Universal/Standard Infection Control Precautions

Reference Number: 622

Author & Title:
J acqueline Cosgrave, Infection Control Nurse

Responsible Directorate:
Corporate

Review Date: April 2014
Ratified by (committee): Operational Governance Committee
Date Ratified: April 2011
Version: 2

Related Procedural Documents
Aseptic Non Touch Technique Policy
Blood Borne Virus Policy
Clostridium difficile Policy
Hand Decontamination Policy
Isolation Policy
Influenza A, Control and treatment of
Linen Policy
Diarrhoea and /or Vomiting Policy,
Management of
Waste policy, Management and
disposal of
Medical Sharps Policy
Meningitis Policy
MRSA Policy
Operating theatre dress policy
Scabies Policy
Tuberculosis Policy


Document name: Universal/Standard Infection Control Precautions Ref.: 622
Issue date: April 2011 Status: Final
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Index:

1. Introduction _________________________________________________________ 3
2. Purpose of this policy _________________________________________________ 3
3. Aims and Objectives of this policy _______________________________________ 3
4. Duties / Responsibilities _______________________________________________ 4
5. Monitoring Compliance ________________________________________________ 4
6. Risk assessment _____________________________________________________ 4
7. Procedure ___________________________________________________________ 5
8. References _________________________________________________________ 15
Appendix 1: Consultation Schedule ______________________________________ 16
Appendix 2: Risk Assessment guide for selection of protective equipment based
on risk of exposure to blood or body fluid ___________________________________ 17
Appendix 3: Moments for hand hygiene __________________________________ 18
Appendix 4: Guidance for the selection of masks __________________________ 19
Equality Impact Assessment Tool __________________________________________ 20
Consultation Checklist ___________________________________________________ 21
Ratification Check List ___________________________________________________ 22


Document name: Universal/Standard Infection Control Precautions Ref.: 622
Issue date: April 2011 Status: Final
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1. Introduction

Universal/Standard precautions are the practices that must be adopted by all
healthcare workers (HCW) when potentially coming into contact with any patients
blood, tissue or body fluid. They are based on a set of principles designed to
minimise exposure to and transmission of a wide variety of micro-organisms.
Since every patient is a potential infection risk it is essential that universal/standard
precautions are used for all patients all of the time.


2. Purpose of this policy

The purpose of this policy is to provide guidance for staff within the Royal United
Hospital, Bath NHS Trust about the requirements and processes for implementing
Universal/Standard Infection Control Precautions.

There are eight key elements to Universal/standard control precautions, all of which
when appropriately implemented are designed to reduce the risk of transmission of
micro-organisms.

The application of transmission based precautions when patients are managed with
known infections will support the prevention of the spread of healthcare associated
infections.

This policy applies to all individuals in the employ of the Royal United Hospital Bath
NHS Trust


3. Aims and Objecti ves of this policy

The policy aims to make explicit the principles of infection prevention and control
which will minimise exposure to and the transmission of micro-organisms.

There are eight key elements of universal/standard infection control precautions:
Hand hygiene,
Personal protective equipment,
Sharps disposal,
Waste disposal,
Linen handling and segregation,
Blood and body fluid spillage procedure,
Handling and transport of specimens,
Decontamination of equipment and the environment.



Document name: Universal/Standard Infection Control Precautions Ref.: 622
Issue date: April 2011 Status: Final
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4. Duties / Responsibilities

All staff have a responsibility for ensuring that the principles outlined within this document
are universally applied.

4.1 Chief executi ve
The Chief Executive has overall responsibility to ensure that the policy is
implemented and adhered to across the trust.

4.2 Director Infection Prevention Control (DIPC)
The DIPC reports directly to the Chief Executive, Trust Board and is a member of the
Clinical Governance Committee and patient safety structures.
The DIPC oversees infection control policies and their implementation and is
responsible for the Infection Prevention and Control Team.

4.3 Infection Prevention and Control Team
The Infection Prevention and Control Team are responsible for developing the policy, for
providing expert advice, training and monitoring compliance with the policy.

