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Last Updated Aug 2019

Clinical Staff

Annually

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Please email your answers to Infection.prevention@anhst.nhs.uk

You must score 8 correct answers to update your mandatory

training.

If you fail to achieve this, you will be asked to attend the

Infection Prevention Level 2 face to face session offered twice

a month in the lecture theatre.

Infection Prevention Level 2

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More serious illness

Prolonged stay in a health care facility

Long-term disability

Excess deaths

High additional financial burden

High personal cost on patients and their families

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Introduction

Good infection control is essential to ensure that people who use Health and Social

Care Services receive safe and effective care. Effective prevention and control of

infection must be part of everyday practice and be applied consistently by

everyone.

Good management and organisational processes are crucial to make sure that high

standards of infection prevention and control are set up and maintained.

As the regulator of Health and Adult Social Care in England, the Care Quality

Commission (CQC) will provide assurance that the care people receive meets

essential levels of quality and safety.

The Health and Social Care Act outlines what hospitals in England need to do to

ensure compliance with the registration requirement for cleanliness and infection

control, and sets out 10 compliance criteria.

1. Systems to manage and monitor the prevention and control of infection.

These systems use risk assessments and consider how susceptible patients

are and any risks that their environment and other patients may pose to them.

2. Provide and maintain a clean and appropriate environment in managed

premises that facilitate good hygiene practices.

3. Provide suitable and accurate information on infections to patients and their

visitors.

4. Provide suitable accurate information on infections to any person concerned

with providing further support or nursing/medical care in a timely fashion.

5. Ensure that people who have/develop an infection are identified promptly and

receive the appropriate treatment and care to reduce the risk of passing on

the infection to other people.

6. Ensure that all staff and those employed to provide care in all settings are fully

involved in the process of preventing and controlling infection.

7. Provide or secure adequate isolation facilities.

8. Secure adequate access to laboratory support as appropriate.

9. Have and adhere to policies designed for the individual’s care and provider

organisations that will help to prevent and control infections.

10. Ensure, so far as reasonably practicable, that care workers are free of and are

protected from exposure to infections that can be caught at work and that all

staff are suitably educated in the prevention and control of infection

associated with the provision of health and social care.

The Health and Social Act 2008

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Infection Prevention

The term HCAI (Health Care Associated Infection) covers a wide range of infections.

The most well-known include those caused by methicillin resistant Staphylococcus

aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Clostridium

difficile (C.diff) and Escherichia coli (E.coli).

HCAIs cover any infection contracted:

as a direct result of treatment in, or contact with, a health or social care setting

as a direct result of healthcare delivery in the community

as a result of an infection originally acquired outside a healthcare setting (for

example, in the community) and brought into a healthcare setting by patients,

staff or visitors and transmitted to others within that setting (for example,

Norovirus).

Infection prevention and control is a key priority for the NHS, and Public Health

England (PHE) has a responsibility to advise and support the NHS and others in their

efforts to prevent HCAIs and any associated risks to health.

In 2011 and 2016, Airedale hospital took part in the Europe wide point prevalence

survey of hospital acquired infection. Our HCAI rate has dropped from 6.8% to 5.5%

which is excellent news and which shows that staff are ‘adhering to policies,

designed for the individual’s care and provider organisations that will help to

prevent and control infections.’ (Criteria 9)

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Staphylococcus Aureus

Gram positive skin organism

Methicillin (Flucloxacillin) sensitive staphylococcus aureus (MSSA)

All bloodstream infections reported to PHE. Post infection review for hospital

acquired cases.

Can cause minor skin infections:

(pimples,

impetigo,

boils,

cellulitis,

folliculitis,

abscesses

Can cause life-threatening diseases:

pneumonia

meningitis

osteomyelitis

endocarditis

bacteraemia

Orthopaedic joint infections

Can produce Toxins

Key themes seen:

Staph aureus blood stream infections

Source: unobserved cannulae becoming infected.

Prevention

Good hand hygiene of staff members and patients.

Encourage patients not to touch invasive devices

Check cannulas twice a day for signs of infection

Encouraging patients to wash or shower every day

Ensuring wounds are clean and covered

Wear aprons for changing bed linen

Don’t sit on beds

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Staphylococcus Aureus

Staphylococcus aureus (S. aureus) is a Gram positive bacterium that commonly

colonises human skin and is carried in the nose, throat, axillae, toe webs and

perineum without causing infection. Once the bacteria gains access to the body, for

example through a cannula site or a surgical procedure, a mild to life-threatening

infection may develop. S. aureus, (whether MSSA or MRSA) is one of the most

common culprits associated with orthopaedic implant infections. Patients with an

Orthopaedic joint, with a S. aureus bacteraemia may go on to develop an implant

infection in around 34% of cases. (Clinical services Journal 2010)

S. aureus can produce toxins which can cause:

Scalded skin syndrome which attacks skin cells, causing them to split causing

large red weeping areas. Paediatrics patients and neonates are more at risk.

Toxic shock syndrome causing hypotension, fever, diarrhoea, skin shedding rash.

Enterotoxin causes acute sudden onset gastroenteritis, when food is contaminated

with S. Aureus, by interfering with electrolyte imbalance in the gut.

