Infection Control Policy

Code: B.4.3-1

Date: 17/06/2014

Reviewed: 18/09/2019, 19/01/2024, 13/05/2025

Purpose:

To reduce as far as is practicable the transmission of infection within the surgery.

• Between Clients

• Between Clients and Staff

Responsible Staff:

Implementation: Senior Practice Nurse

Action: All Staff

Training Resources:

Infection Control Protocol (situated in Grey folder in reception)

Blood Test Protocol

Autoclave manual

5 moments of hand hygeine

Policy:

Objective

To protect patients, staff and the public from blood/body substance exposure through the use of appropriate infection control measures.

PROCEDURES

Hands:

Hand washing is the single most important procedure for preventing transmission of infections.

All staff must accept responsibility for their skin integrity prior to the commencement to work. All cuts, abrasions and broken skin (e.g. Eczema) must be occluded with a waterproof dressing and/or gloves.

Hands and other skin surfaces must be washed immediately with soap and water if they become contaminated with body substances.

Hands should be washed with soap and water or sterilised with alcohol rub after each patient contact.

Facilities

• A sink with running water.

• Hand cleaning agent and a single-use hand drying facility.

• Hand washing facilities should be located close to the work area.

• Gloves (Latex) of all sizes are to be wall-mounted in each room within easy reach.

• Latex free gloves are stored in the rear store area and under the sinks in clinical rooms.

Procedure:

Hand washing is mandatory for:

• All staff who have patient contact

• All staff who handle anything that has been involved in patient care.

• All staff, if their hands become contaminated with blood/body substances.

Hand washing should involve thorough lathering of all surfaces, rinsing under running water and careful drying of all surfaces with single use hand drying facility.

Hands must always be washed after wearing gloves because hands become hot and moist, allowing resident organisms to multiply and gloves may be punctured during the procedure. A significant number of gloves have microscopic holes, allowing fluid to permeate through the glove.

Types of Soap

• Liquid/foaming soap is provided for use at each hand washing station.

• Alcohol hand rub is provided in each clinical area. Staff may specify any preferred type.

Staff Skin Problems

Health care workers who have dermatitis, eczema, paronychia or any other skin lesion may pose a risk to patients and other health care workers because:

• Dermatitis skin is more likely to be colonized with large numbers of potentially pathogenic organisms.

• Hand washing of dermatitic skin does not appreciably reduce skin bacterial counts.

• Personnel with dermatitic skin tend to avoid hand washing.

Staff with skin problems which may reduce the efficacy of hand washing must discuss their infection control risk with the infection control officer.

STAFF IMMUNITY

When new staff are employed they should be offered advice regarding the chances of coming into contact with infectious diseases. As a good employer consider offering blood tests to determine their immunity to Hepatitis B and Rubella and the need for other tests, such as HIV may be considered.

Tuberculosis Note Mantoux status, consider updating.

Tetanus: Note date of last booster, consider updating.

MMR/Rubella: Should be immune if caring for pregnant women.

Varicella: Should be immune if caring for pregnant women

Hepatitis B Virus: Consider vaccination if not immune

Influenza: While most health workers are not considered to be a high-risk from influenza and its complications, vaccination is recommended to protect themselves and their patients also. Persons with influenza are infectious for 24 hours prior to symptoms appearing.

Pertussis:  All staff should ensure that they have current immunisation against pertussis.

Where appropriate the practice shall fund immunisation against these conditions for all staff.

Gloves

All gloves are powder free as this reduces dermatitis risk. Gloves are to be worn when in contact with:

• blood or body fluids.

• mucous membranes

• non-intact skin of all patients

• surfaces soiled with blood or body fluids.

Gloves should be used for invasive procedures. Gloves must be changed after contact with each patient and hands washed immediately after gloves are removed. Heavy-duty kitchen gloves should be worn when dealing with large spills of blood or body fluids.

“If it's wet, and it's not yours, WEAR GLOVES”

Disposable Plastic Aprons

Plastic aprons are to be worn when it is likely that blood or body fluids will come in contact with clothing. Plastic aprons can be found hanging on the back of the treatment room door.

Masks, Eyeglasses

Masks and eyeglasses are to be worn if there is the potential for blood or body fluids to splash or aerosol into the eyes, mouth or nose. e.g. When incising wounds, cysts, abscesses, injecting local anesthetic or cleaning contaminated medical equipment.

