About the Infection Prevention and Control Manual for older people and adult Care Homes

The National Infection Prevention and Control Manual (NIPCM) was first published on 13 January 2012, by the Chief Nursing Officer (CNO (2012)1), and updated on 17 May 2012 (CNO(2012)01-update). The Scottish Government expectation is that it is mandatory for use in all NHS care settings and in all other care homes to support health and social care integration, the content of this manual must be considered best practice.

 

In order to support care homes successfully adopt and implement the NIPCM, this context specific Care Home Infection Prevention and Control Manual (CH IPCM) has been co-produced with national and local stakeholders. The content of the CH IPCM is completely aligned to the evidence based NIPCM and is intended to be used by all those involved in residential care provision.

The CH IPCM contains chapters on:

1. Standard Infection Control Precautions (SICPs);
2. Transmission Based Precautions (TBPs);

There are web links in some sections taking you directly to information contained in the NIPCM.

The CH IPCM is a practice guide for use in care homes, which when used, can help reduce the risk of infections and ensure the safety of those being cared for, staff and visitors in the care home environment. 

It aims to:

• make it easy for care home staff to apply effective infection prevention and control (IPC) precautions;
• help reduce the risk of infection;
• reduce variation and optimise IPC practices throughout care home settings;
• help align practice, monitoring, quality improvement and scrutiny.

Who should use the CH IPCM?

• Care home providers
• Care home staff
• Health Protection Teams
• Professionals providing IPC support

It should be adopted for all infection prevention and control practices and procedures.

Is the content based on scientific literature?

The recommendations for practice in the manual are developed from literature reviews of the current scientific literature (for example Medical Journals) that are updated real time and are considered best practice.  Any major changes identified in the scientific literature may lead to a change being made to the content. 

A number of ‘SBAR’s’ are available which are short communication or guidance reports that advise on the situation, background, assessment and recommendations on a specific topic.

• View the literature reviews

Are there any other IPC materials that can be used?

The resources page links to SICPs materials, education and training links and posters and other supporting tools.

• View the resources

How can I find out what the scientific and medical words mean?

You can use the glossary to find out what these words mean. Sometimes we have added the meaning of important words within the chapter or section. 

Responsibilities for the CH IPCM

ARHAI Scotland to:

• ensure that the content of the CH IPCM remains evidence based.

Care Home providers to:

• ensure that the CH IPCM is adopted and implemented in their care homes in accordance with local governance processes;
• ensure that systems and resources are in place to facilitate implementation and compliance monitoring of IPC as specified in the manual in all care areas - compliance monitoring includes all staff (permanent, agency and where required external contractors);
• ensure there is a system in place which promotes incident reporting or potential hazards and focuses on improvement that ensures safe working practices, through regular monitoring and review;
• ensure there is a nominated lead with responsibility for IPC.

Care Home Managers to:

• ensure that all staff are aware of, have access to and know where to locate the CH IPCM;
• ensure that all staff have completed appropriate IPC training relevant to their roles and that this is centrally recorded. Training could include resources developed by your organisation, your local NHS Board or Health and Social Care Partnership, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC);
• ensure that all staff have adequate support and resources available to enable them to implement, monitor and take corrective action to ensure compliance with this manual (if this cannot be implemented, a robust risk assessment must be undertaken and approved through local governance procedures);
• ensure that all staff include IPC as an objective in their Personal Development Plans (or equivalent) and are encouraged to discuss any issues around this with their line manager.

Care Home staff to:

• ensure that they fully understand and apply the principles of IPC contained in the CH IPCM;
• maintain competence, skills and knowledge in IPC through completing appropriate training relevant to their role as directed by their line manager. Training can be via resources developed by their organisation, local NHS Board or Health and Social Care Partnership, NHS Education for Scotland (NES) or the Scottish Social Services Council (SSSC);
• communicate IPC practices to be taken by colleagues, those being cared for, relatives and visitors without breaching confidentiality;
• report to line managers and document any deficits in knowledge, resources, equipment and facilities or incidents that may result in transmission of infection including near misses e.g. sharps or PPE failures;
• not provide care while at risk of potentially transmitting infectious agents to others e.g. when having a cold/flu or experiencing the symptoms of Norovirus (diarrhoea). If in any doubt they must consult with their line manager;
• contact HPT/IPCT if there is a suspected or actual HAI incident/outbreak. Outbreak definitions are found on Chapter 3 of the NIPCM.

Infection Prevention and Control Teams (IPCTs) and Health Protection Teams (HPTs) to: 

• engage with and support care home staff to develop systems and processes that lead to sustainable and reliable improvements in relation to the application of IPC where required;
• provide expert advice on the application of infection prevention and control in care homes and on individual risk assessments as required;
• have systems in place capable of distinguishing individual case or cases of infection requiring investigations and;
• complete documentation when an incident/outbreak or data exceedance is reported.

Chain of infection

In order for infection to occur several things have to happen.  This is often referred to as the Chain of Infection. The six links in the chain are:

1. The Infectious Agent – or the microorganism which has the ability to cause disease.
   
   
2. The Reservoir or source of infection where the microorganism can live and thrive. This may be a person, an animal, any object in the general environment, food or water.
   