4.4 Consultants, Managers/Matrons and Senior Sisters
Managers/Matrons and Senior Sisters are responsible for the operational implementation of
this policy; ensuring their staff are aware of their responsibilities, adhere to the guidance
within the policy. They must ensure that new staff have attended Infection Prevention and
Control induction.

4.5 All staff
The employee has a responsibility to carry out risk assessments and use the
appropriate equipment provided.
Employees are responsible for ensuring that any breach of this policy is immediately
reported to their manager.
All staff must attend the mandatory Infection Prevention and Control update at two
yearly intervals.
Clinical staff have a responsibility towards the safer working practices of their
colleagues or co-workers such as students or trainees under their supervision.


5. Monitoring Compliance

Infection Prevention and Control Team will audit components of the policy as part of the
annual audit programme with the support of the Audit department.
Audits of compliance with the policy will be undertaken by Ward managers/Senior
Sisters using the Saving lives High Impact Interventions audit tools
Results of audits are reported at weekly Task Force meeting.
Where short falls are identified, Ward managers and Matrons will ensure that
improvement programmes are agreed and put in place to improve compliance.


6. Risk assessment

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Implementation of universal/standard precautions is dependent on an initial risk
assessment of the patient, the task being undertaken and the situation. All body
fluids may pose a risk of transmission of micro organisms.

Staff must select the appropriate protective equipment. The Risk assessment guide
for selection of protective equipment based on risk of exposure to blood or
body fluid: Appendix 1. will support staff in assessing the risk of contamination to
the healthcare workers clothing and skin by the patients blood, body fluids,
secretions and excretions.

Additional precautions

Where a patient is known to have a specific infection or colonisation then reference to
specific Infection Control Policy is recommended for additional precautions:

Antibiotic Resistant Micro-organisms,
Blood borne viruses,
Chicken pox,
Clostridium difficile,
Meningitis,
Meticillin resistant Staphylococcus aureus (MRSA),
Influenza,
Scabies,
Transmissible Spongiform Encephalopathy Agents Including CJ D and vCJ D,
Tuberculosis,
Viral diarrhoea and vomiting.

7. Procedure

7.1 Hand decontamination

Hand decontamination is the most effective means of preventing cross infection
(Fraise & Bradley, 2009).

All trust employees must receive training in the appropriate hand hygiene techniques
on induction into the Trust.

Ongoing assessment and training of the techniques are undertaken as part of the
Trusts mandatory infection control updates for Trust employees at two yearly
intervals.

The RUH embraces the Five Moments for Hand Hygiene Appendix 2 ( WHO
2009), aiming to link specific hand hygiene actions to specific infectious outcomes in
patients, by giving clear advice on how to integrate hand hygiene into the complex
task of care. Appendix 2.

Bacteria and viruses cannot penetrate intact skin. It is vital to maintain skin in a good
condition and prevent cracking, chapping and drying of the skin. Moisturiser is
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available in all clinical areas to maintain skin moisture. Staff must inform their line
manager if their hands become sore or cracked.

7.1.1 Hand decontamination using liquid soap and water

The following activities are examples of when hands must be washed using
detergent and water:

Whenever hands are visibly dirty,
After removal of gloves,
Following any handling of blood or body fluids,
After any microbial contamination (e.g. wound examination, wound dressing,
sputum aspiration etc),
Before performing an aseptic procedure,
Before preparing, handling or eating food,
After visiting the toilet,
After patient toileting,
After handling laundry,
After dealing with patients symptomatic with diarrhoea and vomiting e.g.
Norovirus or Clostridium difficile.

This is not an exhaustive list.

7.1.2 Hand decontamination using alcohol based gel or solution.

The following activities are examples of when alcohol based gel or solution can be
used on socially clean hands:

Prior to and following examination of a patient,
Prior to handling patient equipment,
On entering and leaving the clinical environment,
Between social patient contact e.g. ward rounds,
Before entering and leaving an isolation room or area,
Before and after transfer of patients from / bed/ chair/ trolley,
Venepuncture.

This is not an exhaustive list.

Refer to Hand Decontamination Policy

7.2 Personal Protective Equipment

Personal Protective Equipment (PPE) consists of aprons, gloves, masks and eye
protection.

