Infection Prevention and Control Policy No 1 Universal Precautions

Clinical Policy Document
Infection Prevention and Control
Policy No 1
Universal Precautions
For use in:
For use by:
Used for:
Document owner:
Board approved:
Policy indexed
Controlled Document No:
Status
All areas of the Trust
Staff with direct and indirect patient contact
i.e. via food/equipment
Infection Prevention and Control
Pauline Bradshaw
Infection Prevention and Control Lead
Halton and St Helens PCT Policy Readopted Feb
07 to be reviewed July 08
CLINP/LP/IC1
HSHPCT/CLINP/LP/IC/1
Clinical Policy
This policy is due for review: July 2008
After this date, policy and process documents may become invalid. Policy
users should ensure that they are consulting the current version of this
document.
Issue Date: Nov ‘04 Author: Pauline Bradshaw Version 1
Issue Date: Sept ‘06 Author: Pauline Bradshaw Version 2
Review Date July ‘08 Lead Director:: Fiona Johnstone

CONTENTS
1. Introduction 1
1.1 Status 1
1.2 Purpose 1
1.3 Scope 1
2. General Policy Statement 1
3. Components of Universal Precautions 2
3.1 Hand Decontamination 2
3.2 Personal Protective Equipment 2
3.2.1 Gloves 2
4. Needle and Sharp Instrument Safety 3
5. Environmental Cleaning and Disinfection 4
6. Blood Spills 4
7. Contaminated Medical Devices 4
8. Linen 4
9. Isolation Precautions 5
10. Waste 5
Further advice 6
References 7

1. Introduction
Universal or Standard Infection Control Precautions are based on the premise
that a health care recipients infectious status is unknown, and that contact
with blood, body fluids, broken skin and mucous membranes may pose a risk
of transmission of micro-organisms. All body fluids are therefore regarded as
potentially infectious.
1.1 Status
This is a Clinical Policy Document
1.2 Purpose
This policy contains measures to protect health care workers against infection
from blood, body fluids, broken skin and mucous membranes.
1.3 Scope
This policy applies to all staff (permanent and temporary) who come into
contact with blood, body fluids, broken skin or mucous membranes
2. General Policy Statement
All staff with direct/indirect patient contact must take appropriate precautions
to prevent person to person spread of infection. It is the responsibility of the
Primary Care Trust to ensure all staff have access to personal protective
clothing.
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3. Components of Universal Precautions
3.1 Hand Decontamination
Decontamination covers all the processes required to remove
pathogenic organisms that may be carried on the hands, i.e. washing
with liquid soap and water, use of alcohol rub/gel.
Hands should be decontaminated when visibly dirty, when they may
have become contaminated with micro-organisms and before and after
contact with a vulnerable patient or a susceptible site on a patient.
Alcohol hand rub gel may be used if hands are visibly clean. If hands
are visibly contaminated with dirt organic matter alcohol will be
ineffective and liquid soap and water must be used first. Build up of
residue from alcohol gels/rubs on the hands must be washed off
periodically, i.e. after every 3-4 applications as continued build up will
prevent alcohol penetration to the skin. (Please refer to Infection
Prevention and Control Policy No 2 Hand Decontamination for further
guidance).
Minor cuts and grazes should be covered by a waterproof dressing,
which is replaced if integrity becomes compromised.
3.2 Personal Protective Equipment
3.2.1 Gloves
Gloves should be worn whenever contact with blood/body fluids is
anticipated. In situations where the risk of contact with blood/blood
stained fluids is low, a vinyl non-sterile glove is usually appropriate.
Sterile/aseptic procedures require sterile gloves.
Where there is regular contact with blood/blood stained fluids, gloves
should conform to BSEN 455 parts 1, 2 and 3. A suitable alternative to
natural rubber latex should be chosen if possible, i.e. nitrile,
polychloroprene or vinyl (if complies with BSEN 455 parts 1, 2 and 3
glove manufacturer will advise).
During procedures where a degree of manual dexterity is required,
gloves should be chosen that fit comfortably and allow full range of
hand movements.
Hands must always be decontaminated after glove removal.
In addition to gloves wear a mask, protective eyewear and disposable
gown/apron during any patient care activity when splashes or sprays of
body fluids are likely.
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Wear a disposable plastic apron when there is a risk of staff clothing
becoming wet, when in close contact with the patient or with their linens
and when handling food. The usual colour coding for aprons is: white –
general patient care and aseptic procedures, blue – food handling and
green – minor surgery.
Immediately following use, disposable equipment such as gloves,
masks, gowns and aprons are disposed of as clinical waste. Nondisposable
items are cleaned and disinfected in accordance with the
manufacturers guidelines.
4 Needle and Sharp Instrument Safety
The user of needles and other sharp instruments are responsible for
their safe use and disposal. Do not recap needles. Do not pass
unprotected sharp instruments from person to person by hand.
Immediately following use, dispose of non-reusable needles, syringes
and other sharp patient-care instruments into puncture resistant
containers (sharps containers are required to be compliant to BS 7320
1990). Sharps containers are replaced when no more than ¾ full. In
surgical settings the disposal of needles and other sharps may not be
immediate due to the need to count needles and scalpel blades prior to
and after closure of the surgical site, in these instances needles and
blades should be placed on a discard pad and disposed of as one unit
into the sharps container.
Used hypodermic needles with syringes and other used sharp medical
instruments may at times be discarded in inappropriate areas. Great
care needs to be taken when retrieving these items for safe disposal,
personal protective clothing as described above is required to be worn,
hands should not come into direct contact with the sharp device, long
handled forceps, pliers or a dust pan and brush may be safely used to
place the item directly into a sharps container. The person who does
this task is required to have received training in Universal (Standard)
Precautions and will have been offered Hepatitis B immunisation. If
devices are found outside of Trust property on public or council land
then notify St Helens Cleansing Department Customer Services
(01744 456470).Halton Borough Council / regeneration neighbourhood
Services 0151 907 8300.
If injury occurs from a needle/sharp instrument, follow immediate first
aid action:-
• Encourage to bleed, wash with soap and water
• Apply water proof plaster dressing
• Follow further guidance in Infection Prevention and Control
Policy No 6. Management of occupational exposure to blood
borne viruses and post exposure prophylaxis.