   
3. The Portal of Exit from the reservoir. This describes the way the microorganism leaves the reservoir. For example, in the case of a person with flu, this would include coughing and sneezing. In the case of someone with gastro-enteritis microorganisms would be transmitted in the faeces or vomit.
   
   
4. The Mode of Transmission. This describes how microorganisms are transmitted from one person or place to another. This could be via someone’s hands, on an object, through the air or bodily fluid contact.
   
   
5. The Portal of Entry. This is how the infection enters another individual. This could be landing on a mucous membrane, being breathed in, entering via a wound, or a tube such as a catheter.
   
   
6. The Susceptible Host. This describes the person who is vulnerable to infection.

Infection can be prevented by breaking the Chain of Infection.

The chain of infection diagram illustrates and gives examples of actions that can be taken to break it. The overall aim of Standard Infection Control Precautions (SICPs),  is to break the Chain.

Select image for full size version.

 

Chapter 1: Standard Infection Control Precautions (SICPs)

It is essential that optimal IPC measures are applied continuously as people living in care homes may be elderly or have underlying medical conditions which could make them more at risk from infection which may then be serious and in some cases life threatening. By applying optimum IPC measures you will provide safe and effective care to the people in your care, fellow staff and visitors to your care home.

There are 10 Standard Infection Control Precautions (SICPs)

1. Resident Placement/Assessment for infection risk
2. Hand Hygiene
3. Respiratory and Cough Hygiene
4. Personal Protective Equipment
5. Safe Management of Care Equipment
6. Safe Management of Care Environment
7. Safe Management of Linen
8. Safe Management of Blood and Body Fluid Spillage
9. Safe Disposal of Waste
10. Occupational Safety: Prevention and Exposure Management (including sharps)

1. Resident placement/assessment for infection risk

If residents have been admitted from another care setting, for example, external care home or hospital try to pre assess them before they are admitted by speaking to the staff from the other care setting.

Before the resident comes into the care home it is important to risk assess them for infection.

 

Residents who may present a cross-infection risk include those with:

• diarrhoea
• vomiting, being sick
• unexplained rash
• fever or temperature of 37.8 C or higher
• respiratory symptoms such as coughing and sneezing
• known to have been previously positive with a Multi-drug Resistant Organisms (MDRO) e.g. Meticillin Resistant Staphylococcus aureus (MRSA), Carbapenemase Producing Enterobacteriaceae (CPE)

If you suspect or know that a resident has an infection, then details must be confirmed in order for you to put in place the correct IPC measures.

 

Appendix 11 of the National Infection and Prevention Control Manual tells you the precautions you need to put in place for different infections.

The Influenza (flu) guidance for care homes and norovirus guidance for care homes will help you prepare and manage these infections in your care home.

Use the NES SIPCEP Breaking the Chain of Infection module to learn about breaking the chain of infection in care homes. 

Read the placement literature review to understand the evidence base for resident placement.

2. Hand Hygiene

The most important thing you can do to prevent the spread of infection in a care home is to keep your hands clean. This is called hand hygiene.

Hand hygiene is essential to reduce the transmission of infection in care home settings. All staff and visitors should clean their hands with soap and water or, where this is unavailable, alcohol-based hand rub (ABHR) when entering and leaving the care home and when entering and leaving areas where care is being delivered.

 

 

When hand hygiene should be performed

before touching a resident;

before clean/aseptic procedures. If ABHR cannot be used, then antimicrobial liquid soap should be used;

after body fluid exposure risk;

after touching a resident;

after touching a resident’s immediate surroundings;

before handling medication;

before preparing/serving food;

after visiting the toilet;

before putting on and after removing PPE;

between carrying out different care activities on the same resident;

after cleaning care equipment;

after disposing of individual’s personal waste;

after handling dirty linen.

It is important that residents are routinely encouraged to perform hand hygiene and given assistance if required.

The four moments for hand hygiene poster can be used in your care home to show staff when hand hygiene should be done and the reasons why.

Select image for full size version.

Before carrying out hand hygiene make sure:

your arms are bare below the elbow;

you take off all your hand and wrist jewellery (a single, plain metal finger ring is allowed but should be taken off (or moved up) during hand hygiene);

bracelets or bangles which are worn for religious reasons, such as the Kara, can be pushed higher up the arm and secured in place;

your finger nails are clean and short;

you cover all cuts or abrasions with a waterproof dressing;

you do not wear artificial nails or nail varnish/products.

Choose the correct product

Liquid soap and water must be used:

if your hands look dirty; 

If you are caring for a resident who is being sick or having diarrhoea or has diarrhoeal illness such as norovirus or Clostridioides difficile then you must use soap and water for hand hygiene. 

Do not use ABHR as it will not work in these cases.

 

 Make sure you wet your hands before applying liquid soap.

Use paper towels to turn off taps if the taps are not elbow operated mixer taps.

Elbow operated mixer taps are considered to provide the best temperature and flow for optimum hand hygiene and should be considered for any new build, refurbishment or if they need repaired/changed.

