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                 • Key Points
                    • Dress
    • Keep sleeves rolled above the wrist
• Do not wear a wrist watch or any jewellery
                   • Gloves
• Use non-sterile gloves to protect yourself
  • Use sterile gloves to protect the patient
              (aseptic procedures)
• Scrub properly before performing aseptic
                   • Aprons
    • Use aprons to protect your clothes
    You should keep the following points in
      mind when deciding what to wear:
• Keep sleeves rolled above the wrist
• Wear a name badge at all times
• Do not wear a wrist watch or jewellery
• Keep hair neat and tidy; long hair must be tied
• Keep fingernails short and no false nails or
  varnish (Liquid applied as a coating for
  protection and appearance) are permitted
• Healthcare workers in all settings carry out patient
  care that involves close or direct contact with patients
  and inevitably, contamination of clothing will occur.
  This may be gross contamination with body fluids or
  invisible contamination with micro-organisms,
  particularly staphylococci.

• When providing care to a patient, (e.g. bed bathing,
  changing dressings, when dealing with body fluids,
  etc.) it is important even when wearing a uniform
  that healthcare workers wear some sort of protective
wear some sort of protective clothing
Plastic Aprons
    Protective Clothing Guidance
           Plastic Aprons
• To ensure that aprons are used correctly, a system
  of colour-coded aprons has been introduced in most
  organisations. Where available, yellow / pink
  (depending on your local hospital) plastic aprons
  should be worn for nursing patients in Source
  Isolation and should come into contact with only one

• White plastic aprons may be worn to protect the
  carers' clothing from moisture or soiling. Aprons used
  for these purposes must be discarded after contact
  with each patient.
      Disposal of Plastic Aprons
• Aprons must be removed and discarded
  appropriately. Hands should then be washed and
  dried or decontaminated with alcohol gel.

• In some units (Intensive Care Units) all staff may be
  asked to wear aprons but they should change
  aprons when attending to another patient.

• Colour coded aprons are used at each bed space
  in the Intensive Care Unit.
    Disposal of Plastic Aprons
• Aprons used for Source Isolation or that
  have been contaminated with blood or body
  fluids should be discarded immediately into
  a yellow clinical waste bag.

• Aprons used for other purposes should be
  discarded into a black bag for domestic
          Face Protection

• Goggles and visors must be worn to
  prevent splashing of body fluids into the
  eye when performing risky procedures.
Face Shield

• Surgical masks do not protect against
  aerosol inhalation but may protect against
  splashes in surgery.

• Guidance on the use and disposal of
  aprons and face protection...
       Standard Precautions
                   • Key Points
• Prevent blood / body substance contact with
      non-intact skin and mucous membranes
   • Minimise blood / body substance contact
                   with intact skin
            • Prevent sharps injuries
    • Immunise staff against hepatitis B virus
      Prevent contaminated items being used
                  between patients
• All precautions should be allied to good skin
  care and safe infection control practices at all
 times in order to protect both staff and patients
     United Kingdom Department of Health
         1998 Guidelines on Standard
•      Cover any cuts and grazes with an
  impermeable dressing
• Wash hands or use an alcohol handrub before
  and after contact with each patient, and before
  putting on and removing gloves
• Change gloves between patients
• Assess risk of accidental contamination with
  blood and body fluids
• Wear appropriate protective clothing where
  contact with blood can be anticipated
• Avoid contamination of clothing and skin with
• Avoid sharps injuries
• Clear up spillages (however small) properly
• Follow safe procedures for the disposal of
  contaminated waste
   Infections associated with intravascular
• Local (exit site, tunnel) and systemic infections may occur
• They are most common in intensive care units.
• Key practices for all vascular catheters
• avoiding catheterization unless there is a medical
• maintaining a high level of asepsis for catheter insertion
   and care
 limiting the use of catheters to as short a duration as
• preparing fluids aseptically and immediately before use
• training of personnel in catheter insertion and care
Foley Catheters
Urinary tract infections (UTI)

• Urinary tract infections are the most frequent
  nosocomial infections 80% of these infections
  are associated with an indwelling urethral