Panton-Valentine Leukocidin (PVL) is a toxin that destroys white blood cells and

causes extensive tissue necrosis and severe infection. It is carried by < 2% of

isolates of S. aureus, (See Management of PVL associated Staphylococcus aureus

infections (PVL-SA) Guideline on Aireshare)

Preventing the spread of infection

Therefore good hand hygiene of both staff members and patients is needed to

prevent transferring the germ around the ward/ hospital.

Staff should wear clean clothes or uniforms daily.

Staff should wear an apron for changing bed linen to prevent skin cells

getting on their uniform and should dispose of used linen straight into a linen

skip at the bed side, to prevent skin cells from becoming airborne. Hand gel

should be applied between beds.

Staff should cover any cuts or abrasion with waterproof plasters to prevent

themselves from getting wound infections from germs found in the hospital

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environment. (Contamination injury)

Staff and visitors should not sit on patients beds to prevent the transfer of

organisms to or from the patient.

Methicillin (Flucloxacillin) resistant

Staphylococcus Aureus (MRSA)

Rising numbers of mupirocin resistance

Screening Programme (Acute and some elective patients)

Management of cases/expectations

All bloodstream infections reported to PHE

Post infections reported to PHE

Post infection review for Hospital Acquired Cases

Staphylococcus aureus that are resistant to Flucloxacillin are called MRSA as

Methicillin was the previous antibiotic used before Flucloxacillin came on the market.

MRSA can vary in resistance to other antibiotics. Our bacteraemia (or blood stream

infection) target is Zero MRSA Blood stream infections.

Screening Programme

All acute admissions to hospital get screened for MRSA and some elective

patients. This is due to a DoH study that found that only 1% of elective admissions

were MRSA colonised. The exceptions are patients coming for elective orthopaedic

operations, pacemaker insertion and breast reconstruction surgery as the surgery is

considered a high risk of infection.

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Mupirocin resistant

Since January 2017 we have seen a large increase in Mupirocin (Bactroban)

resistant MRSAs. This is partly due to the germ becoming more resistant and the lab

using more sensitive testing equipment that picks up more cases than we would

through the agar plate method that was previously used. When the germ is resistant

to Mupirocin (Bactroban) we have a second line treatment that should be used.

Management of cases/expectations

If a patient is found to be colonised from a nasal screen or infected from a

swab/sample, they should be isolated (gold standard) or nursed in a bay with other

low risk patients who have no wounds, catheters or cannulas. The patient is

prescribed 5 days of nasal antibiotic cream and 5 days of antiseptic body wash

which supresses the MRSA present on the skin and allows healthy skin flora to take

its place.

(NB: Naseptin (used for pregnant mums) nasal cream is a 10day course.)

The MRSA patient information leaflet explains how to correctly apply the

suppression. Medical staff will decide treatment of any positive swab (e.g. wound) or

sample (e.g. urine) with the microbiologist. The MRSA carepathway (Infection

prevention Aireshare page) informs you of all the necessary actions that are needed

to prevent further spread of infection whilst caring for the patient.

Post Infection Reviews

Any MRSA blood stream infection will have a post infection review (PIR), where

nursing and medical staff meet to look at how the patient got the infection, whether it

was preventable or unpreventable and lessons learned.

MRSA Alert symbol!

The yellow IC triangle symbol above the patients name on the SystmOne ward board

identifies that the patient as having a history of MRSA colonisation or infection. For

more information, see MRSA Management Guideline’ on AireShare.

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MRSA Screening

Patient groups to be screened:

All adult general acute admissions

Patients admitted to/attending high risk areas as per individual departmental

protocols

Elective orthopaedic, pacemaker insertion and breast implant patients at pre-

assessment.

MRSA colonistion suppression to be started on:

Patients found to be MRSA positive on

screening

All patients admitted from a

nursing/residential home

All acute orthopeadic patients on admission if

over 65 years of age

Please remember to screen any invasive device that the patient has

insitu on admission for MRSA, aswell as their nasal screen. MRSA

may be colonising these sites (as it is a skin organism) but may

precede to cause an infection if staff are not aware.

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Winning the Battle Against MRSA

Invasive devices can be an entry point

for infection.

Preventing a Catheter associated urine infection

Urinary catheters bypass the body’s natural defence of the flushing action of urine.

They are frequently responsible for hospital acquired urinary tract infections and are the most common source of bloodstream infections here at Airedale.

Germs can enter the urinary tract due either to poor aseptic technique on insertion, as a result of contamination by staff members’ hands during handling of the device, poor personal hygiene of the patient, lack of post insertion

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catheter care or simply the catheter bag touching the floor thus allowing germs access to the device.

Please ensure that the Urinary Catheter

Monitoring Bundle is correctly filled in

daily. It also conatins

Monitoring peripheral cannulae/central lines

for signs of infection

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Peripheral Vascular Catheter (PVC)

Infection

There are four possible pathways leading to peripheral vascular catheter (PVC)

infection.

First: Migration of microbes down the catheter tract i.e. through the ‘wound’

created to insert the catheter. These microbes may be from the patient’s skin, or

contaminated disinfection or the healthcare worker’s hands. The process may

happen on insertion if the catheter is contaminated and then introduced into the

patient or via microbiologic migration at any time while the catheter is in situ. The

insertion of a PVC provides a portal or entry for bacteria to cross from an unsterile

external environment to the normally sterile blood.

