRIPTION USE Destination
Clear Plastic bag
(large)
Non risk Domestic
waste Wrappings, flowers,
plastic bottles etc
 Oxygen face masks,
clear tubing i.e. oxygen
& ventilator tubing.
 Enteric Feeding Bags
 Non- contaminated
gloves, aprons &
masks
 Non- infectious
nappies, disposable
sheets etc. Common
sense must prevail –
wrap dry area of the
item around the wet
area.
Corporation
Landfill
Compacted
before
transit
White plastic bag
(small) Shopping Bag
Type.
Non risk Domestic
wasteTo carry on E.C.G rounds
etc.
Empty into large Clear
plastic bag
Corporation
Landfill
Black plastic bag
(large)
Non Risk Cardboard
Waste
Fold cardboard before
disposing in black bag
If too large for black bag,
fold and place in
cardboard box. Secure
with Black Tag
Rehab
Recycling
Patient Property Bags Green Plastic - marked
patient property
Non Risk Patient
Property
Home - On
patient’s
discharge.
Glass
Cardboard Box
Intact glass & Broken
glass – NB. Broken
glass- boxed, securely
taped and clearly marked
“BROKEN GLASS for
collection by Maintenance
Recycling
Patient
Property
Waste Food container
Non risk - Waste Food
Buckets (kitchen)
To waste food unit –
ground, compressed and
treated
Corporation
Landfill
Battery Disposal
container
Location: Clinical Waste
Compound
Non risk potentially
hazardous - Batteries
To be stored separately on
depts for collection by
maintenance staff
Recycling
by Return
Batt
Fluorescent light
disposal box
Location: Clinical Waste
Compound
Non risk potentially
hazardous – fluorescent
lights
Recycling
by Irish
Lamp
Recycling
Grey Wheelie Bin
Location: Bins
throughout the hospital
Marked confidential
For all confidential paper
material /any paper
Rehab
Recycling
Skip
Location: Clinical Waste
Compound Yard
Non risk discarded
furniture & medical
equipment assessed as
non infectious
(Excluding electronic
equipment)
Landfill
Yellow Plastic bag
(large)
Healthcare risk waste
 All blood stained or
contaminated items
including dressings,
swabs, IV giving set
(NB sharp removed),
personal protective
equipment i.e. aprons,
gloves if infectious)
 Suction catheters,
tubing and wound
drains
 Incontinence wasteonly if infectious (risk
assessed)
STG,
Unit 12,
Western
Industrial
Estate,
Naas
Daily
collection
Yellow Plastic Bag
(small)
Healthcare risk waste
Similar contents to large
yellow bag. Useful to
accompany phlebotomy
trolley.
STG
(as already
outlined)
Yellow Sharp’s Bin
(large)
(Red covers and clearly
marked Sharps)
Healthcare risk Sharps
Syringes/needles (discard
syringe and needle as one
unit), scalpels, IV
cannulas, razors, stitch
cutters, guide wires,
contaminated glass etc.
STG
(as already
outlined)
Yellow Sharp’s Bin
(small)
(usually Red covers and
clearly marked Sharps)
Sharps- Similar contents
to large bin. Useful to
accompany Phlebotomy
trolley, IV tray, Out
Patients Dept. etc.
STG
(as already
outlined)
Yellow rigid bin with
yellow lid
(Leak-proof)
Healthcare risk fluid
waste – material
containing free fluids
(contained), laboratory
wastes, blood, plasma,
histology waste
NB Contaminated wastes
should be disposed using
an inner receptacle & liner
STG
(as already
outlined)
Yellow sharps bin with
Purple lid
Stored in Cages in
Clinical Waste
Compound
Healthcare risk
Cytotoxic Sharps
Needles, syringes (syringe
and needle discarded as
one single unit), IV giving
set and cannula (discard
as a single unit), drug
ampoules
AbroadOnyx
C1 Forms
with
Maintenance
Yellow rigid bin with
Purple lid
(Leak-proof)
Healthcare risk Nonsharps Cytotoxic waste
Discarded chemicals &
medicines, pharmaceutical
waste
Abroad (as
immediate
entry
(Leak-proof)
Healthcare risk Anatomical
waste and processed
blood products where the
volume exceeds 100ml
Abroad
Yellow wheeled
Transport Bins (Large)
Transport & storage of
Healthcare risk waste
Healthcare risk waste
destined for two different
disposal routes must
never be mixed together in
one wheeled bin. Bins
should be locked and
parked with brakes ON
Carriage of
Healthcare
risk waste
Special Spillage kit
- Front hall porter
attends to spillage
Healthcare risk Mercury
waste
Collected by
Indaver,
Ireland
Drum for disposal
“ “
Sharps container
within Lead shielded
container
- until rendered safe
Healthcare risk
Radiological waste
- See section on
Radiological waste
Xray
Supervisor
Mr. Andrew
Owen Clear Plastic bag with
Blue Print - (Autoclave
Bags)
Healthcare risk
Laboratory Waste plates, urines, faeces,
blood specimens etc.