• Interventions effective in preventing
  nosocomial urinary infection include:
• avoiding urethral catheterization unless there
a compelling (Urgently requiring
• limiting the duration of drainage, if
  catheterization is necessary
• maintaining appropriate aseptic practice
  during urinary catheter insertion and other
  invasive urological procedures (e.g.
• hygienic handwash or rub prior to insertion
  and following catheter or drainage bag
• sterile gloves for insertion
• perineal cleaning with an antiseptic solution
  prior to insertion
• non-traumatic urethral insertion using an
  lubricant maintaining a closed drainage system.
• Other practices which are recommended, but not
  proven to decrease infection include:
• maintaining good patient hydration
• appropriate perineal hygiene for patients with
• appropriate staff training in catheter insertion and
• maintaining unobstructed drainage of the bladder
  to the collection bag, with the bag below the level of
  the bladder.
• Generally, the smallest diameter catheter
  should be used.
• Catheter material (latex, silicone) does not
  influence infection rates.
• For patients with a neurogenic bladder:
• avoid an indwelling catheter if possible
• if assisted bladder drainage is necessary,
  clean intermittent urinary catheterization
  should be
    Care of patients with long-
     term urinary catheters
• Assessing the need for catheterisation
• Indwelling urinary catheters should be used only
  after alternative methods of management have
  been considered.
• The patient’s clinical need for catheterisation
  should be reviewed regularly and the urinary
  catheter removed as soon as
• possible. Catheter insertion, changes and care
  should be documented.
     Catheter drainage options
• Anticipated duration of catheterisation, patient
  preference and risk of infection should be selected.
• Intermittent catheterisation should be used in
  preference to an indwelling catheter
• For urethral and suprapubic catheters, the choice of
  catheter material and gauge will depend on an
  assessment of the patient’s individual
  characteristics and predisposition to blockage.
• In general, the catheter balloon should be inflated
• with 10 ml of sterile water in adults and 3–5 ml in
        Catheter maintenance
• Indwelling catheters should be connected to a
  sterile closed urinary drainage system.
• Healthcare personnel must decontaminate their
  hands and wear a new pair of clean, non-sterile
  gloves before manipulating a patient’s catheter,
  and must decontaminate their hands after
  removing gloves.
• Urine samples must be obtained from a
  sampling port using an aseptic technique.
• The meatus should be washed daily with soap
  and water.
       Catheter maintenance
• Catheters should be changed only when
  clinically necessary, or according to the
  manufacturer’s current recommendations.

• Healthcare personnel should ensure that
  the connection between the catheter and
  the urinary drainage system is not broken
  except for good clinical reasons.
• Urinary drainage bags should be positioned
  below the level of the bladder, and should
  not be in contact with the floor.
• The urinary drainage bag should be emptied
  frequently enough to maintain urine flow and
  prevent reflux, and should be changed when
  clinically indicated.
• Each patient should have an individual care
  regimen designed to minimise the problems
  of blockage and encrustation.
• Bladder instillations or washouts must not be
  used to prevent catheter associated

• Antibiotic prophylaxis when changing
  catheters should only be used for patients
  with a history of catheter associated urinary
  tract infection following catheter change, or
  for patients who have a heart valve lesion,
  septal defect, patent ductus or prosthetic
           Catheter insertion
• All catheterisations carried out by healthcare
  personnel should be aseptic procedures.
• After training, healthcare personnel should be
  assessed for their competence to carry out
  these types of procedures.
• Intermittent self catheterisation is a clean
• A lubricant for single-patient use is required
  for nonlubricated catheters.
• For urethral catheterisation, the meatus
  should be cleaned before insertion of the
  catheter, in accordance with local

• An appropriate lubricant from a single-use
  container should be used during catheter
  insertion to minimise urethral trauma and
   Care during enteral feeding

• Preparation and storage of feeds
• Wherever possible prepackaged, ready-to-use
  feeds should be used in preference to feeds
  requiring decanting (pour out), reconstitution or
• When decanting,reconstituting or diluting feeds, a
  clean working area should be prepared and
  equipment dedicated (Designed for a particular use
  or function) for enteral feed use only should be
• Where ready-to-use feeds are not available, feeds
  may be prepared in advance, stored in a
• Effective hand decontamination must be
  carried out before starting feed preparation.

• Feeds should be mixed using cooled boiled
  water or freshly opened sterile water and a
  no-touch technique.

• Feeds should be stored according to the
  manufacturer’s instructions and, where
  applicable, food hygiene legislation.
     Care of insertion site and
       enteral feeding tube
• The stoma should be washed daily with water and
  dried thoroughly.

• To prevent blockage, the enteral feeding tube
  should be flushed with fresh tap water before and
  after feeding or administering medications.

• Enteral feeding tubes for patients who are
  immunosuppressed should be flushed with either
  cooled freshly boiled water or sterile water from a
  freshly opened container.
Central vascular
      Central vascular catheters
• Clean the insertion site with an antiseptic solution.
• Do not apply solvents or antimicrobial ointment to
  the insertion site.
• Mask, cap, and sterile gloves and gown must be
  worn for insertion.
• The introduction of the catheter and the
  catheter dressings require a surgical hand wash or
• Follow appropriate aseptic care in accessing the
  system, including disinfecting external surfaces of
  hub and ports.
• Change of lines should normally not occur more
  often than once every three days.
• A change of line is necessary, however, after the
  transfusion of blood, blood products, or intralipids,
  and for discontinuous perfusions.
• Change dressing at the time of the change of lines,
  following surgical asepsis.
• Use a sterile gauze or transparent dressing to
  the catheter site.
• An increased number of catheter lumens may
  increase the risk of infection.
• A single lumen catheter is preferred
  wherever possible.
• Antimicrobial impregnated catheters may
  decrease infection in high-risk patients with
  short-term (<10 days) catheterization.
• Use the subclavian site in preference to
  jugular or femoral sites.
• Consider using a peripherally inserted
  central catheter, if appropriate.
                Care of patients with
              central venous catheters
• General principles for catheter management
• The injection port or catheter hub should be
  decontaminated using either alcohol or an alcoholic
  solution of chlorhexidine gluconate before and after
  it has been used to access the system.
• In-line filters should not be used routinely for
• Antibiotic lock solutions should not be used
  routinely to prevent catheter-related bloodstream
  infections (CRBSI)

• Preferably, a sterile 0.9 percent sodium chloride
• In general, administration sets in continuous use
  need not be replaced more frequently than at 72-
  hour intervals unless they become disconnected or
  a catheterrelated infection is suspected or

• Administration sets for blood and blood components
  should be changed every 12 hours, or according to
  the manufacturer’s recommendations.