When you have washed your hands  dry them thoroughly using paper towel and  dispose of the paper towel in a foot operated waste bin.

 

To make sure you clean your hands properly with soap and water you must follow the steps in the poster ‘How to hand wash step by step images’. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.

Select image for full size version

Alcohol based hand rub (ABHR)

Alcohol based hand rub (ABHR) is a gel, foam or liquid containing one or more types of alcohol that is rubbed into the hands to stop or slow down the growth of microorganisms (germs).

If your hands look clean then you can use ABHR for routine care

 

Do not use ABHR if you are caring for a resident who has sickness or diarrhoeal illnesses such as norovirus or Clostridioides difficile.  You must use soap and water as ABHR will not work.

 

To make sure you clean your hands properly with ABHR you must follow the steps in the poster ‘How to hand rub step by step images’. This poster can be printed off and displayed throughout the care home to ensure that all staff and visitors are aware of and practice this hand hygiene method when required in the care home.

Select image for full size version

Skin care:

Use warm/tepid water to reduce the risk of dermatitis. Avoid using hot water.

After hand washing pat hands dry using disposable paper towels. Avoid rubbing which may lead to skin irritation/damage.

Use an emollient hand cream during breaks and when off duty.

Refillable dispensers or communal tubs of hand cream should not be provided or used in the care setting.

Staff with skin problems should seek advice from Occupational Health Department if available or their GP

 

Read the hand hygiene literature reviews to find out more about the evidence base for hand hygiene.

3. Respiratory and cough hygiene

It is easy for infections to spread within a care home by coughing and sneezing so it is very important that respiratory and cough hygiene is used by everyone including staff, residents and visitors.

 

 

If anyone has a cough, cold or other respiratory symptoms then they must:

cover their nose and mouth with a disposable tissue when sneezing, coughing, wiping and blowing the nose;

put used tissues into a waste bin immediately after use;

wash their hands with soap and water after coughing, sneezing, using tissues, or after contact with respiratory secretions or objects contaminated by these secretions;

keep hands away from the eyes nose and mouth.

 

Staff must:

help residents with their respiratory and cough hygiene where required;

make sure that residents are given everything they need for respiratory and cough hygiene including tissues, waste bag and hand hygiene products and make sure that it is close enough for them to use;

use hand wipes followed by ABHR if there is no running water available or hand hygiene facilities are out of reach then wash your hands at the first available opportunity.

 

Read the respiratory and cough hygiene literature review to find out the evidence for respiratory and cough hygiene practice.

4. Personal Protective Equipment (PPE)

Health and Safety at Work Act (1974), Control of Substances Hazardous to Health (COSHH) (2002 as amended) regulations and Personal Protective Equipment at Work Regulations 1992 (as amended) legislate that employers must provide PPE which gives you adequate protection against the risks associated with the task being undertaken.

Employees also have a responsibility under these laws which is to make sure that they wear the correct PPE for the task they are doing and wear it correctly.  

Deciding which PPE to use:

Before doing any procedure or task you need to:

think about or find out if you could be exposed or come into contact with blood and/or other body fluids (BBF); and

make sure that the PPE worn gives you enough protection against the risks associated with the procedure or task you are doing. 

Examples of potential risks are:  

• caring for an individual with a known infection
• inserting or caring for urinary catheters
• changing wound dressings
• cleaning tasks using disinfectant products

All PPE should be:

located close to the point of use

stored in a clean and dry area to prevent contamination until needed for use;

within expiry dates;

single-use only items unless specified by the manufacturer;

changed immediately after individual use and/or following completion of a procedure or task;

disposed of after use into the correct waste stream i.e. healthcare waste or domestic waste.

Reusable PPE items, for example non-disposable goggles, face shields and visors, must have a decontamination schedule with responsibility assigned.

Gloves must be:

worn when it is likely that you will be exposed to blood and/or other body fluids (BBF);

appropriate for use, fit for purpose and well-fitting. The glove selection chart can help you select the correct glove;

changed immediately after each individual and/or following completion of a procedure or task;

changed if damaged or a perforation or puncture is suspected.

Using gloves reduces the risk of contamination but does not remove it all. Gloves should not be used instead of carrying out hand hygiene.

Gloves should never be decontaminated or cleaned with ABHR or by washing with cleaning products.

Choose the correct gloves

Use the glove selection chart to support you to select the correct glove type.

Select image for full size version

Aprons must be worn:

by care staff when there is a risk of clothing being contaminated with blood or other body fluids;

during direct care, bed-making or when undertaking the decontamination of equipment;

when delivering food and/or supporting residents with nutrition.

 

 

Eye/face protection (including full face visors) must:

be worn if blood and/or body fluid contamination to the eyes/face is expected/likely;

not be touched when worn.

Facial accessories such as piercings or false eyelashes must not be worn when using eye/face protection;

Regular glasses or safety glasses are not considered eye protection.