Autoclaved
in the
Mercy U.
Hospital - to
render safe
for collection
by STG
White Canvas laundry
Bag - with draw strings
Used Linen (non-soiled,
non- infected).
NB. Do not overfill,
Separate before placing
in the bag
Hospital
Laundry
Avoid “foreign bodies”
mixed with laundry
Water Soluble
(Alginate) Clear white
plastic Bag with pink
strings to tie
Infected Linen- soiled
linen
Remember to tie
immediately with pink
string. Leaving the bag
open defeats the
purpose.
Hospital
Laundry-in
Red Plastic
Bag
Large Red Canvas Bag
Closed “Alginate” Bags
are to be placed in
these Red Bags for
transfer to the Laundry
Hospital
Laundry
Blue Bin
Waste Oils from kitchen
Bins allocated in the
Waste Yard
Collected by
Maintenance
And brought to bins
Recycledmonthly
collection
=======
Black Tags
Sealing of all Refuse
Bags and Sharp Bins.
These coded tags
indicate the source (dept)
of the waste, to facilitate
tracing.
Available
from Stores
13.4 Guidelines for Safe Handling/Disposal of
Healthcare risk Waste
All containers including wheeled bins should conform to basic UN
requirements relating to manufacture, colour coding, labelling,
filling, closure and traceability
 Manufacturers of all packaging should conform to approved UN
standards.

 Colour Coding assists in segregation but is not a UN requirement.
The basic colour for the body of each container is yellow.

 Labelling – All healthcare risk waste should be labelled with
information about the contents and recommended method of disposal e.g.
diamond shaped risk label including appropriate biohazard symbol and
method of disposal. Black & purple lidded bins, destined for overseas
incineration, should also be labelled as Mercy University Hospital waste.

 Filling – Containers must not be overfilled. In general rigid boxes
should be no more than ¾ full while bags should be no more than 2/3 full (to
aid closure of the bags). Wheeled bins must not be filled beyond the point
where closure of the lid is obstructed or causes the contents to be squashed.

 Closure – It is essential that lids are fitted and closed in accordance
with manufacturer’s recommendations. Plastic bags should be tied with plastic
tie. Wheeled bins should be locked during storage and transportation.

 Traceability
 All waste packages must be tagged with the black plastic coded tag,
which is traceable to the point of production.
 Records of tags issued to particular locations should be retained for a
period of not less than 3 years.
 Departments should not borrow tags from other areas as the tags are
individualized for each department.
The plastic waste bags should be secured in a foot operated, lidded bin or
carrier frame and lids marked, i.e. Clinical Waste.
To avoid injury the bags should be handled by the neck only and kept upright
and away from the body. Do not put your hand underneath waste bags while
lifting.
Waste should be stored in a neat fashion within the designated area on each
Department. The designated storage areas should be cleaned regularly and
kept dry.
Central collection/storage areas must be secured from unauthorized access,
elements, pests and rodents.
During transport and storage of waste, segregation must be maintained.
Bags must be removed from the Department daily or more frequently if
necessary (particularly areas without adequate storage space), especially
from isolation areas or during periods of infection on general wards.
Frequency of collection should be arranged to ensure that storage areas are
always cleared before becoming over-filled.
Double bag before leaving Isolation areas for high risk cases e.g. Viral
haemorrhagic fever, Typhoid, SARS.
Standard precautions should be used when contact with blood/body fluids is
likely (See Infection Control manual).
