1.1 Patient Placement/Assessment for infection risk

Patients must be promptly assessed for infection risk on arrival at the care area (if possible, prior to accepting a patient from another care area) and should be continuously reviewed throughout their stay. This assessment should influence patient placement decisions in accordance with clinical/care need(s).

Patients who may present a particular cross-infection risk should be isolated on arrival and appropriate clinical samples and screening undertaken as per national protocols to establish the causative pathogen. This includes but is not limited to patients:

• With symptoms such as loose stools or diarrhoea, vomiting, fever or respiratory symptoms.
• With a known (laboratory confirmed) or suspected infectious pathogen for which duration of precautions as outlined in appendix 11 are not yet complete
• Known or suspected to have been previously positive with a Multi-drug Resistant Organism (MDRO) e.g MRSA, CPE.
• Who have been a close contact of a person who has been colonised or infected with CPE in the last 12 months.
• Who have been in contact with a confirmed COVID-19 individual and are still within the 14-day self-isolation period.
• Who have been hospitalised outside Scotland in the last 12 months (including those who received dialysis).

For assessment of infection risk see Section 2: Transmission Based Precautions.

Resources

Further information can be found in the patient placement literature review.

1.2 Hand Hygiene

Hand hygiene is considered an important practice in reducing the transmission of infectious agents which cause HAIs.

Hand washing sinks must only be used for hand hygiene and must not be used for the disposal of other liquids.  (See Appendix 3 of Pseudomonas Guidance)

Before performing hand hygiene:

• expose forearms (bare below the elbows);
• remove all hand/wrist jewellery* (a single, plain metal finger ring or ring dosimeter (radiation ring) is permitted but should be removed (or moved up) during hand hygiene); bracelets or bangles such as the Kara which are worn for religious reasons should be able to be pushed higher up the arm and secured in place to enable effective hand hygiene which includes the wrists;
• ensure finger nails are clean, short and that artificial nails or nail products are not worn; and
• cover all cuts or abrasions with a waterproof dressing.

Hand washing should be extended to the forearms if there has been exposure of forearms to blood and/or body fluids.

 *For health and safety reasons, Scottish Ambulance Service Special Operations Response Teams (SORT) in high risk situations require to wear a wristwatch.

To perform hand hygiene:

Alcohol Based Hand Rubs (ABHRs) must be available for staff as near to point of care as possible. Where this is not practical, personal ABHR dispensers should be used.

Perform hand hygiene:

1. before touching a patient;
2. before clean/aseptic procedures. If ABHR cannot be used then antimicrobial liquid soap should be used;
3. after body fluid exposure risk;
4. after touching a patient; and
5. after touching a patient’s immediate surroundings

 

Some additional examples of hand hygiene moments include:

• Before handling medication
• Before preparing food
• Before donning (putting on) and after doffing (taking off) PPE
• After visiting the toilet
• Between carrying out different care activities on the same patient
• After cleaning and disinfection procedures
• After handling waste

Resources

Download and print the 5 moments of hand hygiene poster.

Wash hands with non-antimicrobial liquid soap and water if:

• hands are visibly soiled or dirty;
• caring for patients with vomiting or diarrhoeal illnesses; or
• caring for a patient with a suspected or known gastro-intestinal infection e.g. norovirus or a spore forming organism such as Clostridioides difficile..

In all other circumstances use ABHRs for routine hand hygiene during care.

Staff working in the community should carry a supply of Alcohol Based Hand Rub (ABHR) to enable them to perform hand hygiene at the appropriate times. 

Where staff are required to wash their hands in the service user’s own home they should do so for at least 20 seconds using any hand soap available. 

Staff should carry a supply of disposable paper towels for hand drying rather than using hand towels in the individual’s own home.  Once hands have been thoroughly dried, ABHR should be used.

The use of antimicrobial hand wipes is only permitted where there is no access to running water.  Staff must perform hand hygiene using ABHR immediately after using the hand wipes and perform hand hygiene with soap and water at the first available opportunity.

(The video above demonstrating Hand Washing and Drying Technique was produced by NHS Ayrshire and Arran)

Resources

For how to wash hands see Appendix 1

For how to hand rub see Appendix 2

Skin care

• Alcohol based hand rubs when used for hand hygiene should contain emollients in their formulation.
• Warm/tepid water should be used to reduce the risk of dermatitis; hot water should be avoided.
• Pat hands dry thoroughly after hand washing using disposable paper towels; avoid rubbing which may lead to skin irritation/damage.
• Use an emollient hand cream during work and when off duty.
• Do not use refillable dispensers or provide communal tubs of hand cream in the care setting.
• Staff with skin problems should seek advice from Occupational Health or their GP.