The primary use of PPE is to protect staff and reduce opportunities for transmission
of micro-organisms (ICNA 2002).
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The selection of the PPE is based on a risk of transmission of micro-organisms to
the patient and the risk of contamination of the HCW clothing and skin by the
patients blood, body fluids, secretions and excretions.

Under Health and Safety legislation the Trust has a responsibility to ensure that staff
have access to appropriate PPE.
Staff have a responsibility to use PPE in appropriate situations (Health & Safety
Executive 1999).

7.2.1 Gloves

The use of gloves can reduce the risk of acquiring infection through direct skin
contact between HCW and patients. Gloves should not be worn unnecessarily or as
a substitute for hand decontamination as prolonged and indiscriminate use may
cause adverse reactions and skin sensitivity (WHO 2009).

Gloves are a single use item.
Gloves can reduce the likelihood of contact dermatitis in staff exposed to
chemical agents.
Gloves must be worn when direct contact with contact with blood, body fluids,
non-intact skin or mucus-membranes is anticipated.
Gloves must be changed between patients and different procedures on the
same patient.
Gloves must be disposed of in an orange clinical waste bin.
Hands must be decontaminated with soap and water immediately on removal of
gloves.

Indications for wearing gloves:
Venepuncture,
Wound inspection,
Cannula insertion,
Aseptic Non Touch Technique,
Emptying urinary catheter bags/stoma bags,
Cleaning soiled equipment,
IV drug administration,
Invasive procedures,
Dealing with body fluids,
Surgical procedures use sterile gloves.

This is not an exhaustive list.

7.2.2 Sterile gloves

Training on the correct procedure for donning and removing sterile gloves must be
provided for staff to prevent the contamination of the outer surface of the glove and
the hands.

7.2.3 Gloves and latex allergy
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If a healthcare worker has a latex allergy or sensitivity to specific chemicals in
gloves, they must report this to their line manager and should seek advice from the
Occupational Health Department as alternative gloves must be made available in the
persons area of work.

Where a patient is known to be allergic to latex, staff must use non-latex gloves.

Refer to Skin Management, Protective Gloves and Latex Sensitivi ty Policy

7.2.4 Disposable aprons and gowns

Plastic aprons must be worn to reduce the level of contamination of uniforms/clothing
where direct patient care is given and there is potential for the dispersal of
pathogens.
Such activities may include:
Assisting patients with toileting,
Bathing,
Bed making,
Procedures causing splashing of body fluids or blood.
This is not an exhaustive list.

Sterile gowns protect patients from infection where they are undergoing procedures
such as insertion of central venous catheters.

The type of apron or gown to be worn depends on an assessment of risk of contact
with body fluids:

Aprons:
Must be worn where there is a risk of blood or body fluid contamination of the
uniform,
Must be changed between patients and different procedures on the same
patient,
The apron must be disposed in an orange clinical waste bin. as clinical waste,
May be worn for decontamination activities, including cleaning and disinfection.
Gowns:
Full body gowns must be worn by operating theatre scrub staff. These should
be either single use waterproof disposable or re-usable waterproof gowns,
Worn where there is a risk of extensive contamination of uniform or clothing,
Must be single use and replaced after each episode of care or task,
If disposable; discarded in an orange clinical waste bin.
For general clinical procedures long sleeved non sterile gowns should fully
cover the area to be protected,
Gowns are not required for the routine care of patients with influenza unless
aerosol generating procedures are being performed,
Gowns may be required when nursing patients with Norwegian scabies,
Gowns may be required when nursing a patient with possible/confirmed viral
haemorrhagic fever.
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Refer to Operating theatre dress policy/ Influenza policy/ Scabies policy


7.2.5 Eye protection

Mucous membranes of the eyes and mouth must be protected when there is a risk of
blood splashes.
Eye protection may be achieved through the use of goggles, visors or spectacles
with side pieces. They must be comfortable to wear, fit correctly and allow for clear
vision.
Eye protection that is designed for multi-use must be cleaned with detergent
between each task and patient.

