August 2017

Liz Collinson


Healthcare associated infections (HCAI) are infections that are acquired following admission tohospitals or as a result of healthcare interventions in other healthcare facilities. There are a widerange of pathogens and communicable diseases besides Methicillin Resistant StaphylococcusAureus (MRSA) and Clostridium difficile (CDI). Much of the morbidity and mortality associated withHCAI is preventable, and there is ongoing public and political interest in ensuring that the risks ofpreventable infections are minimised. Infection control is also an indicator of broader clinicalgovernance and quality issues. Healthcare workers may also acquire infections related to exposureto microorganisms at their workplace.


This document provides guidelines on infection prevention and control to staff at Pringle Street Surgery in order to reduce HCAI and to reduce transmission of infections to healthcare professionalsand patients.


Every member of staff has a duty of care to prevent healthcare associated infection. The practiceinfection control policy will be overseen by the Rachel Stubbs, Infection Control lead (I/C Lead), who will ensure that thesearrangements remain compliant with the Health and Safety at Work Act (1974) and its relevantassociated legislation.


Monitoring Group in the Practice

The Partners, Practice Nurse and Practice Manager have overall responsibility in ensuring effectiveinfection control practices at Pringle Street Surgery. Other practice staff, including receptionists, will be encouraged to gain an understanding of infection control to enable them to understand the issues involved.

The I/C Lead Rachel Stubbs has the responsibility for ensuring that the I/C Audit Tool is completed at leastannually.

An action plan from the outcome of the Self Audit Tool will be produced annually and discussed at the partnership meeting. Improvements made should be reflectedthrough the subsequent audits.

The I/C lead has the responsibility to:

• Ensure that the Practice is compliant with the Code of Practice for The Health & Social Care Act


• Ensure that the Practice is compliant with the required staff immunisation programme; and that

records of immunisation are kept for the Care Quality Commission (CQC) inspection.

• Along with the practice manager Liz Collinson, ensure that all clinical staff have yearly mandatory training update on infection control and thatrecords are kept for CQC inspection. Training will be undertaken annually through elearning for health and also via the I/C lead during staff meetings and documented on the minutes. Training will ensure that employees know how to work safely and withoutrisks to health with the specific sharps equipment and procedures that they will use.

Under the HSE Sharps Regulations, the training provided to employees will cover:

 the correct use of safer sharps;

 safe use and disposal of medical sharps; and

 what to do in the event of a sharps injury


Hand Hygiene

Reason for hand hygiene

Hand washing is the single most important means of controlling the spread of infection. The microorganismson the hands are grouped into two categories – resident and transient flora. Resident floraare usually of low virulence and rarely cause infections except when introduced into the body throughintroduction of a urinary catheter, or an open wound. Transient flora may consist of many differentpathogenic micro-organisms. They are not firmly attached to the skin and can usually be removedquickly and effectively with soap and water.

Hands should be decontaminated either by washing orusing an alcohol hand gel after every patient contact. If hands are visibly dirty and have been incontact with blood or body fluids, the choice for hand hygiene should be hand washing. Alcoholichand gel, if used, should be rubbed into hands using the “Six Stages of Hand washing Technique”.

The purpose of hand hygiene with adequate drying is to remove transient microbial contaminationthat has been acquired during contact. The hands should be dried properly after washing becausethis reduces the number of organisms subsequently released from the hands.Dedicated hand washing basins are available in all clinical areas. They are fitted with elbow operated taps. Hand hygiene training for all staff is incorporated in the annual infection control update module.

• Wash hands before and after episode of patient contact

• Wash hands between different clinical activity for the same patient

• Wash hands before putting gloves on and after taking them off

• Wash hands when hands are visually dirty

• Wash hands when have been in touch with a contaminated object

Table 1: Hand washing agents

Hand washing technique

An appropriate technique for hand washing will ensure that hands are cleaned effectively. Whatfollows is a good, basic technique that should be followed every time hands are washed in the clinicalenvironment.

• Get water to correct temperature, not too hot or too cold.

• Wet your hands before putting liquid soap on.

• One squirt of liquid soap.

• Perform six-stage hand washing technique for 10-20 seconds of rubbing. Remember to include thewrists.

• Rinse hands thoroughly – remove all traces of soap.

• Dry hands with paper towels – especially between fingers.

• Dispose of paper towels into foot-operated domestic waste bin.

• Turn taps off – with elbows if elbow operated taps or with a clean, dry paper towel.

SIx Stage Hand Washing Technique:

1. Palm to palm.

2. Palm to dorsum, fingers interfaced – both sides.

3. Palm to palm, fingers interlaced.

4. Clasping of fingers.

5. Rotational rubbing of thumbs.

6. Tips of fingers in palm of hand – both sides – both sides.

Personal Protective Equipment (PPE):

• Wear gloves for a procedure which could have direct contact with blood/ body fluids.

• Wear gloves when handling samples of blood /body fluids.

• Risk assessment must be made for each patient contact with known infectious disease, e.g.

Methicillin Resistant Staphylococcus Aureus (MRSA) that the correct protective clothing is worn.