5. Environmental Cleaning and Disinfection
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In clinic settings surfaces, including patient care equipment and
furniture, are routinely cleaned using detergent and water. Items
contaminated with blood or body fluids are first cleaned and rinsed and
then disinfected using a 10,000 parts per million available chlorine
releasing agent. The same procedure is used for general disinfection
except 1,000 parts per million available chlorine releasing agent is
used.
6. Blood Spills
Spills of blood or of body fluids stained with blood are dealt with
immediately. A member of staff wears the appropriate level of personal
protective equipment, and then sprinkles the spill with NaDCC (Sodium
Dichloroisocyanurate) granules. This compound absorbs the spill and
deactivates any micro-organisms, the resulting material is then
disposed of in a clinical waste bag and the site is cleaned using
detergent and water. Care must be taken when using the granules that
there is sufficient ventilation. Granules should not be used on
chemicals or mixed with other cleaners.
If NaDCC granules are not available, i.e. in a patients home, the spill
should be absorbed using paper/kitchen towels and the site cleaned
and disinfected. Personal protective equipment should be worn and
waste disposed of in a clinical waste bag. In the home environment
care needs to be taken that cleaning agents are not damaging to
furnishings.
7. Contaminated Medical Devices
Contaminated reusable medical devices are not reused on another
patient until decontaminated, and the appropriate level of disinfection
and/or sterilisation has occurred. Used and unused devices are stored
separately in locations/containers that minimise the risk of injury and
cross infection. Single use devices are appropriately disposed of
immediately after use.
8. Linen
Linen contaminated with blood or body fluids should be placed inside a
red plastic water-soluble bag, and then securely tied before placing
inside a red fabric bag. The outer bag is then securely fastened,
labelled with the contents and the name and address of the facility, and
then left in the designated area for transport to the laundry.
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Care must be taken not to overfill either the inner or outer bags. Avoid
direct contact with items soiled with blood and body fluids by using the
appropriate level of personal protective equipment. As far as possible
disposable linen should be used
9. Isolation Precautions
In a clinic setting patients who are unable to control their body
substances due to diarrhoea, bleeding, urinary incontinence, vomiting,
draining lesions, or uncontrollable or severe coughing, need to be
withdrawn from the public waiting area and placed in an examination
room. Isolation is not required if urinary incontinence is controlled by
effective incontinence aids, or if wounds or lesions are covered with an
intact dressing that is not soaked through.
10. Waste
All waste contaminated with blood or body fluids should be discarded
into yellow plastic bags for incineration. The top of the bag is securely
tied and care is taken to ensure that no fluid leaks from the bag. If
there is a risk of leakage place inside a second yellow bag or in a more
rigid clinical waste receptacle. Please follow Interim Infection Control
Policy No.8 Safe Disposal of Clinical Waste

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For further advice contact:
Pauline Bradshaw
Infection Prevention and Control Lead
Halton and St Helens Primary Care Trust
Tel No: 01744 674001
Mob No: 07917 001742
e.mail: pauline.bradshaw@hsthpct.nhs.uk
Jeanette Owens
Infection Prevention and Control Nurse
Halton and St Helens Primary Care Trust
Tel No: 01744 611501
Mob No: 07917 00 1729
e.mail: jeanette.owens@hsth.nhs.uk
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References
Advisory Committee on Dangerous Pathogens. (1995) Categorisation of
Pathogens According to Hazard and Categories of containment. Fourth
Edition London: HMSO.
Advisory Committee on Dangerous Pathogens. (1990) HIV – The
Causative Agent of AIDS and Related Conditions. Second Revision of
Guidelines (
Advisory Committee on Dangerous Pathogens. (1990) Protection against
blood-borne infections in the workplace: HIV and Hepatitis. HMSO
British Medical Association (BMA). (1990)
use and Disposal of Sharps. BMA. June
A Code of Practice for the Safe
Department of Health (DOH). (1993) Decontamination of equipment,
linen or other surfaces contaminated with Hepatitis B and/or HIV. HC
(91) 33.
Department of Health (DOH). (1995)
used and infected linen for HSG 18.
Hospital laundry arrangements
Department of Health (DOH). (1998) Guidance for Clinical Health Care
Workers. Protection against infection with Blood Borne Viruses. UK
Health Departments. HSC 063
Garner, J S, Hospital Infection Control Practices Advisory Committee(1996)
Guideline for Isolation Precautions In Hospitals, Centers for Disease
Control and Prevention, Public Health Service, US Department of Health and
Human Services, Atlanta, Georgia.
Health Services Advisory Committee (HSAC) (1990)
Clinical Waste HSAC HMSO.
. Safe Disposal of
ICNA (2002) Protective Clothing (Principles and Guidance).
RCN (2000) Universal Precautions for the Control of Infection.
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