Eye protection must be available in all areas especially where splash is more likely:
Emergency Department,
Endoscopy,
Theatres,
Central Delivery Suite,
Critical Care Unit.

Eye protection should be worn where:
Splash or spray of blood or body fluid is likely,
When dealing with chemicals,
During aerosol and sputum generating procedures.

7.2.6 Masks and respirators

Masks are worn to protect the wearer from potential exposure to micro-organisms via
splashes of blood or body fluid.

The use of a mask must be based on an assessment of risk of body fluid exposure.
Staff may select a face mask or respirator depending on the level of protection
required. Refer to Guidance for the selection of masks: Appendix 3

Masks are rarely worn in general ward environments.

Surgical face masks protect the wearer from expelling droplets (>0.5 microns) into
the environment. If the mask is fluid resistant, the wearer will be protected from
splashes.

Respirators are made to specific standards EN 149 2001, FFP2, FFP3.
Respirators are worn to protect the healthcare worker from airborne particle
(<0.5microns) such as viruses. Staff must receive training in the correct application
of these masks to ensure their efficacy.

Guidance for the selection of masks

Selection of the appropriate mask is required to ensure protection is adequate.
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Where a mask is required it should be applied prior to entering the isolation
room.
Masks must be worn correctly and be close fitting.
Handled as little as possible.
Changed between operations or patients.
Changed if wet.
Discarded immediately after removal in an orange clinical waste bin.
Hands must be washed on removal of mask.

Guidance for the selection of masks: Appendix 3.

7.3 Blood /body fluid spillage

Protective clothing, e.g. gloves and apron, must be worn when dealing with
blood/body fluid spillage. The area must be made safe to prevent further
contamination and protect staff and patients.

Blood/body fluid spillage can be divided into groups:
Spillage on the floor or a large surface area,
Soiling of equipment or where it is not practicable to use a hypochlorite powder.

7.4 Spillage on the floor or a large surface area

For spillages on the floor or a large surface area, a 10 000 ppm hypochlorite powder
must be used e.g. Titan Sanitizer.

Use PPE, wear gloves and apron.
Cover the spillage with chlorine releasing powder e.g. Titan Sanitiser.
Hypochlorite containing products must not be used on urine spillage as chlorine
gas will be released.
Use paper roll to remove the spillage and place in a in an orange clinical waste
bag.
Wash area with detergent and water.
Dispose of PPE in an orange clinical waste bin.
Decontaminate hands using soap and water.

7.5 Small blood spillage on equipment and in other areas where it is
not practicable to use hypochlorite powder

Use PPE, wear gloves and apron.
Clean the area with detergent and water.
Surfaces or equipment contaminated with blood should be disinfected with a
chlorine based disinfectant E.g. Actichlor Plus.
Dispose of waste in an orange clinical waste bin.
Dispose of PPE as in an orange clinical waste bin.
Decontaminate hands using soap and water.

7.6 Body fluids e.g. vomit, urine, faeces
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Use PPE, wear gloves and apron.
Clear away spillage with paper roll.
Wash area with detergent and water using paper roll.
Dispose of used paper roll in an orange clinical waste bin.
Dispose of PPE in an orange clinical waste bin.
Decontaminate hands using soap and water.

7.7 Waste Disposal

Waste bins/bags must be of the appropriate UN-approved type, colour, size,
Adequate supplies of waste bags/bins must be available to ensure that waste
segregation is able to take place correctly,
Waste bag holders are fire-proof, leak-proof, foot pedal operated, secure, well-
maintained and well-cleaned,
Signs and notices must be displayed to ensure that staff can quickly refer to
correct information about segregation of waste and the correct container to use,
Waste bins and other containers must be kept clean.

7.8 Segregation of waste

All waste is to be segregated at the point of use.