Surgical Hand Antisepsis

Surgical scrubbing/rubbing: (applies to persons undertaking surgical and some invasive procedures)

Perform surgical scrubbing/rubbing before donning sterile theatre garments or at other times e.g. prior to insertion of central vascular access devices.

• Remove all hand/wrist jewellery.
• Nail brushes should not be used for surgical hand antisepsis.
• Nail picks (single-use) can be used if nails are visibly dirty.
• Soft, non-abrasive, sterile (single-use) sponges may be used to apply antimicrobial liquid soap to the skin if licensed for this purpose.
• Use an antimicrobial liquid soap licensed for surgical scrubbing or an ABHR licensed for surgical rubbing (as specified on the product label).
• ABHR can be used between surgical procedures if licensed for this use or between glove changes if hands are not visibly soiled.
  
  

Resources

For surgical scrubbing technique see Appendix 3.

For surgical rubbing technique see Appendix 4. 

Hand Hygiene posters/leaflets can be found at Wash Your Hands of Them Resources.

Information on the WHO World Hand Hygiene Day 2021 with the theme 'Achieving hand hygiene at the point of care' is available.

Further information can be found in the Hand Hygiene literature reviews:

• Hand washing, hand rubbing and indications for hand hygiene
• Hand hygiene products
• Skin care
• Surgical hand antisepsis in the clinical setting

  (The video above demonstrating Surgical Scrubbing using ABHR was produced by Golden Jubilee National Hospital)

1.3 Respiratory and Cough Hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross-transmission of respiratory illness (pathogens):

• Cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose. If a disposable tissue is not available use elbow to cover the nose and mouth when coughing or sneezing.
• Patients showing symptoms of respiratory illness should be encouraged to wear a surgical (TYPE II R FRSM) face mask where it is clinically safe and tolerated by the wearer.
• Dispose of used tissues and face masks promptly into a waste bin.
• In the absence of disposable tissues and hand hygiene facilities only, individuals should cough or sneeze into their elbow/sleeve.
• Wash hands with non-antimicrobial liquid soap and warm water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions.
• Where there is no running water available or hand hygiene facilities are lacking, staff may use hand wipes followed by ABHR and should wash their hands at the first available opportunity.
• Keep contaminated hands away from the eyes nose and mouth.

Staff should promote respiratory and cough hygiene helping those (e.g. elderly, children) who need assistance with this e.g. providing patients with tissues, plastic bags for used tissues and hand hygiene facilities as necessary.

Resources 

Further information can be found in the cough etiquette/respiratory hygiene literature review.

1.4 Personal Protective Equipment

Before undertaking any care task or procedure staff should assess any likely exposure to blood and/or body fluids and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.

All PPE should be:

• located close to the point of use;
• stored to prevent contamination in a clean/dry area until required for use (expiry dates must be adhered to);
• single-use only items unless specified by the manufacturer;
• changed immediately after each patient and/or following completion of a procedure or task; and
• disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.

Reusable PPE items, e.g. non-disposable goggles/face shields/visors must have a decontamination schedule with responsibility assigned.

Further information on best practice for PPE use for SICPs can be found in Appendix 16.

Gloves must:

• be worn when exposure to blood and/or other body fluids is anticipated/likely;²
• be changed immediately after each task performed;
• be worn appropriately and removed after use
• never be worn inappropriately in situations such as; to go between patients, move around a care area, work at IT workstations,
• be changed if a perforation or puncture is suspected;
• be appropriate for use, fit for purpose and well-fitting.

Double gloving is only recommended during some Exposure Prone Procedures (EPPs) e.g. orthopaedic and gynaecological operations or when attending major trauma incidents and when caring for a patient with a suspected or known High Consequence Infectious disease.  Double gloving is not necessary at any other time.

Resources

For appropriate glove use and selection see Appendix 5.

Further information can be found in the Gloves literature review.

Aprons must be:

• worn to protect uniform or clothes when contamination is anticipated/likely
• when in direct care contact with a patient or their immediate environment e.g providing toileting support or changing bed linen;
  and
• changed between patients and following completion of a procedure or task.

Full body gowns/Fluid repellent coveralls must be:

• worn when there is a risk of extensive splashing of blood and/or other body fluids e.g. in the operating theatre;
  
  
• worn when a disposable apron provides inadequate cover for the procedure/task being performed;
  
  
• changed between patients and immediately after completion of a procedure or task.

The choice of apron or gown is based on a risk assessment and anticipated level of body fluid exposure. Routine sessional use of gowns/aprons is not permitted.