Masks and eyeglasses are kept in the sluice room.

CLEANING, DISINFECTION AND STERILISATION

Disposable Items:

All items that are designed for single use only are not re-used and discarded appropriately and safely following manufacturers instructions.

Cleaning:

Cleaning is the removal of visible dirt, organic matter or other foreign material from an item. Cleaning reduces the bacterial load to very low levels, so items that have been cleaned can usually be considered safe for intact skin contact. All items should have debris removed and be cleaned prior to autoclaving or disinfecting. It is important to wear protective clothing when cleaning all instruments e.g. Gloves, apron, and eyeglasses.

Approved Antiseptics:

It is important that only approved antiseptics are used and that these are used in accordance with the manufacturer's directions.

For general cleaning and disinfection of instruments and medical equipment use:

• Alcohol wipes (for between-patient cleaning of appropriate medical equipment)

For hard surfaces use:

• Clinell Wipes or;
• Clinidet.

For contaminated surfaces where the above is not appropriate:

• Household bleach diluted 1:50 (10ml bleach in 0.5L water)

For general cleaning:

• Household bleach dilute 1:100 (10ml bleach in 1L water)

Blood Glucose Meters:

• Clean as per manufacturers instructions.

• Hard surface foaming wipes are particularly suitable for this purpose.

Ear Syringing Equipment:

Non disposable Speculae from otoscope and jet tips should be cleaned with dish washing liquid and sterilized in approved antiseptic for 1 hour. Leave to air dry on paper towel.

The chamber of the propulse should be sterilised using the propulse sterilising tablets found under the sink in the treatment room. This should be done at the end of each day if the machine has been used that day. 1 tablet placed in a chamber of water, when dissolved run liquid through tubing and leave for 5minutes. Rinse chamber and fill with fresh water, run all this water through tubing. Dry thoroughly.

Finger Prick Devices:

• These vary: preferably use “Glucolets” with disposable needles.

Instruments:

• Rinse under running warm water (low pressure) to remove visible contamination

• Check instruments individually, scrub with a brush where appropriate.

• Most instruments should be cleaned using the ultrasonic cleaner. Remove all staining/debris. Wash all surfaces of the items with detergent including lumens and valves. Place in ultrasonic bath at 40º for 10minutes. Dental syringes and ENT mirrors are damaged by the ultrasound and should be cleaned manually.

• Remove, rinse and dry with a lint-free cloth. Drying reduces the risk of contamination as residual moisture may impede the sterilisation process and damage instruments.

• Visually inspect the cleanliness and condition of all items.

• Autoclave in accordance with the Autoclave Directions (below)

Linen:

• All linen that is blood stained or contaminated with human waste should be soaked, e.g. Napisan, then washed using a hot water cycle, an appropriate detergent and preferably dried in the sun. Alternatively send to a commercial cleaner.

Medicine Measures:

• Wash in warm water with detergent then soak in approved antiseptic.

• Preferably use disposable syringe.

Oxygen Masks, Nebuliser Bowls and Mouthpieces: (If reusing the following is advised)

• Wash in warm water with detergent and soak in approved antiseptic.

• Rinse three times after removal from disinfecting solution.

• Some nebulsier bowls and mouthpieces can be autoclaved (check with manufactuer's instructions).

• Leave to air dry on a paper towel.

Oxygen Tubing:

• This should be dated and discarded monthly or if contaminated.

Spacers:

• Normal use involves priming a spacer, e.g. Wash device in warm water and dishwashing detergent, air dry – this is to be highlighted to patients when taking the device home for individual use.

Where a spacer or inhaler trainer is re-used in the surgery:

• Spacers must be washed in warm water with a detergent.

• Soak in approced antiseptic, then rinse 3 times.

• Wash again in warm soapy water to reprime, and allow drying naturally.

• Do not dry with a towel as this increases electrostatic charging.

• Reassemble after drying.

Sphygmomanometer:

• It is recommended that the cuff be washed or wiped if contaminated using Clinell wipes.

Stethoscopes:

• The earpieces should be removed and washed in warm soapy water when contaminated.

• The diaphragm should be wiped with a clinell wipe.

Vacutainer Needle Holders:

• Discard if visibly contaminated.

• Rinse under running water and soak in approved antiseptic weekly.