The most common waste categories are:
Orange bag: potentially infectious clinical waste,
Yellow bag: Diagnostic specimens from permitted areas only,
Sharps bins: yellow lidded sharps bins take standard clinical sharps including
sharps contaminated with medicines; purple lidded bins take sharps
contaminated with cytotoxic/cytostatic substances
Yellow burn bins: Recognisable anatomical waste, drugs for incineration must
go in separate burn bin (refer to waste policy).
Black bags, General non recyclable waste, non hazardous waste,
Clear plastic bags: Waste for recycling i.e. paper, cans, plastic bottles and
containers, separated and put into tied, clear plastic bags & flattened cardboard,
loosely loaded,
Hazardous Waste (e.g. solvents and chemicals, aerosols, gas cartridges,
chemicals, oils, batteries, inkjet and toner cartridges, tyres, Fluorescent tubes
and compact fluorescent lights (CFLs), mercury, sodium lamps, Waste Electrical
and Electronic Equipment (WEEE),
Tiger-striped bags for offensive waste, used in selected areas of the Trust.

Orange clinical waste bags and tiger striped bags must be closed using the swan
necked method and tied with a coded zip tie.

Only staff that have been suitably trained and are aware of the correct procedure
should be involved in the handling of clinical waste.

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Sharps bins must be kept separate from other clinical waste and MUST NOT be put
into clinical waste bags.

In order for waste to be traced back to the point of generation:
Sharps bins must have the front label fully filled in and signed,
Burn boxes must be have the RUH Department name, date and signature of the
person who closed the box written on the box.

Refer to Management and Disposal of Waste policy

7.9 Sharps

Sharps can be defined as any object in the healthcare setting that could puncture the
skin and permit the entry of bacteria or viruses into the body.
Sharps include needles, scalpels, suture needles, lancets, scissors, surgical
instruments stitch cutters, glass ampoules, intravenous cannulae, vacuum blood
collecting systems, fragments of bone and patients teeth. This is not an exhaustive
list.

7.10 Inoculation (Sharps) injury

An inoculation injury occurs where a needle or other sharp contaminated with blood
or other high risk body fluid penetrates percutaneously (through the skin). Such
injuries also include cuts, pinches, scratches, bites which break the skin and
splashes of body fluids to the eyes.
Accidents with needles are the most common, so injuries from sharps are often
called needle stick injuries.

7.11 Preventing inoculation injury

The emphasis on preventing contaminated inoculation injury must focus on ensuring
safe handling practices are in place:

Attend Infection Prevention and Control Induction and Infection Prevention and
Control Clinical Update,
Use appropriate PPE,
Used sharps must be discarded into a sharps container at the point of use.
Needles and syringes must not be disassembled by hand prior to disposal,
Do not re-sheath needles,
Do not carry loose sharps in your own hands - use a plastic tray,
Sharps must not be passed directly from hand to hand, use a tray so that the
same sharp device is not touched by more than one person,
Sharps containers must not be filled above the mark indicating they are full,
Temporary closure mechanisms should be used when sharps boxes are not in
use,
Sharps containers should be located in a safe position,
Report all incidents (including near misses) involving contaminated sharps at
the time of occurrence, or as soon as possible afterwards, to the line
manager/Supervisor/Team Leader on duty and Occupational Health.
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Refer to Policy for Protection against infection with Blood Borne Viruses
Policy/ Medical Sharps Policy


7.12 Linen disposal

Used linen is a potential source of infection as it is likely to be contaminated with
potentially pathogenic organisms.

Gloves and aprons must be worn when dealing with soiled, wet or blood stained
lined.
Linen should be bagged by the bedside, never carried through a clinical area by
hand.
Linen bags must be half full only. They must not be overfilled.
Lined from infected patients or blood stained must be placed in an inner red
alginate bag, and then placed into an outer red plastic bag.
When removing soiled linen avoid the production of aerosols.
If patients clothing is being laundered at home, place soiled laundry in a water
soluble clothing bag, inside an outer plastic bag. Inform visitors that laundry is
awaiting collection in the patients locker.

Refer to Linen Policy

7.13 Pathology specimens

All specimens should be handled with care. PPE must be used when handling
specimens.