Fluid Resistant Type IIR surgical face masks must be:

worn if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is expected/likely;

a full face visor may be used as an alternative to fluid resistant Type IIR surgical face masks to protect against splash or spray, however:

• • If you are using droplet precautions, you must always wear a surgical face mask as well as the full face visor (droplet precautions will be discussed further in Chapter 2 Transmission Based Precautions)

well-fitting, fully covering the mouth and nose and fit for purpose, you must follow the manufacturer’s instructions to ensure effective fit/protection.

removed or changed;

• • at the end of a procedure/task;
  • if the mask is damaged or there is a build up from moisture after extended use or from gross contamination with blood or body fluids; and
  • following specific manufacturers’ instructions.

Putting on personal protective equipment (PPE) - donning

Always perform hand hygiene before putting on PPE.

The order for putting on PPE is:

1. Apron or Gown
2. Surgical Mask
3. Eye Protection (where required)
4. Gloves

Taking off personal protective equipment (PPE) - doffing

The order for taking off PPE is:

1. Gloves
2. Apron or Gown
3. Eye Protection
4. Surgical Mask

Always carry out hand hygiene immediately after taking off PPE.

All PPE should be removed before leaving the area and disposed of as healthcare waste.

 

A poster showing the order for putting on and removing PPE is available to print.

Select image for full size version

 

Read the PPE literature review to find out more about the evidence base for PPE use.

 

5. Safe management of care equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and infectious agents and this can spread infection.

For routine cleaning general purpose detergent and water solution or detergent impregnated wipes are sufficient.

If the resident has a known infection or the equipment is contaminated with blood or body fluids, then a disinfection agent needs to be used.

Do not use household bleach as the required dilution cannot be guaranteed.

Do not use refillable spray container for cleaning products as there is a risk of contamination. 

Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.

Types of equipment

There are three different types of care equipment that you will use in your care home and it is important that you know how to deal with each type.

You must use and follow manufacturers guidance for all equipment and products you use including those used for cleaning and decontamination.

Before using any sterile equipment, you should check that:

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

1. Single-use - equipment which is used once on a single resident and then discarded.

Single-use equipment must never be reused even on the same resident. The packaging carries the symbol.

Needles and syringes are single-use devices. They should never be used for more than one resident or reused to draw up additional medication.

Never give medications from a single-dose vial or intravenous (IV) bag to multiple residents.

 

2. Single individual use – equipment which can be reused by same resident e.g. nebuliser equipment and decontaminated following use as per manufacturers instructions.

3. Reusable non-invasive equipment (often referred to as ‘communal equipment’) – equipment which can be reused on more than one resident following decontamination between each use e.g. commode, moving and handling equipment or bath hoist.

Cleaning or decontaminating reusable non-invasive equipment

Residents should be given their own reusable (communal) non-invasive equipment if possible.  

Reusable equipment should be checked frequently for cleanliness and signs of integrity. This will include mattresses and pillows which should be clean, have a waterproof covering which is in a good state of repair. 

You should clean or decontaminate reusable equipment:  

between individual use;

after blood and/or body fluid contamination;

as part of the regular scheduled cleaning process;

before inspection, servicing or repair.

 

Staff must:

follow the local cleaning protocol/schedule which should include responsibility for; frequency of; and method of decontamination required;

use a general purpose detergent and water solution/detergent impregnated wipes;

or

a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.);

or

a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl;

make up cleaning/disinfection solution following manufacturers guidance;

follow the manufacturer’s contact time for the cleaning/disinfection solution;

rinse and dry reusable equipment then store it clean and dry.

 

 

Read the management of care equipment literature review to find out more about why we do things this way for care equipment.

 

The decontamination of non-invasive care equipment poster can help staff decide how to clean equipment.

Select image for full size version

6. Safe management of the care environment

There are many areas in care homes that become easily contaminated with micro-organisms (germs) for example toilets, waste bins, tables.

Furniture and floorings in a poor state of repair can have micro-organisms (germs) in hidden cracks or crevices.

To reduce the spread of infection, the environment must be kept clean and dry and where possible clear from clutter and equipment.
Non-essential items should be stored and displayed in such a way as to aid effective cleaning

Keeping a high standard of environmental cleanliness is important in the care home settings as the residents are often elderly and vulnerable to infections.

The care home environment should be:

visibly clean, free from non-essential items and equipment to help make cleaning effective

well maintained and in a good state of repair

routinely cleaned in accordance with the specified cleaning schedules:

• • 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, 1,000 parts per million available chlorine (ppm available chlorine (av.cl.) should be used routinely on sanitary fittings.

Staff must:

Report any issues with the environment cleanliness or maintenance to the person in charge to ensure that the care environment is safe.  The person in charge must then act on problems reported to them.

Be aware of the environmental cleaning schedules and clear on their specific responsibilities.

Cleaning schedules should include:

• responsibility for;
• frequency of; and
• method of environmental cleaning.

Managing cleaning services:

Cleaning services should be managed in a systematic way, and staff responsible for cleaning should be appropriately trained to carry out the tasks they are responsible for.

The Care Home Manager is responsible for managing the cleaning service which has a number of essential elements outlined in the cleaning services diagram.

Select the diagram for full size version

Cleaning Services

An effective service will include all of the elements above.