Sterile surgical gowns must be:

• worn by all scrubbed members of the operating theatre surgical team;
• worn for insertion of central venous catheters, insertion of peripherally inserted central catheters, insertion of pulmonary artery catheters and spinal, epidural and caudal procedures.

Reusable gowns must:

• not be worn in the operating theatre environment or for aseptic surgical procedures;
• be appropriately processed between uses based on manufacturer’s instructions.

If hand hygiene with soap and water is required, this should not be performed whilst wearing an apron/gown in line with a risk of apron/gown contamination; hand hygiene using ABHR is acceptable.

Resources

Further information can be found in the Aprons/Gowns literature review.

Eye/face protection must:

• be worn if blood and/or body fluid contamination to the eyes/face is anticipated/likely  and always during Aerosol Generating Procedures.
  
  
• be worn by all scrubbed members of the surgical team for all surgical procedures;
  
  
• not be impeded by accessories such as piercings/false eyelashes;
  
  
• not be touched when worn;
  
  
• cover the full peri-orbital region and wrap around the sides of the face;
  
  
• be removed or changed in accordance with manufacturer’s instructions, if vision is compromised through contamination with blood or body fluids, if the integrity of the equipment is compromised, at the end of a clinical procedure/task and/or prior to leaving the dedicated clinical area.

Regular corrective spectacles and safety spectacles are not considered eye protection.

Resources

Further information can be found in the eye/face protection literature review.

Fluid Resistant Type IIR surgical face masks must be:

• worn by a patient known or suspected to be infected with a micro-organism spread by the droplet or airborne route when leaving their room or when moving between clinical areas.

• worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is anticipated/likely;
  (as part of SICPs a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray.)

• worn in combination with a full face shield, integrated half face shield or goggles for AGPs on non-infectious patients;
  
  
• worn to protect patients from the operator as a source of infection when performing invasive spinal procedures such as myelography, lumbar puncture and spinal anaesthesia ,inserting a Central Vascular Catheter (CVC), performing intra-articular (joint) injections;
  
  
• worn by all scrubbed members of the theatre surgical team for all surgical procedures;
  
  
• worn by non-scrubbed members of the theatre surgical team if deemed necessary following a risk assessment of exposure to blood and/or body fluids;
  
  
• well fitting and fit for purpose (fully covering the mouth and nose);
  
  
• removed or changed;
  • at the end of a procedure/task;
    
    
  • if the integrity of the mask is breached, e.g. from moisture build-up after extended use or from gross contamination with blood or body fluids;
    and
  • in accordance with specific manufacturers’ instructions.

Resources

Further information can be found in:

• aerosol generating procedures literature review
• surgical face masks literature review
• section 2.4 of the NIPCM
• appendix 11 of the NIPCM

Footwear must be:

• non-slip, impervious, clean and well maintained, and support and cover the entire foot to avoid contamination with blood or other body fluids or potential injury from sharps
• removed before leaving a care area where dedicated footwear is used e.g. theatre. Employees must clean and decontaminate footwear upon removal and when visibly soiled with blood and/or body fluids following manufacturers recommended instructions for cleaning and disinfection
• dedicated for use in settings such as theatres and stored in a designated area when not in use
• Footwear found to be defective should be repaired or replaced before further use.
• Overshoes/shoe covers should not be used in the general health and care environment.

Resources

Further information can be found in the footwear literature review.

Headwear must be:

• worn in theatre settings/restricted and semi-restricted areas;
• worn as PPE for procedures where splashing/spraying of body fluids is anticipated, and as source control when performing clean/aseptic procedures where risk of infection is deemed to be high.
• well fitting and completely cover the hair;
• changed/disposed of at the end of a single clinical procedure/task; or at the end of a theatre session (for sessional use); immediately if contaminated with blood and/or body fluids;
• removed before leaving the theatre/clean room.

Resources

Further information can be found in the headwear literature review

For the recommended method of putting on and removing PPE see video below and Appendix 6.

COVID-19 - the correct order for donning, doffing and disposal of PPE for HCWs in a primary care setting from NHS National Services Scotland on Vimeo.

²Scottish National Blood Transfusion Service (SNBTS) adopt practices that differ from those stated in the National Infection Prevention and Control Manual.

1.5 Safe Management of Care Equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents. Consequently it is easy to transfer infectious agents from communal care equipment during care delivery.

Care equipment is classified as either:

• Single-use – equipment which is used once on a single patient and then discarded. Must never be reused even on the same patient. The packaging carries the symbol below.
  • Needles and syringes are single use devices. They should never be used for more than one patient or reused to draw up additional medication.
  • Never administer medications from a single-dose vial or intravenous (IV) bag to multiple patients.
• Single patient use – equipment which can be reused on the same patient.
• Reusable invasive equipment - used once then decontaminated e.g. surgical instruments.
• Reusable non-invasive equipment (often referred to as communal equipment) - reused on more than one patient following decontamination between each use e.g. commode, patient transfer trolley.