All specimens must be safely contained in a leak proof container which is
additionally placed in a sealed polythene bag.
The request form should be attached.
Ensure the outside of the container, bag and form remain free from
contamination with blood or body fluids, faeces or vomit

7.13 Bio-hazard specimens from known or clinicall y suspected infected
patients

The request form must be labelled with inoculation risk (hand written on the
request form or free text on ICE).
If there is a risk of spillage of contents then the specimen should be placed
inside a second polythene bag i.e. double bagging.
The following bio-hazard specimens must not be sent via the vacuum tube
system;
Classic or variant Creutzfeldt-J akob disease (CJ D),
Diphtheria,
Hepatitis B or C,
HIV,
Paratyphoid,
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Rabies virus,
Tuberculosis,
Typhoid.
If Viral Hemorrhagic fever is suspected, the microbiologist must be
contacted before any specimens are taken or sent

7.14 Decontamination of equipment

Equipment that is used on several patients can be a potential source of infection if
not appropriately decontaminated after each use.

Selection of the appropriate decontamination method will ensure that the equipment
is clean and fit for purpose.

Cleaning is an essential stage in the decontamination process and must always
precede disinfection and /or sterilization. Check manufacturers instructions for use
of suitable cleaning agents.

The user of the device is responsible for ensuring that it is visibly clean and free
from contamination with blood/body fluids following each procedure and prior to re-
use or prior to sending for repair (internally/externally).
The user must sign and date the appropriate labels to confirm that cleaning has
taken place.
During decontamination, the user must check clinical equipment for signs of damage
and send for repair or disposal if appropriate.
A completed label must accompany each piece of equipment sent for repair.

Suitable personal protective equipment must be worn during decontamination
procedures to protect the healthcare worker from exposure to microorganisms or
infectious agents, where the risk of splash is anticipated.

Refer to Decontamination policy for detailed guidance of suitable methods of
decontamination

7.15 Last Offices

When carrying out the last offices the following should be implemented.

Wear PPE; gloves and apron
Remove all drains, catheters and intravenous lines except where a post mortem
is required.
Contain leakage from wounds and line sited by ensuring they are covered with a
waterproof dressing

After carrying out last offices a body bag must be used in the following
circumstances:

When a body is leaking body fluids or there is gross external contamination with
blood
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Staff must ensure that mortuary staff are aware of the reason for using a body
bag
When a patient has or is strongly suspected of having one of the following
biohazard conditions:
Anthrax
Classic or variant Creutzfeldt-J akob disease (CJ D)
Diphtheria
Hepatitis B, C
HIV
Meningococcal septicaemia / meningitis if death occurs before 48
hours of appropriate antibiotic therapy being completed
Rabies virus
Invasive -haemolytic Streptococcus Group A disease if death occurs
before 48 hours of appropriate antibiotic therapy being completed
Tuberculosis
Typhoid/ Paratyphoid
Viral Hemorrhagic fever
Any soiled patients clothing must be placed in a water soluble clothing bag
which must be secured and placed inside a property bag. Any itemised list of
contents must be attached.

If in doubt contact Infection Prevention Control - Bleep 7991


8. References

Department of Health. Saving Lives: reducing infection, delivering clean and safe
care. London: Department of Health. 2007

Department of Health. The Health Act 2008 Code of practice for the prevention and
control of healthcare associated infections. London: Department of Health. 2009.

Fraise, A and Bradley, Christine (eds) (2009) Alliffes Control of Healthcare
associated Infection. London, Hodder Arnold

Health & Safety Executive, Control of Substance Hazardous to Health (COSHH)
1999

National Audit Office. Reducing Healthcare Associated Infections in Hospitals in
England. London. The Stationary Office. 2009


Pratt et al (2007) Epic2 National Evidence Based Guidelines for Prevention
Healthcare Associated Infections, J ournal of Hospital Infection 65 supplement 1 Feb

Protective clothing Principles and Guidance. Infection Control Nurses Association
2002

WHO guidelines on hand hygiene in health care, 2009
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Appendix 1: Consultation Schedule