Care Homes Cleaning Specification

The Care Homes Cleaning Specification provides a guide to planning cleaning services. It has tools to help with the planning and recording of cleaning activities and with the management activities marked with a * in the diagram above. These include:

• A structure to identify all spaces within a care home and plan appropriate cleaning tasks and frequencies.

• A set of weekly and monthly cleaning templates to be assigned to each space within a care home. These can be used to develop a schedule and to provide a method for recording all cleaning activity. An example of a cleaning schedule and record is provided:

Table 1: Example cleaning schedule residents room

• Standard operating procedures (SOPs) for all cleaning tasks. Each SOP outlines the correct equipment, safety considerations, method, and outcomes required for each task. The example shows the important steps that must be taken during the cleaning of floors.

Table 2: Example cleaning SOP: Floors

• A process for checking the cleanliness of the care environment, to ensure standards are being maintained and to identify areas for improvement.

The tools within the Cleaning Specification should be used by the care home manager in the planning, training of staff, delivery, and checking of standards of the cleaning services they provide.

Decontamination of soft furnishings

Decontamination of soft furnishings may require to be discussed with the local HPT/ICT. If the soft furnishing is heavily contaminated with blood or body fluids, it may have to be discarded. If it is safe to clean with standard detergent and disinfectant alone then follow appropriate procedure.  

If the item cannot withstand chlorine releasing agents staff are advised to consult the manufacturer’s instructions for a suitable alternative to use following or combined with detergent cleaning. Any alternative disinfectant used must meet the relevant BS EN Standards as detailed previously

 

Read the routine cleaning of the care environment literature review to find out more about why we do things this way for the care environment.

7. Safe management of linen

Examples of linen you may have in the care home includes:

• bed linen (bed sheets, duvet, duvet covers, pillowcases);
• blankets;
• curtains;
• hoist slings;
• towels;
• resident’s clothing (nightdresses, pyjama tops and bottoms).

There are three categories of linen:

Clean – Linen washed and ready for use

Used – All used linen in the care setting not contaminated by blood or body fluids

Infectious – All linen used by a person known or suspected to be infectious and/or linen that is contaminated with blood or body fluids, e.g. faeces.

Used or infectious linen may also be categorised as heat-labile: usually personal clothing where the clothing may be damaged (shrinking/stretching) by washing at a higher than recommended temperature than the label advises. If such linen needs to be washed at a higher temperature for example if soiled or resident has a known infection they or their relatives need to be advised that the clothing may be damaged.

All clean, used and infectious linen should be handled with care and attention paid to the potential spread of infection.

Clean linen:

Should be stored in a clean, allocated area.

This should be an enclosed cupboard but a trolley could be used as long as it is completely covered with a waterproof covering that is able to withstand cleaning.

Used linen:

Staff must: 

put on disposable gloves and apron prior to handling used linen;

make sure that a laundry trolley or container is available as close as possible to the point of use for immediate linen deposit.

Staff must not:

rinse, shake or sort linen on removal from beds or trolleys;

place used linen on the floor or any other surfaces for example on a locker or table top;

re-handle used linen once bagged;

overfill laundry receptacles or trolleys;

place inappropriate items in the laundry receptacle for example used equipment/needles.

Infectious linen:

Staff must:

wear disposable gloves and apron before handling infectious linen;

put infectious linen directly into a water soluble laundry bag and secure before putting into a clear plastic bag and placing into a laundry receptacle/trolley.

Washing linen

Micro-organisms are destroyed by heat and detergent and also by the dilution effect of the water in the washing machine.

wash items using the highest temperature you can and following the washing instructions.

use your normal washing powder or detergent and follow the instructions on the correct amount to use.

tumble-dry (if possible) following the washing instructions.

iron according to washing instructions. If possible, use a hot steam iron.

If visitors wish to take their relatives clothes home to be laundered, place laundry in an appropriate bag and provide them with a washing clothes at home leaflet.

If the residents clothing is very soiled or infectious, staff may recommend that the clothing is washed in the care home’s laundry service if available, otherwise, the item should be disposed of in the appropriate healthcare waste stream following discussion with the resident or their relative(s).

 

Read the safe management of linen literature review to find out more about why we do things this way when dealing with linen.

8. Blood and body fluid spillages

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

Blood and body fluid spillages must be decontaminated:

immediately by staff trained to undertake this safely;

using body fluid spill kits/equipment available.

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

Read the management of blood and body fluid spillages literature review to find out more about why we do things this way for blood and body fluid spillages.

Use the poster management of blood and body fluids to help you when you clean up blood and body fluid spillages.

 

Select the image for full size

 

9. Safe disposal of waste (including sharps)

Different types of waste will be produced within care homes. 

Some waste may be disposed of through the domestic waste route but other types of waste needs special handling and disposal for example sharps and waste from people who have or may have an infection.

Waste bags in care settings may be colour coded to denote the various categories of waste.

Local procedures and policies on waste disposal must be followed.