Maintenance staff should wear heavy-duty clothing/heavy duty gloves,
appropriate footwear, a face visor/respiratory mask, as required when
handling waste bags/bins etc (London Waste Regulation Authority, 1994).
Blood / Body fluids which are contained in a secure container e.g. enclosed
suction systems, must be carefully handled and placed in the appropriate
yellow rigid bin. Remember to close the bin properly.
The central waste store should be equipped with spillage kits and washing /
cleaning / disinfection facilities for dealing with spillages.
Spillages should be treated according to the methods outlined in the
Cleaning/Disinfection Protocol -See Section 12.
All accidents/incidents involving healthcare risk waste must be reported
without delay to the Maintenance Supervisor, Initiate first aid immediately, and
refer the casualty to the Accident & Emergency Dept.
The Occupational Health Nurse should be informed:
Monday – Friday 8 am – 5 pm (Bleep 6626)
 Record and report the accident through the normal accident reporting
system - See Policy for Accident / Incident reporting.
 Report the incident to a member of the Infection Control Team for
assessment, investigation and advice if required. (Damani N., 1997)
Radioactive Waste
The policy for safe handling/disposal of radioactive waste in the Mercy
University Hospital X-ray Dept. is in conjunction with the Radiation Protective
Institute of Ireland (R.P.I.I). Any syringe/needle/item containing traces of
radioactivity is placed in a sharp’s bin, within a lead-shielded container. When
full, the bin is sealed, dated (replaced) and placed in a second, similar container
until the next replacement is required. This 2nd re-process renders it completely
inactive and the bin can now be disposed of as per usual Sharps Policy. The full
guidelines, which are local to the X- ray Department, are kept on the
Department.
13.5 Guidelines for Safe Use, Handling and
Disposal of Sharps
Introduction
Sharps are defined as any items which can cause laceration or puncture wounds
and may be contaminated with blood/body fluids. Examples include
syringes/needles, intravenous cannulas, scalpels, suturing needles, broken glass,
sharp objects, jagged metal etc. Sharp instruments frequently cause injury to
healthcare workers and are a major cause of transmission of blood-borne virus
(PHLS AIDS & STD Centre 1999).
Studies have found the cause of sharp injuries to be associated with disassembly
of devices E.g. IV cannulas; recapping of needles; transfer of used sharps to
point of disposal; sharps not discarded after use or overfilled containers
(Eisinstein & Smith 1992, Jagger et al 1988, Weltman et al 1995)
Under Section 9 of the Safety, Health and Welfare Regulations, 1993(No.
44) each employee must –
 Take reasonable care for their own safety, health and welfare and that
of any other person who might be affected by their acts or omissions.
 Co-operates with the employer to enable the employer to comply with
statutory obligations.
GENERAL PRINCIPLES FOR HANDLING & USE OF SHARPS
Every healthcare worker has a responsibility to ensure proper disposal of the
sharps they have used.
Avoid sharp usage or handling wherever possible.
Avoid rushing when handling needles / sharps wherever possible.
Before undertaking any procedure involving the use of sharps, assess
the risk involved and what protection may be necessary.
Seek assistance when administering injections, withdrawing blood or
administering IV therapy to difficult or non co-operative patients.
DO NOT leave sharps lying around on patient’s lockers, bed tables,
IV trays/ anywhere else posing a risk to patients, visitors or staff.
Always use the designated tray with sharps bin to carry syringes/
needles/sharps to and from the patient’s bedside.
Ensure sharps containers are placed at points of use.
Extreme care should be exercised to avoid dropping sharps on the floor
instead of in the sharps container.
DO NOT use needles if there is any suspicion e.g. a broken seal that may
have been used previously.
NEVER place a needle / sharp in a refuse bag.
NEVER bend, break or re-sheathe a needle .Dispose of syringe/needle as
one single unit.
Sharps MUST NOT be carried or passed by hand to another person; nor
should they be placed in pockets and carried to locker / bed rooms etc
Please display Sharp Posters on your Departments
Use of Sharp Containers
Sharp containers should conform to British Standard 7320 and be UN
approved for the packaging of sharps. Sharp containers MUST be correctly
assembled and used according to the manufacturers instructions. The label
on the side of the container MUST be signed by the person assembling the
container and securing the container as well as attaching the black coded tag
to the lid. These tags should not be borrowed from other departments for
traceability reasons
Sharps containers MUST be kept in a location which excludes injury to
patients, visitors and staff and is readily accessible to staff. Special care
should be exercised to prevent children from having access to sharps/sharps
containers.