• Wear a plastic apron when the procedure could possibly cause splashes of blood & body fluids.

• Change between patients.

• Change between procedures.

• Wear eye protection and surgical mask when risk of splashing or when aerosol formation is


• Supplies of disposable gloves and aprons are accessible in clinical rooms.

Waste Management:

Producers of clinical waste have a responsibility under the Health & Safety at Work Act (1974), tostore and dispose of clinical waste and sharps safely. The duties of care provisions of theEnvironmental Protection Act (1990) impose serious penalties if segregation and disposal proceduresare not followed.

• Contaminated dressings and all disposable items and protective clothing are infectious hazardous

(clinical) waste; e.g. wound dressings, apron & gloves and used specimen containers.

• The yellow plastic bin-liners are for clinical waste bins.

• Sharps (syringes & needles) are to be disposed of directly into a yellow rigid sharps containermade to BS 7320 and UN3291 standard. Sharps generated by a doctor/ nurse at a patient’s homeshould be disposed of by the doctor/ nurse in one of these purpose made sharps containers andtaken to the practice for safe disposal.

• Domestic (non-hazardous) waste is in clear or black bin-liners for all other waste.

Waste Collection:

SRCL waste disposal contractor has been appointed in accordance with the duty of careand is a registered carrier of waste. Clinical wasteis stored in the yellow clinical waste bins and is collected every two weeks by SRCL.


• Black waste collection containers are for domestic waste – for landfill only.

• Yellow waste collection containers are for clinical waste – for treatment / sterilisation before landfill – which is contracted to SRCL.

• Sharps bins (with yellow lids) should not be included in the yellow collection container because it isfor incineration. They should be collected from the practice staff.

Cleaning of Medical Equipment & Environment

Cleaning of Medical Equipment:

• Medical equipment will be cleaned as per manufacturers’ instructions between patients and at the end of every clinic by the user.

• Single-use items must be disposed of after each use.

General Environmental Cleaning

• All rooms and corridors will be cleaned or vacuumed regularly with a cleaning detergent.

• Toilets will be cleaned at least daily with a specific toilet cleaning product with a chlorinebase solution.

• Work tops should be clean before commencing work.

• Flooring and walls should be free from holes/cracks and body fluids stains.

• The horizontal surfaces of all clinical rooms must be wiped down each day.

• High & low dusting should be carried out regularly by the cleaners.

• Records of cleaning specifications will be maintained by the Practice Manager.

• A checklist is to be completed by the cleaner and record kept for inspection in the cleaning cupboard.

Cleaning and disinfectant policy

Treatment Room/Minor Surgery (injections only)

Pringle StreetSurgery has a treatment room. There are appropriate changingfacilities for patients to respect their privacy & dignity.


• A mixer elbow tap hand basin with wall mounted soap dispenser and alcohol rub for handdecontamination before patient contact.

• The room will be clear from unnecessary storage and clutter to allow for easy cleaning at the

end of each session.

• The couch should has wall mounted lighting fitted for the procedures.

• The couch is covered with disposable couch paper and to be changed with each patient.

• The couch should be wiped down with Hypochlorite solution after each session of surgery.

• Aseptic technique should be used for all minor surgeries and the trolley is to be wiped down in between patients and before and at end of clinic with ChlorClean using PPE. The cleaning sheet needs to be signed at the end of every session.

• All waste from this room should be treated as clinical waste; except the packaging of products.

• Disposable instruments must be disposed of at the end of each case into the sharps bin or clinicalbin, if the instruments have no sharp ends. Single-use instruments are preferably used for all procedures.

• The horizontal surfaces of the minor surgery room must be wiped down aftereach session; with 1,000 parts of sodium hypochlorite solution (ChlorClean/ActiChlor).

Instruments Storage of Sterile Instruments

Correct storage of sterile instruments is important in order to protect the integrity of sterilised


• All sterile packages, including sterile fluids, are stored above the ground to avoid contamination andto allow proper cleaning of the floor.

• All sterile packages should be stored in door cupboards or enclosed drawers.

• All sterile packages should be stored away from dirty areas and away from hand basins.

Instruments in a wet package are considered non-sterile.

• Store sterile instruments in plastic or other wipeable containers, but not those made from cardboardas it sheds and creates dust and debris.

• Before use, examine wrapping for damage or damp & expiry dates.

• Expired single-use instruments should be disposed of.

• The Practice Manager is responsible for periodically for ensuring correct storage and for checking thedate of expiry of single-use and re-usable instruments.

Blood sampling

Needlestick injuries are instrumental in the transmission of bloodborne viruses. Most of these injuriesoccur due to mishandling of sharps. All staff should be aware of their health-related obligations andensure that their own routine immunisations are up-to-date.

The Practice Manager will maintain a record of staff immunisation status.

Safer sharps will be utilised if available, reliable and appropriate, e.g blood needles with sheaths attached.

Safe methods of work:

• Monovette system is for blood sampling procedures in Pringle Street Surgery.

• A sharps disposal bin is on or close to the blood sampling trolley.