Cleaning Up Spills of Body Substances:

• It is important to wear suitable gloves to ensure that spilt materials do not penetrate the gloves e.g. Light small spills of urine or blood may be wiped up while wearing latex gloves, heavier spills requiring more involved cleaning will require a thicker grade of gloves such as domestic rubber gloves (or 2 pairs of disposable gloves) in order to protect hands.

• Eyewear and plastic apron should also be worn where there is a risk of splashing occurring.

• Absorb the spill with disposable material e.g paper towels and dispose of contaminated material appropriately.

• Clean the spillsite with any suitable disinfectant, allowing time for it to act.

• Rinse the site

• Dry the site to prevent slipping

• Large spills on carpet may require the services of a commercial steam carpet cleaner.

   

DISINFECTION PROCEDURES:

Chemical Disinfectants:

Chemical disinfectants can be expensive and misuse can lead to the development of bacterial resistance. All disinfectants require more than a few seconds of exposure to be effective and they are not active when dry. Always check manufacturers' instructions.

To achieve disinfection requires more than just exposure of the object to the agent. The object must be thoroughly clean and free of soap, detergent or any other substance that may neutralize the disinfectant. Chemical disinfectants do not penetrate through dense organic material.

The appropriate disinfectant must be made up at the appropriate concentration for the task and given the recommended time to act on the surfaces being disinfected.

Written proof from the manufacturer of the appropriateness of any disinfectant for the task should be retained at the practice e.g. Place manufacturers written information sheets in Practice Resource folder with Infection Control Resource. Documentation of any change in use of chemical disinfectants is required. Do not discard old directions as they may be useful in the future.

The process of disinfection is commonly divided into three levels – low, intermediate and high. The

first step in the process is to thoroughly clean the item. Disinfectants will not work in the presence of debris, therefore clean, disinfect and dry. Foreign material will inactivate or limit the penetration and effectiveness of both chemical and physical agents. Clinell wipes are very effective and be used for cleaning most surfaces and objects including toys.

The purpose for which an instrument is to be used dictates the level of disinfection required. For objects that contact intact skin but do not penetrate, the lowest level of disinfection is satisfactory.

It is expected that medium and high level disinfection will only be used where sterilisation cannot be achieved (eg: in emergency situations where there has been power loss) Documentation of the reason for ANY medium or high level disinfection and the details of the patients on whom the instruments have been used, both before and after the sterilisation must be recorded.

Low Level Disinfection:

Definition: Items on contact with normal and intact skin.

Examples: Stethoscopes, blood pressure cuffs

Suitable Method: Cleaning and drying usually adequate, sometimes low level disinfection required.

Clinell wipes

Intermediate Level Disinfection:

Definition: Items in contact with mucous membranes or other items contaminated with

particularly virulent or readily tansmissible organisms, or items to be used on

highly susceptible patients.

Examples: Respiratory equipment, speculae.

Suitable Method: Sterilisation required. High level disinfection required by heat where

possible.

If heat sensitive or an emergency, intermediate or high-level chemical disinfection is recommended.

High Level Disinfection

Definition: Items in close contact with mucous membrane or broken skin or introduced into a

normally sterile body area.

Examples: Surgical instruments, syringes syringes, needles, intrauterine devices and

associated equipment, dressings, urinary and other catheters.

Suitable Method: Sterilisation required. High level disinfection may sometimes be acceptable if sterilisation is not possible or practicable.

Activities of Chemical Disinfectants:

• The above disinfectants must be prepared and used in accordance with manufacturer's recommendations.

   

Body Substance Injury/Exposure

Recording and notification of accidents and serious harm is a requirement of the Health and Safety in Employment Act 1992.

ALL such exposures MUST be recorded in the incident book.

Definitions

Recipient - the person exposed to blood or body substance

Source – the person whose blood or body substance the recipient was exposed to. The source may be unknown.

Types of Contact to be Reported

• Injury resulting from contact with used needles or sharp objects (eg. Scalpel blades) that have been contaminated with blood or body substance.

• Splashing of blood or body substance onto mucous membrane (eg. Eyes, nose or mouth) or onto a cut, burn or broken skin (eg. Dermatitis).

• Human bites where the skin surface is broken.

Procedure

1. Wash injured area under running water, squeeze to help area bleed.

For eye and mucous membrane exposure, irrigate with water/saline or under running tap water.