Second: The second route is via the catheter hub, which can become

contaminated by healthcare workers’ or patients’ skin flora during connection of

fluids, medicine administration or during extraction of blood. Nishikawa reported that

bacterial contamination was more common in the hub area than indwelling catheter

segments, and the hub seems an important risk in post-insertion care, in addition

to adequate aseptic technique on catheter insertion (Nishikawa et al, 2010; Zingg

and Pittet, 2009)

Third: The third route is for catheters to be contaminated directly by bacteria

circulating in the bloodstream. That is, the patient has an existing bloodstream

infection and microbes are able to attach to the catheter as they pass by the device.

Fourth: The fourth is that of contaminated infusate which may occur at the

manufacturing stage (intrinsic) or during manipulation by healthcare workers

(extrinsic). Research confirms that infusates other than water, including heparin,

have great potential to form crystals in the intraluminal surface of PVCs, which can

induce bacterial attachment and colonisation. (Nishikawa et al, 2010).

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A microbial attachment on the PVC surface is likely to be followed by biofilm

development and maturation and dispersion of microbial cells from the biofilm into

blood stream. The most frequently isolated bacteria from PVCs are coagulase-

negative staphylococci and staphylococcus aureus. These bacteria can originate

from the skin flora of the patient or the hands of healthcare workers and then reach

the patient’s tissues and organs via the blood, causing serious infections and

high mortality rates. Thus the infectious route for these organisms is likely skin-

bloodstream; i.e. the bacteria enter the bloodstream through PVC wounds in the skin

and cause subsequent infection in other organs.

The next most common pathogens for PVC related infections are Gram-negative

bacilli such as E. coli. These microorganisms are generally acquired from the

hospital environment. (Infection risks associated with Peripheral vascular catheters,

Zhang et al 1016)

Ensure the point of insertion is visible under the dressing

allowing staff to check for sign of phlebitis. Ensure that the

dressing is dated with the insertion date and the Visual Infusion

Phlebitis (VIP) score and cannula care plan is completed with

the name of the person who inserted the cannula. Observations

of the cannula site should take place twice a day. If any signs of

phlebitis are observed, then the guide below should be followed.

Please ensure that AFFs are completed for any phlebitis that

scores 2 or above.

The new VIP chart for 2018 has an

observation panel on the back. This is

so that staff can monitor any areas of

phlebitis post cannula removal.

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Phlebitis Score

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Clostridium difficile (C.diff)

Often C.diff patients present with confusion, dehydration, acute kidney injury (AKI)

due to profuse diarrhoea and possibly even a fall due to dizziness. A stool sample

should be sent to rule out colitis caused by C.diff in these patients.

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C.diff is an anaerobic germ which means it thrives in the gut where no oxygen is

present but dies when exposed to oxygen. It overcomes this by being able to form a

spore, where it wraps itself in a protective layer and lies dormant in the environment,

waiting to be picked up on hands and ingested (eaten!). Getting patients to:

Wash their hands with soap and water after opening their bowels will

remove any C.diff spores present, thus preventing them from being left in the

environment.

Wash their hands before eating will prevent them from ingesting any

spores picked up from the environment

Communicating with Ward Domestics or Ward Supervisor (x4102)

Communicate to the Ward Domestics or Ward Supervisor:

if a patient has been using the communal toilets on the ward

whilst having diarrhoea so that the toilets can be cleaned with

Tristel fuse and spores removed from the environment

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which side rooms contain infected patients so that they can be cleaned twice

daily with Tristel fuse.

Infection prevention- It is important to physically separate the symptomatic

patient from other vulnerable patients in order to prevent the spread of Clostridium

difficile. They should remain isolated in a single room until 48 hours free of

symptoms. Please see the Clostridium Management Guideline for advice on

treatment options or speak to the Microbiologist. The patient’s side room should

ideally have its own toilet and the side room door should remain closed where

possible, due to airborne dispersal of spores. The side room should be cleaned

twice a day with Tristel fuse and the commode should be cleaned after each

use. Allocate where possible specific equipment for the infected patient e.g.

moving and handling slings, wash bowl, single patient use blood pressure cuff and

tourniquet. These must be decontaminated after use.

Contact precautions- Non-sterile disposable gloves and plastic aprons should be

put on outside the patient’s room and worn when in contact with the patient, with any

body fluids or their environment. Before leaving the sideroom, gloves should be

removed first (without contaminating your hands); then your apron (breaking the neck

strap first and then your hands must be thoroughly washed with warm water and

liquid soap and dried with paper towels. Hygienic hand rub must not be used as an

alternative as this has no effect on Clostridium difficile spores.

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Winning the Battle against C.difficile

Please ensure all staff know

that commodes should only

be cleaned with Tristel Fuse.

This is the only solution that

kills C.difficile.

Detergent wipes should

NEVER be used or even

stored in the sluice.