• Sharps must be disposed of immediately, at point of use, into the sharps bin (BS7320 compliant).

• Sharps bins are locked shut for disposal when 2/3 full or manufacturer’s fill line is reached. Theperson using the sharp is responsible for its immediate disposal.

• The sharps bins must be signed & dated on assembling and before disposal.

• Clinical staff are trained and updated on sharps awareness through their Infection Control annual training.

Sharps, needlestick and splashing incidents

In the event of one of the following incidents:

• Inoculation of a staff member with a patient’s blood/ body fluids by a needle or other sharp itempreviously used on a patient.

• NOT urine or faeces (unless they contain blood).

• Contamination of broken skin with bloody/body fluid.

• Blood/body fluid splashes in the eye, nose or mouth.

• Contamination with a patient’s blood/ body fluid to such a degree that a change of clothing isneeded.

• Contamination of oral mucosa with blood/ body fluid.

The following action should be taken:

• Wash the area under running water and encourage bleeding if skin or mucous membrane are


• Irrigate eye/mouth splashes with copious amounts of saline or water.

• Report immediately to the GP and Practice Manager.

• The GP or Practice Manager should contact the nearest Accident & Emergency

Department for Post Exposure Prophylaxis (PEP) risk assessment.

• It is the best practice to seek attention within one hour following a needlestick or splash incident in

order to achieve up to 90% protection against bloodborne viruses, especially HIV.

• It is important to establish details of both the injured person’s and the source’s Hepatitis B status, aswell as whether the source is a HIV risk.

Obtain the source’s and the injured person’s consent to take serum for an urgent HBsAg test on the

source’s blood and for storing both serums should future tests be required.

• Records will be kept of all counselling, post-exposure management and follow-up.

• Records will be kept of when vaccine and/or immunoglobulin were given, the type of vaccine,dose, batch number, date of expiry, whether booster or part of first course and site of inoculation.

Spillage Management:

• Deal with blood and body fluid spills quickly and effectively. PPE must be worn and a yellow floor warning sign displayed.

• Commercial spillage kits are available to deal with blood and body fluid spillages, and should beused.

• The spillage kits are kept in cleaning cupboard under the stairs. The spillage kits have step by step instructions to follow on them.

• The practice manager ensures that kits remain in date. Inform the practice manager if kits are used so that they may be replaced immediately after use.

• Urine and stool contamination should be treated as an infectious clean, unless they are bloodstained.

How to deal with it:

i. If the spillage is about an incontinence pad size –

Spread the NaDCC granules generously over the spillage, leave it for 3-minutes (this allows thegranules to kill the bloodborne viruses). Move the yellow clinical bin close to the spillage. Threeminutes later, remove the spillage using the kit supplied with apron & gloves and dispose of it directly into the clinical bin.

(NaDCC brand products are: Haztab,Chlor Clean and Actichlor Plus).

Then wipe the area over with 10,000 parts of chlorine base solution provided in the spillage kit(make sure that the windows anddoors are open when using chlorine base solution).

ii. If the spillage is more than an incontinence pad size –

Put on apron & gloves and soak up the blood & body fluids with absorbent pads; place them directly into a close-by yellow clinical bin. Then wipe the area over with10,000 parts of chlorine base solution (make sure that the windows and doors are open when usingchlorine base solution).

Aseptic Technique

Aseptic technique is the term used to describe the methods used to prevent contamination of woundsand other susceptible sites by organisms that could cause infection (Marsden Manual of ClinicalNursing Procedures)

The aims of aseptic technique are:

• To prevent the introduction of pathogens to the site.

• To prevent the transfer of pathogens from the patient to staff or other patients.

An aseptic technique should be implemented during any invasive procedure that bypassesthe body’s natural defences.

An aseptic technique should also be adopted when undertaking dressings and minor surgery.

The procedure is undertaken either with forceps or sterile gloved hands. The important principles arethat the susceptible site should not come into contact with any item that is not sterile. Any items thathave been in contact with the wound will be contaminated and should be disposed of safely ordecontaminated for reusable instruments. Cleaning of trolleys with detergent and hot water issufficient, as the sterile field will be created by the sterile towel contained within the dressing pack.

Bacteria acquired on the clothing during the procedure may be transferred into the wound of anotherpatient; therefore a clean disposable apron should be used for each dressing procedure.

Wound Swabbing

Swabbing should only be undertaken if wound/ site of invasive device exhibits signs of infection.They should not be taken routinely, or if wound/ site is healing.A wound should be swabbed if it looks infected before commencing antibiotics.The specimen swab should be kept in the specimen fridge while waiting for Laboratory collection. All specimens are transported to the lab on the same day.


1. Department of Health (1998). Guidance for clinical health care workers. London: Department of


2. Pratt RJ, Pellowe CM, Wilson JA et al. (2007). Epic 2: National evidence-based guidelines for

preventing healthcare-associated infections in NHS hospitals in England, Journal of Hospital

Infection, 65: S1-S64. Available at:

3. Care Quality Commission ‘Inspection Guides and the Department of Health’s Core Standard’