Name and Title of Individual Date Consulted
Dr E Abrishami - Consultant Microbiologist 29/03/2011
Infection Prevention Control Team 29/03/2011
Dr. Susan Murray Clinical Microbiologist 29/03/2011
Dr Sarah Meisner - Consultant Microbiologist 29/03/2011
Mr C Gallegos Divisional Chair Surgery, 29/03/2011
Dr W Hubbard Divisional Chair Medicine 29/03/2011
Francesca Thompson Director Infection
Prevention and Control
29/03/2011
J o Miller Assistant Director Infection
Prevention and Control
29/03/2011
Beverley Boyd Clinical Manager (Children) 29/03/2011
Mandy Rumble- Clinical Manager
(Emergency Department)
29/03/2011
Caroline Gillice - Matron 29/03/2011
Neil Boyland - Matron 29/03/2011
J an Lynn Head of Nursing, Surgery 29/03/2011
Heather Cooper Theatre Manager 29/03/2011
Mark Grover Respiratory Nurse Specialist 29/03/2011
Stephen Roberts Occupational Health
Manager
29/03/2011
Luke Champion Environment Manager 29/03/2011
Bronia Charity Stores Manager 29/03/2011




Name of Committee Date of Committee
Policy Working Group 22/03/2011
Operational Governance Committee 13/04/2011


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Appendix 2: Risk Assessment guide for selection of
protecti ve equipment based on risk of exposure to blood
or body fluid
















































Assess actual and potential risk of blood or
body fluid exposure in task being
undertaken

No blood/body
fluid contact
Potential
exposure to
blood/body fluid.
High risk of splash
Potential exposure to
blood/body fluid.
Low risk of splash patient
confirmed as infectious e.g.
Chicken pox, MRSA,
Clostridium difficile, TB
1. Gloves not required
2. Apron if clothing may be
exposed i.e. moving
patient or bed making
3. Eye protection and mask
not required
4. Wash hands before and
after contact
5. Dispose of linen in white
linen bag at bedside
6. Decontaminate
equipment between
patients
7. Dispose of waste
appropriately

1. Wear gloves
2. Wear apron as above
and if splash to clothing
likely
3. Wear mask/eye
protection if appropriate
4. Dispose of soiled linen
as infected i.e. red
alginate bag then red
plastic bag at bedside
5. Dispose of soiled waste
in orange clinical waste
bags
6. Decontaminate
equipment with
appropriate method
7. Wash hands after
contact and removal of
gloves

1. Wear gloves
2. Wear apron
3. Wash hands before and
after patient contact and on
removal of gloves
4. Wear mask if
appropriate
5. Wear eye protection if
appropriate
6. Dispose of soiled linen
as infected at bedside
7. Dispose of soiled waste
in orange clinical waste
bags
8. Decontaminate
equipment appropriately

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Appendix 3: Moments for hand hygiene

The RUH embraces the Five Moments for Hand Hygiene ( WHO 2009), aiming
to link specific hand hygiene actions to specific infectious outcomes in patients, by
giving clear advice on how to integrate hand hygiene into the complex task of care.

1. Before patient contact;
When? Clean your hands before touching a patient when approaching him/her.
Why? To protect the patient against harmful germs carried on your hands

2. Before a clean/aseptic procedure:
When? Clean your hands immediately before a clean/aseptic procedure.
Why? To protect the patient from harmful germs, including the patients own from
entering his/her body.

3. After body fluid exposure risk:
When? Clean your hands immediately after exposure risk to body fluids and after
glove removal.
Why? To protect yourself and the healthcare environment from harmful patient
germs.

4. After patient contact:
When? Clean your hands after touching a patient and his/her immediate
surroundings when leaving the patients side.
Why? To protect yourself and the healthcare environment from harmful patient
germs.

5. After contact with the patients surroundings:
When? Clean your hands after touching any object or furniture in the patients
immediate surroundings when leaving even if the patient has not been touched
Why? To protect yourself and the healthcare environment from harmful patient
germs.

