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The Challenge to Reduce Gram

Negative Infections

The previous Secretary of State for Health launched an

ambitious challenge to reduce healthcare associated Gram-

negative (E.coli, Klebsiella and pseudomonas) bloodstream

infection by 50% by 2021. Gram-negative bloodstream infection

is believed to have contributed to approximately 5,500 NHS

patient deaths in 2015.

Enterobacteriaceae are a large family of Gram-negative bacteria

that includes many of the more familiar pathogens (germs that

cause disease), such as Salmonella, Escherichia coli (or E. coli),

Yersinia pestis (causes plague), Klebsiella and Shigella, Proteus,

Enterobacter, Serratia, and Citrobacter. E. coli is a part of all human and animal gut

flora and can be picked up from animals, other humans or through the food chain in

uncooked food.

,

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Ingesting E.coli causes no symptoms (unless the germ produces a toxin as in E.coli

157) as the body does not recognise E.coli as a pathogen. Gut flora are readily

shared among family members, in prisons, hospitals, music festivals, anywhere

where hand hygiene is poor and the environment is contaminated with these germs.

Trying to achieve this target set by the Secretary of State for Health is likely to be a

far harder challenge than previous targets to reduce MRSA blood stream

infections (BSI) and C. difficile, and the evidence base around which to develop

preventive strategies is presently rather thin. Also, there are no accepted

decolonization treatments for people colonized with Gram-negative bacteria.

Consequently, the infection control strategies that have been successful in

preventing MRSA BSI cannot be expected to work for blood stream infections

caused by Gram-negative bacteria. Several guidelines have been published on the

prevention and control of multidrug-resistant Gram-negative bacteria; however, there

are no guidelines that consider the prevention and control of blood stream infections

caused by non-resistant Gram-negative bacteria within healthcare settings. (Journal

of Hospital Infection, March 2018).

E.coli bacteraemia or blood stream

infections

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Sources of E.coli bloodstream infections

A total of 40,580 cases of E. coli bacteraemia

were reported by NHS trusts in England between

1 April 2016 and 31 March 2017. These have

been rising year by year; since the year 2000 but

numbers of hospital acquired cases (48hrs after

admission) have stayed consistent each year at

between 20-23%. The majority of cases are

community acquired, found in elderly people and

occurred primarily through a urinary tract infection

that likely originated from their own bowel flora.

A sentinel surveillance study in England

looking at risk factors associated with E. coli

Bacteraemia found that approximately half of

the community-onset cases has some sort of

healthcare intervention in the four weeks prior

to the bacteraemia onset.

2016/2017 AGH had 132 E.coli bacteraemia; 15 cases were hospital acquired. It is the above 20-23% of hospital acquired cases that we need to reduce.

So how can we do this?

Ensure our patients drink plenty of fluid to aid the natural flushing effect of urine washing bacteria out of the bladder. Dehydrated patients are more prone to urinary tract infections.

Ensure that incontinent patients with pads are checked regularly and are thoroughly cleaned after each episode of incontinence.

Advise patients not to touch their line dressings or urinary catheters unless

their hands are clean and they have been shown what to do.

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Criteria for Urine Specimens (Midstream and Catheter) in

Suspected Urinary Tract Infections (UTI)

Preventing Urinary Catheter associated Urinary

Tract Infection

Key recommendations

Patient self-care: Wherever possible the patient must be taught to care for their

own urinary catheter. This will help to prevent the risk of infection and will give the

patient autonomy. When performing catheter care the nurse must always wear

gloves (non- sterile) and wear a disposable apron.

All urinary catheters should be secured to the patient’s leg by a retaining strap;

this is to prevent the catheter from sliding up and down the urethra. This could lead

to trauma of the urethra, bladder neck and glans of the penis. It also prevents

accidental disconnection or removal.

Cleaning the catheter: Using soap and water to clean the catheter is sufficient. This

can be done in the shower or bath. Daily bathing should be encouraged (Pratt et al

(2001). A disposable wipe can be used to clean the catheter, away from the urethra.

Talcum powder or antiperspirants/perfumes are not to be used around the catheter.

The glans of the penis can be cleaned using a disposable wipe with soap and water.

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The foreskin, retracted for cleaning, must be replaced to prevent a paraphimosis.

Make sure the male patients are aware of this so that they can prevent this from

happening.

Infection prevention: A ‘closed system’ is where the catheter stays attached to the

leg bag/ valve. The only time the system is broken is when the leg bag/ valve is

changed (every 7 days). Attaching a night bag does not break the system.

Maintaining a sterile, continuously closed system is essential to the prevention of

catheter associated infection. Modern closed systems have significantly reduced the

incidence of bacteraemia. Breaches in the closed system, such as unnecessary

emptying of the urinary drainage bag or taking a urine sample, will increase the

risk of catheter related infection and should be kept to a minimum (Pellowe 2005).

The bag should be emptied before it is three quarters full.

Catheter bags must not be allowed to touch the floor.

They should be secured to the patient’s leg or set on a

specifically designed catheter stand. Bacteria can travel

up the catheter system and enter the body causing

infection. The drainage bag must be kept below the level

of the patient’s bladder at all times, (or emptied before a

procedure i.e. turning or physiotherapy). It is essential to always wear

gloves/apron and wash hands before and after contact with the catheter bag as it is

likely to be contaminated with germs from the urine itself.