Cover wound if able with an adhesive waterproof dressing.

2. Seek informed consent from source, if apporpriate, for screening blood tests for HBV, HCV and HIV (10ml sample of blood in a plain tube).

3. Bloods to be taken from recipient for HBV, HCV and HIV (10ml sample of blood in a plain tube).

Obtain informed consent.

4. Time frames for seeking Infectious Disease Specialist input if source is known to be positive for:

HIV: within 2-4 hours

Hepatitis B: within 48hours (if recipient has no immunity)

5. Complete OSH Accident Investigation form, appropriate ACC form to lodge claim with ACC and appropriate laboratory forms.

6. Original copy of OSH Accident investigation form is to be filed in the Practice Incident Book. It is recommended that the recipient retain a copy for their reference.

7. Document injury/exposure in recipient/source medical notes as appropriate.

8. Recipient to contact own GP for follow up of blood results.

9. Ensure that the affected person has been appropriately counselled regarding the possibility of transmission of blood borne disease.

NB: For people vaccinated against Hepatitis B, and who have subsequent immunity (Hepatitis B antibodies), over 90% of those vaccinated will retain immunity for up to 20years even if subsequent laboratory tests show no Hepatitis B antibodies. It is important to retain records of Hepatitis B post vaccination immunity status.

*Post single exposure risk of acquirement from a positive source if recipient unvaccinated:

Hepatitis B – 15-30%

Hepatitis C – 5-6%

HIV 0.3%

AUTOCLAVING

Operating The Autoclave:

Always follow manufacturers' instructions. These are kept with the Infection Control Resource Manual.

The prion cycle should be used for most sterilising. 

Pessary sizing rings and some other soft plastic re-usable items cannot be autoclaved on the prion cycle.  Instead the 121degree cycle should be used. 

All items should have debris removed and be thoroughly cleaned prior to autoclaving for effective sterilisation to occur. See Instrument Cleaning (above)

Non-Packaged Items:

Instruments that need to be sterilised after use but that are not required to be sterile for their purpose, such as speculae, nail clippers and other instruments not used for sterile procedures may be bagged after sterilisation. Bags should be sealed with a label bearing the date of sterilisation in such a way that it is not possible to open the bage without destroying the label.

Packaged Items:

Instuments not required for immediate use can be stored if they are appropriately packaged. Approved autoclave bags should be double folded and sealed with autoclave tape or steripeel.

Always date and label items. Packaged items remain sterile for at least 6 months if packages remain unopened and undamaged and stored correcctly. Only use white-board water based pens on packages. Do not use ball point pens as they may penetrate the package and these and vivid type oil based markers may damage the autoclave. Never use staples.

Placing Items in Autoclaves:

• Correct loading of the autoclave is critical to proper sterilization.

• Ensure items are spaced adequately to allow air removal and allow steam to penetrate.

• Place bowls and kidney dishes on their sides, not stacked over the top of each other as this restricts air removal and steam penetration.

Removal of Sterilised Items:

• Allow all instruments and containers to cool.

• Check the chemical indicators on bags/tape/strips to ensure correct colour change (reprocess items if results are not acceptable).

• If items are packaged,ensure packaging is intact and completely dry (reprocess contents if they are not).

Monitoring:

• Chemical Indicators: Chemical indicators show that the correct temperature and time (or pressure) was achieved.

• Unwrapped Loads: an approved chemical indicator (e.g. Temperature and time) should be placed in with each load. Record result, date and time and initial on template (see template in manual).

• Wrapped Loads: a chemical indicator should be on every item for packaged loads.

• Record as for unwrapped loads.

Change Log:

13/05/2025

Added 5 moments of hand hygeine training resource

Removed audit matrix as ineffective.

19/01/24

Removed reference to clinidet/presept to avoid confusion over approved antiseptics

21/04/15:

Added audit requirement to check that PPE is available in the sluice room.

Changed location of PPE to reflect current storage.

Added section on approved antiseptics.

Removed references to specific antiseptics and replaced with term 'Approved antiseptic'

17/06/2014: 

Removed requirement for chemical indicators in B class autoclaves.

Removed duplicate entry in audit "correct storage of instruments"

09/05/2012:

This policy was merged with the instrument sterilisation, autoclaving and instrument handling policies as much of the material within each was duplicated.