NB: The temporary closure must be activated when not in use.
Sharp Bins MUST not be left on the ground- attach to wall, to trolley, in
special tray or on mobile unit (for the ground).
Always have an empty sharps bin in readiness on the emergency trolley.
Cytotoxic sharps MUST be disposed of as a complete unit (including bag,
administration set, cannula ) in the special cytotoxic sharps bin - purple
lid.
Sharp containers must NEVER be overfilled (3/4 to the marked line) since
used sharps protruding from overloaded containers constitutes a very
significant hazard to those who have to handle them.
 Sharps MUST be dropped in, not pushed down.
 DO NOT use sharp containers for any other purpose e.g. storage of
ward items etc.
 Sharp containers MUST be securely stored on the ward / department
while awaiting collection.
 Transport staff MUST be adequately educated in the safe principles of
dealing with sharps. They MUST take special care and should wear
heavy duty gloves when collecting sharp containers.
 The containers MUST be stored in a secure, locked, depot whilst
awaiting collection, to prevent any unauthorized access.
 Sharps Bins MUST be clean
METHODS OF SAFE DISPOSAL
It is the personal responsibility of the person using a sharp to dispose of it
safely, immediately after use. Where the specific clinical procedure prevents
the user from doing so, the user still retains overall responsibility for safe
disposal of sharps.
If a sharp has been accidentally dropped it MUST be recovered and disposed
of properly. If the search is unsuccessful, the individual should ensure that
other people using the area are informed, so that they can take due care. The
person in charge of the area should be informed and a record kept until the
sharp has been located and properly disposed of.
It is particularly important to consider cleaning staff. Cleaning staff should be
made aware that under no circumstances, at any time should they handle a
sharp. In the event of them finding a sharp of any description they should
report it to the person in charge of the Department.
Scalpel blades from non-disposable scalpels MUST be removed using a
forceps or surgical blade remover and placed in the sharps container. Non
disposable sharps should be placed in a suitable, secure container to await
decontamination (as soon as possible).
Glass slides, glass drug ampoules, razors, disposable scissors, IV cannulas
etc. MUST be discarded into a sharps container.
The attached sharps from IV blood / solution administration sets MUST be cut
off with scissors and discarded into the sharps container. The scissors MUST
be cleaned properly using an alcohol-impregnated swab.
When syringes containing arterial blood are being sent to the laboratory,
needles MUST be removed (placed in the sharp container) and the nozzle of
the syringe sealed by means of the luer rubber cap/blunt hub supplied.
14. Collection of Specimens for
Laboratory Examination
Introduction
Hazards of infection, both to patients and staff, occur during the collection of
specimens, during transport to the laboratory and during examination in the
laboratory.
Faulty technique during collection may result in inadequate, misleading or
delayed laboratory reports which may affect a patient’s treatment, including
management of infection. During collection, especially of urine specimens, the
patient may become infected. The nurse may be infected by contamination of the
hands/clothing or by inhalation of infected aerosol material during transfer to
the containers. During transit the person carrying the specimen may be infected
by contaminants on the outside of the container, or through leakage or breakage
of the container. In addition the environment may become contaminated during
these procedures and lead to an indirect spread of infection (Ayliffe et al, 1993).
Laboratory staff receiving unlabelled, potentially hazardous material (e.g.
sputum from a patient with suspected pulmonary tuberculosis/blood from a
patient with suspected hepatitis) are also at risk. To ensure correct investigation,
specimens should be correctly labelled and accompanying request forms should
contain appropriate and adequate clinical details. Specimens should routinely be
transported in an upright position. High Risk specimens should be placed in dual
compartment “Bio-hazard” plastic bags (Wilson, 1991). See also Section 10“Special Risk Infection” Coding System
14.1 Information on Request Forms
The request form provides a very important source of information for the
laboratory staff. It assists them in the identification of the causative organism.
The request form should therefore always be completed accurately.