Multi-Resistant Enterobacteriaceae (E.coli

Klebsiella and Pseudomonas)

40, 580 cases of E.coli bacteraemia

Often multi-resistant through ESBL enzyme production Now becoming resistant to Carbapenems (Meropenem)

There are a number of different ways that germs can be resistant. One of these

ways is by producing an enzyme called a beta-lactamase that breaks down the

beta-lactam antibiotic family, making it ineffective.

The green IC triangle symbol above the patients name on the SystmOne ward board

identifies that the patient as having a history of ESBL colonisation or infection. For

more information, see Multi-resistant Organism Management Guideline’ on

Aireshare.

IC

ESBLs

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In 1980, the 3rd generation cephalosporin antibiotic family were introduced

(Cefotaxime is one of them) as they had an ‘extended

spectrum of activity’ or greater ability to destroy

resistant gram negative bacteria. By 1985, bacteria were

found to be producing a beta-lactamase enzyme that was

resistant to this new antibiotic family. They were then

named ‘Extended Spectrum Beta-Lactamases’ or

ESBLs.

ESBL producing E.coli, Klebsiella are commonly seen in

urinary tract infections but can cause a variety of other

infections. The source of the infection is mainly from the

patient’s own gut flora when it is transferred accidently to other parts of their body,

such as the bladder. These resistant germs get in the gut either through the food

chain or being picked up on hands from the contaminated environment and then

eating with unwashed hands.

In those countries with level 3 treatment of sewage, such as the UK, sewage

treatment removes E. coli from drinking water (see Yorkshire water website) but

a recent study from the Midlands has shown that significant numbers of ESBL

producing E. coli in treated effluent are discharged into water courses, where they

may then be acquired by people during recreational activity in what appears to be a

perfectly clean river, and also by livestock, which may explain the acquisition by dairy

herds of ESBL gene CTX-M 14 and 15, the two most prevalent types in humans.

( Multidrug-resistant Gram-negative bacteria: a product of globalization:Journal of

Hospital Infection 2015).

Gaze and colleagues measured the presence of third-generation cephalosporin-

resistant (ESBL) E. coli in seawater surrounding England and Wales. 11 of 97

sea water samples were found to contain CTX-M ESBL E. coli. While the

percentage of ESBL E. coli in bathing waters was low, water users are at risk of

ingesting these antibiotic resistant bacteria. (Healio infectious disease, March 31 2015).

The Institute of Soil, Water and Environmental Sciences in Israel, performed a

study where E. coli were added into the hydroponic growing medium of maize

plants and 48hrs later detected E.coli in the shoot of the plant. This is the first

study to demonstrate internalization of E. coli via the root in monocotyledonous

plants.

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A study by the London school of Hygiene & Tropical Medicine in 2011, found that 1

in 6 mobile phones grew E.coli from the unwashed hands of their users.

A number of studies have found that these resistant germs may spread extensively

amongst family members in the home. (The British Infection Society 2010.) We have seen this in Airedale, where we tested a family (with their permission) of a

5 month old child with a history of multiple ESBL UTI infections. We found that the

whole family were gut colonised with the same resistant E.coli. Likewise a study

by Rooney et al. (2009) found that nursing homes can act as a reservoir of ESBL E.

coli. So how do we look after these patients?

Winning the Battle against Resistant

Enterobacteriacea isolation?

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Continent of urine or faeces? - Continent patients pose little risk of infection as the

germs pass down the toilet and if good hand hygiene is performed, germs are not

carried on the hands.

Incontinent patients pose a risk of infection as the germ can spread into the

environment or onto staff members’ hands, thus the need for isolation.

Colonised or Infected?- As we learned earlier, germs can colonise the bladder of

elderly patients and cause asymptomatic bacteriuria, therefore staff must observe

for clinical symptoms of infection rather than just relying on the MSU result.

Catheterised patients can have resistant bacteria living in the residual volume of

urine that remains in the bladder or even in biofilms in the catheter itself.

Hand hygiene– needed by both the patient and staff members is important to

prevent carrying the germ on their hands and potentially transferring it on to others.

Patient education- Informing and educating patients puts them at the centre of

their care.

Cleaning contaminated equipment- Any equipment used by the patient must

be cleaned effectively with Tristel fuse and allowed to dry before use by

another patient to prevent onward transmission of the germ. Use the ’I am clean’

labels to assure others you’ve cleaned it.

Cleaning contaminated environment– A research study recovered ESBL

producing bacteria in the plug-holes of hospital hand wash sinks (also where

pseudomonas is found), around the sinks themselves and on toilet floors. The

predominant germs recovered were Klebsiella which have the ability to survive in the

environment by producing a biofilm whereas E. coli cannot. ‘ESBL-producing Gram

negative organisms in the health care environment’ Journal of Hospital infection

2016 If incontinence care is performed by staff and the water from the wash bowl is

poured down the hand wash sink, it contaminates the sink and the plughole.

Also the wash- bowl itself will need cleaning and be allowed to dry upside down

before storing.

To ensure all interventions are in place to prevent further spread of infection,

please follow the Multi- resistant Organism Care pathway that can be found on the

Infection prevention Aireshare page or in the Multi-resistant Organism

guideline.