Before using any sterile equipment check that:

• the packaging is intact
• there are no obvious signs of packaging contamination
• the expiry date remains valid

Decontamination of reusable non-invasive care equipment must be undertaken:

• between each use
• after blood and/or body fluid contamination
• at regular predefined intervals as part of an equipment cleaning protocol
• before inspection, servicing or repair

Adhere to manufacturers’ guidance for use and decontamination of all care equipment.

All reusable non-invasive care equipment must be rinsed and dried following decontamination then stored clean and dry.

Decontamination protocols should include responsibility for; frequency of; and method of environmental decontamination.

An equipment decontamination status certificate will be required if any item of equipment is being sent to a third party e.g for inspection, servicing or repair.

Guidance may be required prior to procuring, trialling or lending any reusable non-invasive equipment. 

Further information can be found in the management of care equipment literature review.

For how to decontaminate reusable non-invasive care equipment see Appendix 7.

1.6 Safe Management of Care Environment

It is the responsibility of the person in charge to ensure that the care environment is safe for practice (this includes environmental cleanliness/maintenance). The person in charge must act if this is deficient.

The care environment must be:

• visibly clean, free from non-essential items and equipment to facilitate effective cleaning
• well maintained and in a good state of repair
• routinely cleaned in accordance with the Health Facilities Scotland (HFS) National Cleaning Specification:
  • A fresh solution of general purpose neutral detergent in warm water is recommended for routine cleaning. This should be changed when dirty or at 15 minutes intervals or when changing tasks.
  • Routine disinfection of the environment is not recommended. However, 1,000ppm available chlorine should be used routinely on sanitary fittings.

Staff groups should be aware of their environmental cleaning schedules and clear on their specific responsibilities.

Cleaning protocols should include responsibility for; frequency of; and method of environmental decontamination.

When an organisation adopts decontamination processes not recommended in the NIPCM the care organisation is responsible for governance of and completion of local risk assessment(s) to ensure safe systems of work

Further information can be found in the routine cleaning of the environment in hospital setting literature review.

1.7 Safe Management of Linen

Clean linen

• Should be stored in a clean, designated area, preferably an enclosed cupboard.
• If clean linen is not stored in a cupboard then the trolley used for storage must be designated for this purpose and completely covered with an impervious covering that is able to withstand decontamination.

Linen used during patient transfer

• Any linen used during patient transfer e.g. blankets, should be categorised at the point of destination.

For all used linen (previously known as soiled linen):

• Ensure a laundry receptacle is available as close as possible to the point of use for immediate linen deposit.
• Do not:
  • rinse, shake or sort linen on removal from beds/trolleys;
  • place used linen on the floor or any other surfaces e.g. a locker/table top;
  • re-handle used linen once bagged;
  • overfill laundry receptacles; or
  • place inappropriate items in the laundry receptacle e.g. used equipment/needles.

For all infectious linen (this mainly applies to healthcare linen) i.e. linen that has been used by a patient who is known or suspected to be infectious and/or linen that is contaminated with blood and/or other body fluids e.g. faeces:

• Place directly into a water-soluble/alginate bag and secure; then place into a plastic bag e.g. clear bag and secure before placing in a laundry receptacle. This applies also to any item(s) heavily soiled and unlikely to be fit for reuse.
• Used and infectious linen bags/receptacles must be tagged e.g. ward/care area and date.
• Store all used/infectious linen in a designated, safe, lockable area whilst awaiting uplift. Uplift schedules must be acceptable to the care area and there should be no build-up of linen receptacles.

Local guidance regarding management of linen may be available.  

All linen that is deemed unfit for re-use e.g torn or heavily contaminated, should be categorised at the point of use and returned to the laundry for disposal. 

Further information can be found in the safe management of linen literature review and National Guidance for Safe Management of Linen in NHSScotland Health and Care Environments - For laundry services/distribution.

Further information about linen bagging and tagging can be found in Appendix 8.

1.8 Safe Management of Blood and Body Fluid Spillages

Spillages of blood and other body fluids may transmit blood borne viruses.

Spillages must be decontaminated immediately by staff trained to undertake this safely.

Responsibilities for the decontamination of blood and body fluid spillages should be clear within each area/care setting.

If superabsorbent polymer gel granules for containment of bodily waste are used these should be used in line with national guidance. In Scotland refer to http://www.hfs.scot.nhs.uk/publications/1575969155-SAN(SC)1903.pdf.  In England refer to https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102937.