Of particular importance is an accurate indication of the site of the specimen.
Some bacteria may form part of the normal flora in one site of the body and yet
be pathogenic if isolated elsewhere. If the patient is receiving antibiotic therapy,
antibiotic present in the specimen may inhibit the growth of bacteria in cultures
and produce misleading results. The date and time of collection is also
important. A relevant history, including symptoms of infection or suspected site
of infection can assist in the interpretation of the results. For example,
information on the nature/frequency of vomiting and diarrhoea should
accompany a specimen of faeces.
NB: Remember to include the ward/dept. on the form, and to place a label on both
sides of the form. Otherwise the results cannot be returned to the ward/Dept.
Transport of Specimens
Potentially infectious material presents a hazard when it is being transported
and care must be taken to ensure that risk to other people is kept to a minimum.
Recommendations have been made by the HSAC (1991) for the safe transport of
specimens, which include carriage in leak proof containers/boxes and a
procedure for dealing with spillage. The member of staff who collects the
specimen has a responsibility to ensure the following The specimen container is leak proof and securely sealed with no traces of
blood/body fluid on the outside of the container and the specimen
container should not be overfilled.
Secured in a Bio hazard marked bag.
Specimen is accompanied by a fully completed request form.
(See 14.1 for details).
14.2 Collection of Urine Specimens
Faulty technique for the collection of both M.S.U. and C.S.U. can lead to
contamination of the specimen and an erroneous diagnosis of urinary tract
infection (Ayliffe et al, 1993).
Urine specimens easily support the growth of bacteria and their multiplication in
specimens stored at room temperature can produce misleading results. The
specimen should therefore be examined in the laboratory within 2 hours.
Alternatively if delays are unavoidable, the specimen should be placed in the
designated refrigerator in the laboratory. If refrigerated, it can be stored for up
to 24 hours. Specimens should NOT be left to lie around in receptacles, on ledges
etc. REMEMBER to take Standard Precautions when dealing with urine.
Catheterised Specimens of Urine (C.S.U.)
This procedure MUST be carried out under strict aseptic technique.
NEVER disconnect the drainage tubing to obtain a sample, as any
interruption of the drainage system poses a risk of infection to the
patient. NEVER take a sample from the drainage bag (Ayliffe et al,
1993).
If clamping is necessary - clamp ONLY the drainage tubing. NEVER clamp
the catheter.
Sterile gloves should be worn for this procedure and remember to wash
hands before/after wearing gloves.
First disinfect the port with a sterile alcohol (70%) impregnated swab.
The sample may then be aspirated, using a sterile 5ml syringe and needle
(inserting the needle at an angle, to prevent penetration of the distal
end) and transferred to a sterile universal container. The needle
should be removed for transfer of the urine, taking due care to prevent
needle stick injury. REMEMBER to carry a receptacle for the
syringe/needle.
Label the container/dispatch to the laboratory as soon as possible with the
completed request form, indicating that it is a C.S.U.
Mid Stream Specimen of Urine (M.S.U.)
 Ambulant patients should have a shower in preference to having a bath
before collecting an M.S.U. For female patients confined to bed, thorough
washing of the vulval area with mild, non scented soap, clean water and a
clean cloth is all that is necessary.
Explain the procedure clearly to the patient - mid stream urine to be
collected, using a clean disposable carton (in the case of the female
patient) and transfer to the universal container, taking care to avoid
touching the inside of both containers during the process. NO MORE
THAN 5 MLS OF URINE IS REQUIRED.
Label the container, complete the request form (taking care to enter
M.S.U.) and dispatch to the laboratory as soon as possible.
Faecal Specimens
Faecal specimens should be collected from a bedpan using the integral
scoop of the sterile stool container.
Gloves should be worn for this procedure and hands washed on removal
of gloves.
Avoid contamination of the outside/neck or cork of the container.
For bacteriological examination only, a small amount of faeces is all that is
necessary. There is no need to fill a container.
14.3 Sputum
Specimens of saliva are of no value so it is important to ensure that the
specimen is mucoid or mucopurulent. Encourage patients who are
having difficulty in producing sputum, to cough deeply first thing in the
morning. Alternatively the physiotherapist may be called to help.
Sputum specimens should be sent to the laboratory immediately as
respiratory pathogens do not survive for prolonged periods (Wilson,
1995).