IC

ESBLs

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Carbapenemase Producing Enterobacteriaceae

(CPE)

Thanksfully, we have always been able to treat serious (ESBL) infections with an

antibiotic called Meropenem (one of the Carbapenem family) which is our ‘last line

of defence’ when it comes to antibiotics. Gram negatice bacteria have now been

found to produce an enzyme or carbaoenemase that also breaks down Meropenem,

making it resistant (in some cases to all, or nearly all) antibiotics. A number of

countries across Europe have seen large numbes of these infections (Greece

being the highest).

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To identify these patients, the question above has been added to the Triage

questions in Emergency Departments (EDs) and in the admission documentation

at ‘door ways’ to the hospital.

London and Mancester hospitals have had outbreaks with these resistant germs.

Patients that are identified are isolated and are required to have 3 negative stool

samples for CPE before they can be nursed on the open bay. Patients that have a

history of CPE have this symbol above their name on the ward board.

The orange IC triangle symbol above the patients name on the SystmOne

ward board identifies that the patient as having a history of CPE

colonisation or infection. For more information, see Multi-resistant

Organism Management Guideline’ on Aireshare

Suspected CPE Risk

Early isolation and detection

Isolate in a single room (ensuite if possible) and reinforce strict isolation

standard precautions

Screening is either 3x rectal swabs or faeces samples on alternate days.

If all 3 screens are negative – discontinue

If any screens positive – continue for duration of stay

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Pseudomonas Aeruginosa Risks

Often multi-resistant to a number of antibiotics

Common cause of urinary tract infections/pneumonia

Often associated with contaminated water and live in moist environments

around the sink

CPE producing P.Aeruginosa was isolated in a sink drain. Patients closest to

the sink were infected with the same germ. Water

flowing directly into the plug hole may have caused

aerosols across the ward. (Aspeland et al).

Hand wash sinks should not be used for anything

other than hand washing!

Safe water in healthcare premsises – DOH

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Antimicrobial Guidance

Antimicrobial use (AMU) is a key driver of animicrobial resistance (AMR);

understanding the indications, dose used and adherence to guidelines is

important in reducing anitbiotic consumption.

Antimicrobials: a Balancing Act

Antibiotic use is a balancing act of risks and

benefits

Use the Start smart:Then focus guide (below)

The right drug, according to local guidance

Within an hour of presentation for IVs

Then focused to the safest, most appropriate choice

Every use of an antibiotic risks increasing resistance rates

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Infective dose: As little as 10 to 100 virions are required to infect a

host

One single episode of vomiting may generate 300,000 to 3 milliion

infectious doses

Environmental swabbing has shown contamination of common

touch surfaces such as door handles, soap dispensers, patient

equipment, toilet seats and telephone.

Tristel fuse is recommended for environmental decontamination.

Ring Infection Prevention Immediately

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Standard Precautions

Hand hygiene

Maintain skin integrity

Personal Protective Equipment (PPE)

Blood/body substance spillage

Sharps safety

Safe handling of clinical waste

Decontamination of equipment

Decontamination of environment

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Hand Hygiene

It is important to recognise that the hands of

health care staff will always carry bacteria, be

it their own bacteria or those that have

attached as a result of acitivities (e.g.

handling equipment, touching surfaces or

patients). Remember, the greatest concentration of micro organisms are found

beneath your finger nails.

Although it is not possible to sterilise your hands, the number of bacteria present can

be reduced significantly through good hand hygience practice.

Situations that pose the greatest risks include, but are not limited to:

Before patient contact

Before contact with a susceptible patient site (such as an invasive device or

wound)

Before an aseptic task

After exposure to body fluids (blood, vomit, faeces, urine and so on)

After glove removal

After patient contact

After contact with the patient’s immediate environment.

To support compliance with hand hygience in the workplace, health

care workers should meet the following standards while working:

Keep nails short, clean and polish free

Avoid wearing wrist watches and jewellry

Avoid wearing rings with ridges or stones. (A plain wedding

band is acceptable)

Do not wear artifical nails or nail extensions

Cover any cuts and abrasions with a waterproof dressing

Wear short sleeves or roll up sleeves prior to hand hygience

Report any skin conditions affecting hands (for example, psoriasis or

dermatities) to Employee Health and Wellbeing for advice.

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Intact Skin Protects You

Wet hands transfer micro-organisms more effectively than dry ones, and inadequately dried hands can also be prone to developing skin damage.

Disposable paper hand towels should be used to ensure hands are dried thoroughly. Fabric towels are not suitable for use in health care facilities as these quickly become contaminated with micro-organisms.

Applying liquid soap directly to dry hands can irritate and dry out the skin making it painful to wash Therefore, always wet hands first.

Using moisturiser as you start work, before breaks and as you leave will protect and maintain the skin integrity.

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Personal Protective Equipmement (PPE)

A selection of PPE must be based on an assessment of the risk of transmission of

micro-organisms to the patient or carer, and the risk of contamination of the

healthcare practitioner’s clothing and skin by the patient’s blood, secretions or

excretion. The risk assessment should include:

Who is at risk

Whether sterile or non sterile gloves should be worn

Exposure to blood or body fluids

Contact with non-intact skin or mucus membranes

Exposure to hazadous substances.