Segregation (separating) of waste

• Healthcare (including clinical) waste is produced as a direct result of healthcare activities e.g. soiled dressings, sharps
• Special (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, and pharmaceuticals
• Domestic waste – must be segregated at source into:
  • Dry materials that can be recycled (glass, paper and plastics, metals, cardboard)
  • Residual waste (any other domestic waste that cannot be recycled)

Care home waste disposal may differ from categories described and guidance from local contractors may apply.

Safe management of waste

Your care home should make sure that:

waste is correctly segregated according to local regulations;

the correct colour coded bags are being used according to local regulations;

there is a dedicated area for storage of clinical waste that is not accessible to residents or the public;

waste is stored in a safe place whilst awaiting uplift;

there is a schedule for emptying domestic waste bins at the end of the day and during the day if needed.

Staff should:

follow the schedule for emptying domestic waste bins;

always use appropriate personal protective equipment (PPE);

dispose of waste immediately as close as possible to where it was produced;

dispose of clinical waste into the correct UN 3291 approved waste bin or sharps container;

ensure that waste bins are never overfilled. Once the waste bin is three quarters full, tie waste bags up and put into the main waste bin;

use a ‘swan neck’ technique for closure of the bag and label with date and location as per local policy.

• • A ‘swan neck’ is a way of closing bag by tying in a loop and securing with a zip tie or tape to make a handle;

clean waste bins regularly with a general purpose neutral detergent;

remove PPE and perform hand hygiene when you have finished handling waste.

 

Read the safe disposal of waste literature review to find out more about why we do things this way when dealing with waste.

10. Occupational Safety: Prevention and Exposure Management (including sharps)

All care homes should have policies in place to ensure that staff are protected from occupational exposure to micro-organisms (germs), particularly those that may be found in blood and body fluids.

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

Safe management of sharps in your care home

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

always dispose of needles and syringes as a single unit immediately at the point of use;

sharps containers need to be assembled and labelled correctly;

use the temporary closure mechanisms in between use;

if a safety device is being used safety mechanisms must be deployed before disposal;

follow manufacturers’ instructions for safe use and disposal;

do not re-sheath used needles or lancets;

do not store sharps containers on the floor;

ensure sharps containers are not accessible to residents or the public;

sharps containers must not be more than three-quarters full.

Significant occupational exposure

A significant occupational exposure is when someone is injured at work from using sharps or exposed to risk from blood or body fluids which may then result in a blood borne virus (BBV) or other infection.

Examples of this would be:

• a percutaneous injury for example 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.

If you think or know you have had a significant occupational exposure you must:

report this immediately to the designated person in your care home, this is a legal requirement;

follow the local agreed process for management of an occupational exposure incident and follow the management of occupational injuries flow chart.  

 

Read the occupational exposure including sharps literature review to find out more about why we do things this way for occupational exposure.

The management of occupational exposure incidents flowchart should be used within your care home so you know what to do for an occupational exposure.

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Transmission based precautions (TBPs)

Sometimes using standard infection control precautions (SICPs) won’t be enough to stop an infection spreading and you will need to use some extra precautions. These extra precautions are called Transmission Based Precautions or TBPs.

When you should use TBPs?

You would use transmission based precautions if a resident has a suspected or known infection or colonisation.  

How are infections transmitted?

Infections can be transmitted or spread by:

• direct contact with microorganisms (germs) on hands;
• indirect contact from contaminated equipment or environment;
• droplet infection by inhaling infectious droplets e.g. flu or COVID-19;
• aerosols e.g. chickenpox.

Different transmission routes need different TBPs.

The three routes or ways an infection is transmitted or spread are called contact, droplet and airborne. You need to use different transmission based precautions for each route.

Contact precautions are used to prevent infections that spread through direct contact with the resident or indirectly from the resident’s immediate care environment and care equipment.

Droplet precautions are used to prevent and control infections spread over short distances (at least 3 feet or 1 metre) via small droplets from the respiratory tract of one individual directly onto the mucosal surface of another person’s mouth or nose or eyes. Droplets penetrate the respiratory system to above the alveolar level.

Airborne precautions are used to prevent and control infections spread without necessarily having close contact via from the respiratory tract of one individual directly onto the surface of another person’s mouth or nose or eyes. Aerosols penetrate the respiratory system to deep into the lung.

Different infections need different TBPs.

You might have heard of some infections like norovirus, Meticillin-resistant Staphylococcus aureus (MRSA), Clostridioides. difficile (C.diff/CDI) and flu but there are lots of others. 

You can find out more information about the infection the individual has and the precautions you should use in Appendix 11 and/or A-Z of pathogens in the NIPCM.

You can also contact your local Health Protection Team or Infection Prevention and Control Team.

Before using transmission based precautions you need to find out:

What the suspected or known infection/colonisation is?

How is it transmitted?

How severe is the resident’s illness?

What is the care setting and procedures being done?

There are different ways you can find out if a resident has an infection that needs TBPs to be put in place. You can get information about a resident’s infection status from:

• their GP (doctor);
• local Health Protection Team;
• local Infection Prevention and Control Team;
• laboratory;
• hospital or care homes staff from where the resident has been discharged or transferred.