It is often difficult to obtain a specimen of sputum without contamination of
the rim and outside wall of the container. Some protection can be given
to staff handling the container if- after collection of the specimen the
rim and outside of the container are wiped with a paper tissue to
remove major contamination before putting on the lid. The tissue
should be disposed into a clinical waste bag. Gloves should be worn
for the handling of such containers, which should be placed in a dual
compartment Bio- hazard bag, keeping the form separate from the
container (Ayliffe et al, 1993).
14.4 Swabs
Swabs collected from infected sites should be transferred carefully to the swab
container and inserted slowly to avoid contamination of the rim with infected
material. The container should be held as near to the site as possible to avoid
shaking infected material in the air. Send the swab to the laboratory as soon as
possible.
Wound Swabs
Wounds should be swabbed before they are cleaned and the swab should
be taken directly from the area suspected to be infected.
If pus is present it can be drawn up in a sterile syringe and transferred to a
sterile container. A tube of transport medium accompanies most type of
swabs, this will prolong the survival of micro- organisms for several
hour
It is extremely important to label the wound swab accurately, indicating the
exact site from which it has been collected. This helps the laboratory
predict the type of micro- organisms to expect in the swab and to
identify the site of infection should the patient have more than one
wound.
Bacteria isolated from a wound swab should not be considered as
infecting the wound unless there is also evidence of an infection
process occurring in the wound; for example pus, inflammation,
erythema or fever. A swab need only be taken where the wound
exhibits these signs of infection. This is particularly the case in cases of
chronic wounds such as pressure sores or ulcers, where wounds may
be colonized by several different bacteria with no adverse effect.
Other Swabs
Nasal Swabs- The swab should be rubbed inside the exterior nares. One swab can
be used to sample both nostrils.
Perinasal swab of the naso-pharynx- is required where whooping cough is
suspected. The swab is fixed onto a long flexible wire and accompanied by
charcoal transport medium.
Throat Swabs - should be taken by depressing the tongue and gently rubbing the
swab over the pillars of the fauces. Care should be taken to avoid touching other
parts of the mouth, which may contaminate the swab with other bacteria.
Ear Swabs- ears should be swabbed carefully ensuring that the swab is
introduced gradually and not inserted very far. Medical staff, using a speculum
should only undertake deeper swabbing.
Vaginal Swabs- Vaginal swabs should always be sent to the laboratory in
transport medium. Investigation for some sexually transmitted diseases requires
special transport media- Contact the laboratory for advice.
Skin Swabs- e.g. groin/axilla- usually to look for resistant strains of bacteria,
which may colonize the skin, particularly methicillin resistant Staph aureus.
Swabs should be moistened in transport media or sterile saline solution to
improve the efficiency of sampling. One swab will suffice for both groins and one
swab for both axillae.
Chlamydia Swabs (with instructions) available from Infection Control
Procedure for Swabbing for MRSA
 Use swab in transport medium.
 Each swab should be gently rubbed on the surface to be swabbed. The
swab should be rolled over several times during the swabbing so that
the whole of the swab comes in contact with the surface being
investigated.
 In order to standardise the procedure it is best to take a standard
twenty seconds for each swab. In the case of a nasal swab i.e. where
one swab is used per patient, ten seconds should be spent on each
side of the nasal cavity
Blood Specimens
In addition to Hepatitis and HIV infection several other infections, including
typhoid fever, can be acquired from blood specimens. Blood should always
therefore, be regarded as potentially infected and care should be taken to avoid
contact with all blood.
Blood Samples
Intact non-sterile latex gloves should always be worn when taking blood
samples and hands should be washed after removal of gloves. Any cut
or abrasion should be covered with a waterproof plaster.
Extreme care should be exercised to avoid needle stick injury on
withdrawing the needle from the site and on disposal of the needle.
Always carry the yellow tray (sharps bin insitu) to the bed side when
taking blood samples. Never re-sheathe a needle.
When finger prick specimens are taken exercise the same precautions.
Blood Cultures
To identify bacteria in the blood, a sample MUST be taken very carefully to
avoid contamination by skin flora. This is a completely sterile
procedure. Hands MUST be washed, using Hydrex and running water,
and sterile gloves MUST be worn.