Document name: Universal/Standard Infection Control Precautions Ref.: 622
Issue date: April 2011 Status: Final
Page 19 of 22


Appendix 4: Guidance for the selection of masks


Type of mask Protection provided Indication for use
Standard Surgical mask Basic protection
No fluid repellence
General patient care &
isolation
Immuno-suppressed
patient
Short term use
Circulating theatre
staff
Surgical mask with fluid shield Direct fluid repellence
No eye protection
Surgical scrub team
During procedures
outside of the
operating theatre
where fluid exposure is
anticipated

Surgical mask with fluid shield and
integral visor
Fluid repellence
Eye protection
Surgical scrub team
A&E

High level protection PFR mask
conforming to EN149 (Sometimes
called Duck bill)

or FFP3 valved respirator mask
High standard
Filters 0.2 - .5 microns
Lasts up to 8 hours
Suitable for high risk
procedures
Staff require training to
ensure fit is correct
Tuberculosis - N95
recommended (see TB
policy)

SARS, Avian flu - FFP3
mask recommended

Document name: Universal/Standard Infection Control Precautions Ref.: 622
Issue date: April 2011 Status: Final
Page 20 of 22



Equality Impact Assessment Tool

To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval

Initial Screening
Policy, service, strategy, procedure or function: Policy
Lead (e.g. Director, Manager, Clinician): Yvonne Pritchard
Person responsible for the assessment:
Name: J acqueline Cosgrave
Job Title: Infection Prevention Control Nurse
Is this a new or existing policy, service strategy, procedure or function?
Existing
Who is the policy/service strategy, procedure or function aimed at?
Staff
Contractors
Are any of the following groups adversely affected by the policy?
If yes is this high, medium or low impact (see attached notes):
Group
Affected? Impact
Disabled people: No
Race, ethnicity & nationality No
Male/Female/transgender: No
Age, young or older people: No
Sexual orientation: No
Religion, belief and faith: No

If the answer is yes to any of these proceed to full assessment.
This applies whether the impact assessment is high, medium or low.

If the answer is no to all categories, the assessment is now complete
1. Does the policy, service strategy, procedure or function
include measures which promote equality?
No
2. If yes, what are these measures?








Document name: Universal/Standard Infection Control Precautions Ref.: 622
Issue date: April 2011 Status: Final
Page 21 of 22



Consultation Checklist

Author; attach this to each copy of the policy being sent to a meeting for comment.
Dear Chairman
Please would you disseminate this document for comment at your next meeting and return
any amendments/comments to:
Title of meeting:
Date of meeting:
Policy Title and Reference: Universal/Standard Infection Control Precautions
Name of author: J acqueline Cosgrave

Are there any elements of this policy which present
operational issues that require further discussion?
No
If yes, please provide a contact name for the author.
Does the document include a training plan? No / N/A
Does the document include relevant references? Yes
Are up to date National Guidelines included? Yes
If you are the appropriate forum, have the necessary
resources been agreed to implement this document?
N/A
Is there a plan for policy implementation? N/A
Does your meeting recommend further consultation with
groups or staff other than listed in the document?
No
Other comments from meeting.
What are the cost implications of implementing this document?
Equipment
N/A
Staffing (additional)
N/A
Training
N/A
Other
N/A
Are there any other department affected? N/A

Document endorsed without further comment? Yes
Further amendments to document suggested? No

Name of Chair:

Signature: ____________________________________ Date: __________________


Document name: Universal/Standard Infection Control Precautions Ref.: 622
Issue date: April 2011 Status: Final
Page 22 of 22



Ratification Check List

Author; attach this to each copy of the policy being sent to a meeting for comment.
Dear Chairman
Please would you disseminate this document for comment at your next meeting and return
any amendments/comments to:
Title of meeting: Operational Governance Meeting
Date of meeting:
Policy Title and Reference: Universal/Standard Infection Control Precautions
Name of author: J acqueline Cosgrave

Are there any elements of this policy which present
operational issues that require further discussion?
No
If yes, please provide a contact name for the author.
Is the policy referenced? Yes
Are up to date National Guidelines included? Yes
If you are the appropriate forum, have the necessary
resources been agreed to implement this document?
N/A
Is there a plan for policy implementation? No
Does your meeting recommend further consultation with
groups or staff other than listed at the front of the policy?
No
Is the policy referenced? Yes
What are the cost implications of implementing this document?
Equipment
N/A
Staffing (additional)
N/A
Training
N/A
Other
N/A

Document endorsed without further comment? Yes
Further amendments to document suggested? No

Name of Chair:

Signature: ____________________________________ Date: __________________