Further information on transmission based precautions can be found in the definitions of Transmission Based Precautions literature reviews.

1. Individual placement/assessment for infection risk

You need to regularly monitor the resident for infection throughout their stay so the correct precautions are in place to minimise the risk of infection being spread to other residents.

Residents may be an infection risk if they have:

• diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms;
• been previously positive with a Multi-drug Resistant Organism (MDRO) for example Meticillin-resistant Staphylococcus aureus (MRSA); Carbapenemase Producing Enterobacteriaceae (CPE).

CPE should be considered if the resident meets any of the following criteria within the
12-month period before admission:

• been an inpatient in a hospital outside of Scotland;
• received holiday dialysis outside of Scotland;
• been a close contact of a person who has been colonised or infected with CPE.

CPE guidance for a care home setting is available.  

Staff must:

get advice on the resident’s clinical management from their GP and advice on appropriate IPC management from either your local Health Protection Team or Infection Prevention and Control Team;  

make resident placement decisions based on advice received or sound judgement by experienced staff who are involved in the resident’s management;

let the ambulance service know of the resident’s infectious condition if they need to go to hospital;

not move residents within/between care areas unless essential.

Resident isolation requirements within the care home

Sometimes you will need to isolate a resident in their own room or area because of a known or suspected infection, it is important that: 

Residents remain in their rooms whilst considered infectious and the door should remain closed.

If it is not possible for example the resident has dementia, then there needs to be individual risk assessments and decisions taken documented.

Suitable discrete signage is placed on the door advising others not to enter the room.

Consideration is given to the use of a dedicated team of care staff to care for residents in isolation/cohort rooms areas as an additional IPC measure. This is known as ‘staff cohorting’ and must only be done if there are enough staff available.

You do not stop isolation until you have considered individual risk factors and how this could affect other residents, staff and visitors.

You may need to contact your local health protection team or infection prevention and control team for further advice.

 

Read the patient placement, isolation and cohorting literature review to find out more about why we do things this way for resident placement for TBPs.

2. Safe management of care equipment in an isolation room/area

Cleaning of care equipment is essential to reduce the spread of infection when infection is confirmed/suspected

When dealing with the equipment used in the resident’s isolation room or area you should:

use dedicated reusable care equipment for the individual in isolation e.g. commodes where possible.

clean and decontaminate the care equipment after each use.

cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards

For how to decontaminate non-invasive reusable equipment prior to use on another resident see  SICPs - Safe Management of Care Equipment.

Read the management of care equipment literature review to find out more about why we do things this way for patient care equipment for TBPs.

3. Safe management of the care environment

Isolation room/area cleaning

Staff must:

clean and decontaminate the isolation/cohort rooms/area at least daily or more if advised to do so. If you have been advised to clean more than daily this should be added into the environmental cleaning schedule;

clean frequently touched surfaces like door handles, bed frames and bedside cabinets at least twice daily;

make sure you are using the correct product which is:

a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.));

or

a general purpose neutral detergent in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.

follow manufacturers guidance and instructions on how to use the product and what the recommended contact time is for the product to work. This may include rinsing off the disinfection solution to prevent damage to surfaces.

Do not use refillable spray container for cleaning products as there is a risk of contamination. 

Cleaning products which come in non-refillable spray containers may be used as long as they conform to EN standards.

Terminal clean

A terminal clean is carried out by:

removing all healthcare waste and other disposable items from the room;

removing bedding, curtains (bagged before removal from the room) and then wash as infectious linen;

cleaning and decontaminating all reusable care equipment in the room (before removal from the room).

The room should then be decontaminated using either:

• a combined detergent disinfectant solution at a dilution (1,000ppm av.cl.); or
• a general purpose neutral detergent clean in a solution of warm water followed by disinfection solution of 1,000ppm av.cl.

The room must be cleaned from the highest to lowest point and from the least to most contaminated point.

4. Personal Protective Equipment (PPE): Respiratory Protective Equipment (RPE)

In addition to PPE used for Standard Infection Control Precautions, appendix 16 of the NIPCM outlines you what type of PPE and RPE you will need to wear for infections spread by different transmission routes.

Important words and what they mean

Respiratory Protective Equipment (RPE) means FFP3 masks and facial protection and must be thought about when a resident is admitted with a known/suspected infectious agent/disease spread wholly by the airborne route and when carrying out aerosol generating procedures (AGPs) on residents with a known/suspected infectious agent spread wholly or partly by the airborne or droplet route.

An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.

Aerosol Generating Procedure (AGP)

The most common AGPs undertaken in the Care Home Setting are Continuous Positive Airway Pressure Ventilation (CPAP) or Bi-level Positive Airway Pressure Ventilation (BiPAP).