For management of blood and body fluid spillages see Appendix 9.

Further information can be found in the management of blood and body fluid in health and social care settings literature review.

 

 

 

1.9 Safe Disposal of Waste (including sharps)

Scottish Health Technical Note (SHTN) 3: NHSScotland Waste Management Guidance contains the regulatory waste management guidance for NHSScotland including waste classification, segregation, storage, packaging, transport, treatment and disposal.

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for employers and contractors in the healthcare sector in relation to the safe disposal of sharps.

Categories of waste:

• Healthcare (including clinical) waste – is produced as a direct result of healthcare activities e.g. soiled dressings, sharps.
• Special (or hazardous) waste – arises from the delivery of healthcare in both clinical and non-clinical settings. Special waste includes a range of controlled wastes, defined by legislation, which contain dangerous or hazardous substances e.g. chemicals, pharmaceuticals.
• Domestic waste – must be segregated at source into:
  • Dry recyclates (glass, paper and plastics, metals, cardboard).
  • Residual waste (any other domestic waste that cannot be recycled).

Waste Streams:

• Black – Trivial risk:
  • Domestic waste or yellow and black stripes (small quantities of hygiene waste).
  • Final disposal to Landfill.
  • Clear/opaque receptacles may also be used for domestic waste at care area level.
• Orange, Light Blue (laboratory) – Low risk
  • Orange - consists of items which are contaminated or likely to be contaminated with blood and/or body fluids including saliva . Final disposal following heat disinfection is to landfill.
  • Light Blue – laboratory/microbiological waste that must be autoclaved before disposal via the orange stream.

• Yellow– High risk:
  • Waste which poses ethical, highly infectious or contamination risks.
  • This includes anatomical and human tissue which is recognisable as body parts, medical devices and sharps waste boxes that have red, purple or blue lids.
  • Disposal is by specialist incineration.

• Red – Special waste
  • Chemical waste.

For care/residential homes waste disposal may differ from the categories described above and guidance from local contractors will apply. Refer to SEPA guidance.

Safe waste disposal at care area level:

Always dispose of waste:

• immediately and as close to the point of use as possible; and
• into the correct segregated colour coded UN 3291 approved waste bag (either orange/yellow for healthcare waste or black/clear/opaque for domestic) or container (sharps box).

Liquid waste e.g. blood must be rendered safe by adding a self-setting gel or compound before placing in an orange lidded leak-proof bin.

Waste bags must be no more than 3/4 full or more than 4 kgs in weight; and use a ratchet tag/or tape (for healthcare waste bags only) using a ‘swan neck’ to close with the point of origin and date of closure clearly marked on the tape/tag.

Store all waste in a designated, safe, lockable area whilst awaiting uplift. Uplift schedules must be acceptable to the care area and there should be no build-up of waste receptacles.

Sharps boxes must:

• have a dedicated handle
• have a temporary closure mechanism, which must be employed when the box is not in use
• be labelled with date of assembly, point of origin and date of closure.
• be disposed of when the manufacturers’ fill line is reached or following 3 months of assembly (whichever is first)

Local guidance regarding management of waste at care level may be available. 

Further information can be found in the safe disposal of waste literature review.

1.10 Occupational Safety: Prevention and Exposure Management (including sharps)

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory requirements for employers and contractors in the healthcare sector in relation to:

• arrangements for the safe use and disposal of sharps
• provision of information and training to employees
• investigations and actions required in response to work related sharps injuries

Sharps handling must be assessed, kept to a minimum and eliminated if possible with the use of approved safety devices.

Manufacturers’ instructions for safe use and disposal must be followed.

Needles must not be re-sheathed/recapped.⁴

Always dispose of needles and syringes as 1 unit.

If a safety device is being used safety mechanisms must be deployed before disposal.

A significant occupational exposure is:

• a percutaneous injury e.g. injuries from needles, instruments, bone fragments, or bites which break the skin; and/or
• exposure of broken skin (abrasions, cuts, eczema, etc); and/or
• exposure of mucous membranes including the eye from splashing of blood or other high risk body fluids.

There is a potential risk of transmission of a Blood Borne Virus (BBV) from a significant occupational exposure and staff must understand the actions they should take when a significant occupational exposure incident takes place. There is a legal requirement to report all sharps injuries and near misses to line managers/employers.  

For the management of an occupational exposure incident see Appendix 10

Further information can be found in the occupational exposure management (including sharps) literature review.

⁴  A local risk assessment is required if re-sheathing is undertaken using a safe technique for example anaesthetic administration in dentistry.