Exercise the same protective precautions as already outlined (above).
Care should be taken to avoid contamination of the outside of the bottles.
Dispatch to the laboratory as quickly as possible. Complete the request
form with accurate details including any microbial treatment that the
patient is taking.
If in doubt or any queries contact the Microbiologist / Laboratory staff or
Infection Control
Infection Control
Mercy University Hospital, Cork
Equipment - Cleaning / Decontamination Certificate
Standard: All equipment for maintenance/service/repair either within the area or
transferred from the area is pre-cleaned, decontaminated
Department _______________________________
Type of
Equipment____________________________________________
______
Equipment Serial Number____________________________
Description of Cleaning
______________________________________________
________________________________________________________
Type/strength of chemical disinfectant used (if used)
___________________________________________________________
Additional information/ details (if any)______________________________________
_____________________________________________________
________________
Signed _______________________________
Date ________________________
Copy of Decontamination Certificated MUST be kept on file
Infection Control
Mercy University Hospital, Cork
Equipment - Cleaning / Decontamination Certificate
Standard: All equipment for maintenance/service/repair either within the area or
transferred from the area is pre-cleaned, decontaminated
Department _______________________________
Type of
Equipment____________________________________________
______
Equipment Serial Number____________________________
Description of Cleaning
______________________________________________
________________________________________________________
__________________________________________________________________
Type/strength of chemical disinfectant used (if used)
___________________________________________________________
Additional information/ details (if any)______________________________________
_____________________________________________________
Signed _______________________________
Date ________________________
Copy of Decontamination Certificated MUST be kept on file
CONSENT FORM
Date……………………………………….
Patient Number………………………………………
I, Name ……………………………………………………….
Address………………………………………………………….
…………………………………………………………………hereby consent to.
Have a blood test For the HIV (AIDS) virus and/or serum Hepatitis B/C virus.
on Signature of………………………………………………………………..
Patient / Parent /Guardian
Signature of Witness……………………………………….
I confirm that the reason why this test is necessary has been explained to the person
who signed the above form for consent
Medical Practitioner
Signature……………………………………………………..
Name in Capitals………………………………………………….
Name of Patient if patient not giving consent (for Parents/Guardians)
………………………………………………………………………..
Please state your relation to the Patient………………………………
10.9 (A) Mercy University Hospital Patient
Decontamination Protocol for MRSA
Patients colonised with MRSA who are to undergo an elective procedure,
have a prosthesis in situ or are in a clinical area where there is high risk of
colonisation leading to invasive infection, eg ICU should undergo
decolonisation. A risk assessment of other patients such as long stay patients
or patients with chronic nasal colonisation should be carried out to determine
if nasal decolonisation should be attempted in these patients. However,
excessive use of nasal decolonisation agents should be avoided as this may
select for resistance to these agents (SARI (2005) p.19).
This regimen should be commenced on the advice of the Infection
Control Team only and in consultation with the Consultant. It is not a
prescription.
Guidelines for administration of
Prometic Body Wash & Shampoo
Guidelines for the administration
of Mupirocin Nasal Ointment 2%
(Bactroban) as prescribed on drug
chart
Patients should bathe daily for 5
days with special attention to the
known possible carriage s
 Wash skin thoroughly
 Apply body wash using clean
cloth
 Wash whole body paying
particular attention to the
hairline, axillae, perineum,
groin, feet and any patch of
damaged skin. These should
be at least 1 minute contact.
 Rinse skin thoroughly
 Wash hair with the agent twice
during the 5 days
 After washing patient should
have fresh change of clothes &
bed linen
Apply Bactroban 2% Nasal
Ointment to the nose three times
daily for seven days
 Encourage patient to blow the
nose to clear away secretions
 Unscrew cap & squeeze a
small amount (pea size) of
ointment onto a cotton bud
 Apply to the inside of both
nares
 Close nostrils by pressing the
sides of the nose together
 Use Nasal Ointment only as prescribed
 Re- screen with swabs for MRSA after 24 hrs, 3 days and 5
days unless the patient is being discharged.
 Records should be kept of swabbing results
Reference- Strategy for Control of Antimicrobial Resistance (SARI) 2005,
Section B1. 24, P19.

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