The full list of medical procedures for COVID-19 that have been reported to be aerosol generating and are associated with an increased risk of respiratory transmission are:

• tracheal intubation and extubation
• manual ventilation
• tracheotomy or tracheostomy procedures (insertion or removal)
• bronchoscopy
• dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills
• non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
• high flow nasal oxygen (HFNO)
• high frequency oscillatory ventilation (HFOV)
• induction of sputum using nebulised saline
• respiratory tract suctioning*
• upper ENT airway procedures that involve respiratory suctioning
• upper gastro-intestinal endoscopy where open suction of the upper respiratory tract occurs
• high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses involved

*   only open suctioning beyond the oro-pharynx is currently considered an AGP i.e. oral/pharyngeal suctioning is not an AGP.

PPE for aerosol generating procedures (AGPs)

If the individual has an infection spread by the airborne route and an AGP is required staff should wear the following PPE:

PPE for aerosol generating procedures

PPE	PPE used
Gloves	Single-use.
Apron or gown	Single-use gown.
Face mask or respirator	FFP3 mask or powered respirator hood.
Eye and face protection	Single-use or reusable.

All FFP3 respirators must be:

• Fit tested (by a competent fit test operator) on all staff who may be required to wear a respirator to ensure an adequate seal/fit according to the manufacturers’ guidance.
• Fit checked (according to the manufacturers’ guidance) every time a respirator is donned to ensure an adequate seal has been achieved.
• Compatible with other facial protection used such as protective eyewear so that this does not interfere with the seal of the respiratory protection. Regular corrective spectacles are not considered adequate eye protection. If wearing a valved, non-shrouded FFP3 respirator a full face shield/visor must be worn.
• Changed after each use.

• Other signs that a change in respirator is required include:
• if breathing becomes difficult;
• if the respirator is wet or moist,
• if the respirator is damaged;
• if the respirator is obviously contaminated with body fluids such as respiratory secretions.

Rooms should always be decontaminated following an AGP. Clearance of infectious particles after an AGP is dependent on the ventilation and air change within the room. In an isolation room with 10-12 air changes per hour (ACH) a minimum of 20 minutes is required; in a side room with 6 ACH this would be approximately one hour. It is often difficult to calculate air changes in areas that have natural ventilation only.  Natural ventilation, particularly when reliant on open windows can vary depending on the climate. An air change rate in these circumstances has been agreed as 1-2 air changes/hour. 

To increase natural ventilation in care home settings may require opening of windows. If opening windows staff must conduct a local hazard/safety risk assessment.

Post AGP fallow time (PAGPFT)

Time is required after an AGP is performed to allow the aerosols still circulating to be removed/diluted. This is referred to as the post AGP fallow time (PAGPFT) and is a function of the room ventilation air change rate.

The post aerosol generating procedure fallow time (PAGPFT) calculations are detailed in the table below.  It is often difficult to calculate air changes in areas that have natural ventilation only. 

If the area has zero air changes and no natural ventilation, then AGPs should not be undertaken in this area.

The duration of AGP is also required to calculate the PAGPFT and clinical staff are therefore reminded to note the start time of an AGP.  It is presumed that the longer the AGP, the more aerosols are produced and therefore require a longer dilution time.  During the PAGPFT staff should not enter this room without FFP3 masks.  Other residents, other than the resident on which the AGP was undertaken, must not enter the room until the PAGPFT has elapsed and the surrounding area has been cleaned appropriately.  As a minimum, regardless of air changes per hour (ACH), a period of 10 minutes must pass before rooms can be cleaned. This is to allow for the large droplets to settle. Staff must not enter rooms in which AGPs have been performed without airborne precautions for a minimum of 10 minutes from completion of AGP. Airborne precautions may also be required for a further extended period of time based on the duration of the AGP and the number of air changes. Cleaning can be carried out after 10 minutes regardless of the extended time for airborne PPE.

Post AGP fallow times calculation

Duration of AGP (minutes)	1 AC/h	2 AC/h	4 AC/h	6 AC/h	8 AC/h	10 AC/h	12 AC/h	15 AC/h	20 AC/h	25 AC/h
3	230	114	56	37	27	22	18	14	10	8 (10)*
5	260	129	63	41	30	24	20	15	11	8 (10)*
7	279	138	67	44	32	25	20	16	11	9 (10)*
10	299	147	71	46	34	26	21	16	11	9 (10)*
15	321	157	75	48	35	27	22	16	12	9 (10)*

*The minimum fallow time (to allow for droplet settling time) is 10 minutes

Contact your local HPT/IPCT if further advice is required.

 

Read the RPE literature review to find out more about why we do things this way for respiratory protective equipment

5. Infection prevention and control during care of the deceased

If a resident dies when in the care home, Standard Infection Control Precautions or Transmission Based Precautions must still be applied. This is due to the ongoing risk of infectious transmission via contact although the risk is usually lower than for the living.

Washing and/or dressing of the deceased - Appendix 12. Mandatory - Application of transmission based precautions to key infections in the deceased will give you guidance on the precautions that are required and what is permitted for certain types of infections.

Staff should advise relatives of any required precautions following viewing and/or physical contact with their deceased and also when this should be avoided.

 

Read the infection prevention and control during care of the deceased literature review to find out more about why we do things this way when dealing with the deceased.

How to contact us

If you have any questions or feedback about the Care Home IPCM then you can contact us by email or telephone.

Email

Telephone: 0141 300 1175