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Personal Protective Equipmement (PPE)

Aprons: Disposable plastic aprons must be worn

when it is likely that body substance will soil

clothing. Plastic aprons must be worn during all

close patient contact including bed making.

Plastic aprons afford more protection to

uniforms/own cloths than cloth gowns because they

are water repellant, impervious to microial

contamination and can prevent the transmission of

micro organisms from uniforms/clothes to patients.

Plastic aprons must be worn as single use items for one procedure or episode of

patient care and then discarded and disposed of as clinical waste.

Gloves: There are two main indications for the use of

gloves in preventing healthcare associated infection, to

protect the hands from contamination with organic matter

and micro organisms and to reduce the risks of

transmission of micro-organisms to both patients and

staff.

A risk assessment should be made of the type of procedure to be undertaken and

the related risks to the patient and health care worker in order to establish whether

gloves should be worn.

Gloves should be worn as single use items. They should be put on immediately

before an episode of patient care and removed as soon as the activitity is completed.

Gloves must be changed between caring for different patients, or between different

carers for the same patient. Gloves must be disposed of as clinical waste and

hands decontaminated, ideally by washing with soap and water. Hand gel should

never be applied to gloves.

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Personal Protective Equipmement (PPE)

Eye/Mouth Protection: Should be worn

where there is a risk of blood or body fluids

splashing into the mouth or eyes. This is to

protect you from acquiring a blood borne virus or

a bacterial infection. A surgical mask is

waterproof and will prevent this from happening.

Goggles over spectacles or visors will protect your

eyes from spashes. If you receive a spash to your eye, use saline to gently irrigate

your eye, washing from the inner side of your eye (closest to your nose) allowing the

saline to flow over your eye. If you receive a splash to your mouth or broken skin,

rinse/cleanse thoroughly with water and then contact Infection Prevention via the

switchboard. When this happens, it is called a contamination issue. Surgical masks

should be worn when caring for patients with Flu but changed to an FFp3 Respirator

when performing aerosol generating procedures.

FFP3 Respirators: are designed to

protect the wearers from breathing in small

airborne particles which might contain viruses or

Tuberculosis. Staff need to perform a Fit check

before carrying out any procedures. Please see

Flu Guidance on Infection Prevention’s Aireshare

page on how to perform a fit check. If a sucessful

fit check cannot be achieved, remove and refit

the respirator. If you still cannot obtain a

sucessful fit check, try the cone shape respirators. If a sucessful fit check cannot be

achieved, please contact Infection Prevention. FFp3 Respirators should be worn

when performing aerosol generating procedures with patients suspected of having

Flu or worn when in contact with a patient with suspected or known Mycobacterium

Tuberculosis.

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Safe Handling of Spillages

Blood Spillage

(Hep B, C &HIV risk)

Clean spillages promptly

Soak up fluid with paper towels &

discard in orange bag

Disinfect the area using

Hypochlorite solution 10, 000ppm

Body Fluid Spillage

Clean spillage promptly

Soak up fluid with paper towels & discard in

orange bag

Disinfect the are using Tristel fuse 1,000ppm

Deal with any blood/body fluid spllage immediately.

Blood Spillage: Wear PPE to protect your hands and uniform (and a surgical

mask if there is a risk of spashing). Use paper towels to absorb the fluid, then clean

with hot water and detergent followed by 10,000ppm hypochlorite solution. Ensure a

window is opened as the chlorine smell is very strong.

Urine, faeces and vomit: Wear PPE (gloves and apron) and use paper towels to

absorb the fluid. Clean with hot water and detergent followed by 1,000ppm

40

hypochlorite solution or an agent that contains both: e.g. Tristel fuse. Dispose of the

paper towels in a clinical waste bag.

Sharps Safety

Safe disposal of contaminated sharps

This is classified as healthcare waste and must be disposed of

in a rigid sharps container that complies with UN3291 and

BS7329 standards. Refer to Prevention and Management of

contamination Injuries Policies on Aireshare.Ensure that

sharps bin lids are firmly clicked down on assembling and the

label is completed. When sharps containers are ¾ full they must

be closed securely and the person closing must complete and

sign the label on the container. The bin must be placed for collection in the clinical

waste area and must not be placed inside a clinical waste bag,When a sharps bin is

not in use, pull the lid half way across (see picture). This is called ‘temporary closure’

and will prevent sharps from falling out of the bin if it is accidently dropped.

Tips for prevention of sharps injuries:

Never re-sheath needles

Use safety devices where possible

Always use point of use sharpes bin

Do not overfill sharps bin

Do not use sharps bin for objects other than sharps

Disposing of needle and syringe as a unit reduces risk

of injury

Wearing gloves can remove up to 80% of blood from

a needle in the event of an injury

Make sure lighting and space to perform the

procedure is adequate

If a sharps bin is full Do not use it. Close it up and start a new one. This is the

responsibility of all clinical staff.

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Prevention and Management of

Contamination Injuries

First Aid Treatment (Bleed)

Wash the wound

Inform Infection Prevention

Team

Inform Employee Health and

Wellbeing (EHWB)

Complete documentation

Appropriate blood

specimens will be recommended

Ensure you dispose of your waste correctly

42

Decontamination of Equipment

One study showed that frequently touched articles in the

patients’ environment such as cardiac monitors, infusion

pumps and bed rails were grossly contaminated with micro

organisms. Any piece of equipment that is used by or on a

patient should be cleaned before being used on another

patient. Therefore, members of staff need to be aware of

their individual responsiblitiy for practising and promoting

decontamination of reusable medical devices to ensure the

safety of the patient, themselves and the environment.

Equipment such as commodes need to be decontaminated

with the correct cleaning solution. Three patients had the

same strain of Clostridium difficile on one ward. The commodes were swabbed and

the same strain of Clostridium difficile spores were found. The

commodes had been cleaned with detergent wipes which do not remove

C.diff spores instead of Tristel fuse which kill C.diff spores. Refer to:

Medical Devices:Process for Decontamination, Cleaning and Disinfection.

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Safe disposal of linen contaminated with body

substances

Linen skips should be taken to the bedside and

used linen should be carefully placed in them, to

prevent dispersal of skin cells and micro

organisms into the air, to then settle in the

environment. Hand gel should be applied after

handling used linen and before handling clean

linen to prevent the spread of skin cells.Aprons

should be worn for bed making.

Linen heavily contaminated with body

substances must be placed into a water soluble

bag to protect laundry staff from avoidable risk. When handling soiled linen, gloves

and apron must be worn.

The Clinical environment

A dirty or contaminated clinical environment is one of the factors that may

contribute to HCAIs. Exposure to environmental contamination with spores of C.difficile is one example of occasions when the environment contributes to the development of infection. Many micro-organisms can be identified from the patient’s environment and these usually reflect bacteria carried by patients or staff ( in the case of S.aureus). Contact with the immediate patient of a contaminated environmenr by the hands of staff can also be a route for transmission of micro organisms. High standards of cleanliness will help to reduce the risk of cross-infection and are aesthetically pleasing to patients and the public .

Mattress Checks

After a patient has been discharged, please unzip the mattress cover. If staining is present on either the underside of the cover or on the mattress core then please follow and complete a mattress audit form (can be found on the Aireshare Infection prevention page). Please attach the form to the mattress and ask porters to swap it or a clean mattress. The dirty mattress needs taking by porters to

the dirty mattress store on ward 11.

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Clinical Workbook Level 2- Questions

All the answers to the questions below are found in this workbook. Please write your

answers on this sheet and email to the Infection Prevention group email address:

Infection.prevention@anhst.nhs.uk

You will need to get 8 answers correct to complete your update. The questions

will be marked and your record will be updated by the Training dept. If you do not

achieve the pass rate you will need to attend an Infection Prevention session in

the lecture theatre. You will be contacted by email.

1. Which one of the following is not one of the 10 compliance criteria from

the Health and social care act?

a) Provide a clean and appropriate environment.

b) Provide accurate information on infections to patients and visitors.

c) To screen patients for MRSA on admission.

d) To provide adequate isolation facilities.

2. Why should used linen be handled carefully and put into a skip at the

bedside when changing bed linen?

a) Prevents skill cells from becoming airborne.

b) More time efficient.

c) Prevents skin cells getting on your uniform

d) So staff do not need to wear gloves

3. What does this symbol mean?

a) History of CPE colonisation or infection

b) History of CDI colonisation or infection

c) History of MRSA colonisation or infection

d) History of ESBL colonisation or infection

4. The hub (injectable bung) of the cannula should be cleaned with a Sani-

cloth wipe for a minimum of:

a) 5 seconds and allowed to dry

b) 15 seconds and allowed to dry

c) 30seconds and allowed to dry

d) 60 seconds and allowed to dry

5. Contact Precautions- What is the correct order for removing PPE when

leaving a side room?

a) Apron/gloves/ hand wash

b) Gloves/apron/ hand wash

c) Either/ hand wash

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Clinical Workbook Level 2- Questions (Cont)

6. Looking after patients with ESBLs. The source of their infection is

mainly from where?

a) The Patients pet

b) The Patients family

c) The Patients own gut flora

d) The Patients Urine

7. If a patient has been in a hospital abroad in the last 12 months you

should….?

a) Isolate them in a side room and take 3 urine samples

b) Isolate them in a side room and take 3 sputum samples

c) Isolate them in a side room and take 3 stool samples/ rectal swabs

8. When is hygienic hand gel not effective?

a) After contact with a patient suspected of having clostridium difficile

b) After an aseptic technique

c) Before patient contact

d) When leaving the ward

9. How would you clean up a blood spillage?

a) Clean spillage promptly/ soak up fluid with paper towels and place in

an orange bag/disinfect the area with hypochlorite solution 10000ppm

b) Clean spillage promptly/ soak up fluid with paper towels and place in

an orange bag/disinfect the area with Tristel fuse

c) Clean spillage promptly/ soak up fluid with paper towels and place in

an orange bag/disinfect the area with a sani-cloth wipe

10. What shouldn’t you do if you have had a needle stick injury?

a) Encourage the wound to bleed by squeezing the wound.

b) Suck the wound

c) Inform Infection prevention immediately

d) Complete an AEF