• Administration sets used for total parenteral
  nutrition infusions should generally be changed
  every 24 hours.

• If the solution contains only glucose and amino
  acids, administration sets in continuous use do not
• Systemic antimicrobial prophylaxis should not be
  used routinely to prevent catheter colonisation or
  CRBSI either before insertion or during the use of a
  central venous catheter.

• When recommended by the manufacturer,
  implanted ports or opened-ended catheter lumens
  should be flushed and locked with heparin sodium
  flush solutions.

• When needleless devices are used, healthcare
  personnel should ensure that all components of the
  system are compatible and secured, to minimise
  leaks and breaks in the system.

• Preferably, a single lumen catheter should be used
• If a multilumen catheter is used, one port must be
  exclusively dedicated for total parental nutrition, and
  all lumens must be handled with the same
  meticulous attention to aseptic technique.

• When needleless devices are used, the risk of
  contamination should be minimised by
  decontaminating the access port with either alcohol
  or an alcoholic solution of chlorhexidine gluconate
  before and after using it to access the system.

• If needleless devices are used, the manufacturer’s
  recommendations for changing the needleless
  components should be followed.
              Catheter site care
• Preferably, a sterile, transparent, semipermeable
  polyurethane dressing should be used to cover the
  catheter site.

• If a patient has profuse perspiration, or if the
  insertion site is bleeding or oozing, a sterile gauze
  dressing is preferable to a transparent,
  semipermeable dressing.

• Gauze dressings should be changed when they
  become damp, loosened or soiled, and the need for
  a gauze dressing should be assessed daily.

• A gauze dressing should be replaced by a
• Dressings used on tunnelled or implanted
  CVC sites should be replaced every 7 days
  until the insertion site has healed, unless
  there is an indication to change them sooner.

• An alcoholic chlorhexidine gluconate solution
  should be used to clean the catheter site
  during dressing changes, and allowed to air

• An aqueous solution of chlorhexidine
  gluconate should be used if the
  manufacturer’s recommendations prohibit the
  use of alcohol with
Healthcare personnel should ensure that
 catheter-site care is compatible with catheter
 materials (tubing, hubs, injection ports, luer
 connectors and extensions)

• Transparent dressings should be changed
  every 7 days, or sooner if they are no longer
  intact or moisture collects under the dressing.

• Individual sachets of antiseptic solution or
  individual packages of antiseptic-impregnated
  swabs or wipes should be used to disinfect
  the dressing site.
               General asepsis
• An aseptic technique must be used for catheter site
  care and for accessing the system.
• Before accessing or dressing central venous
  catheters, hands must be decontaminated either by
  washing with an antimicrobial liquid soap and water,
  or by using an alcohol handrub.

• Hands that are visibly soiled or contaminated with
  dirt or organic material must be washed with soap
  and water before using an alcohol handrub.

• Following hand decontamination, clean gloves and
  a no-touch technique or sterile gloves should be
  used when changing the insertion site dressing.
Peripheral Venous Cannulation...
            Peripheral intravenous device-related
•    Prevention
1.   Handwashing and aseptic technique
2.   Barrier precautions during peripheral venous cannula
     insertion and care
3.   Selection of peripheral insertion site
4.   Intravenous (IV) device selection and replacement (e.g.,
     use of Teflon or polyurethane cannula or steel needles and
     use of routine or scheduled replacement of IV cannula)
5.   Education and training of health care workers
           Peripheral vascular
• Hands must be washed before all catheter care,
• using hygienic handwash or rub.
• Wash and disinfect skin at the insertion site with
  an antiseptic solution.
• Intravenous line changes no more frequently
  than change of catheters, with the exception of
  line changes after the transfusion of blood or
• A dressing change is not normally necessary.
• If local infection or phlebitis occurs, the catheter
  should be removed immediately.
• Cannula, cannula site, and injection port care (e.g.,
  skin cleansing with 70% alcohol or 10% povidone-
  iodine; use of transparent dressing or sterile gauze;
  use of normal saline or diluted heparin flush
  solution; cleaning of injection ports with 70%
• Replacement of administration sets and IV fluids
• Preparation and quality control of IV admixtures
• Cannula Site Care
• - Before cannula insertion, cleanse the skin site with an
    appropriate antiseptic, including 70% alcohol or 10% povidone-
    iodine. Allow the antiseptic to remain on the insertion site for an
    appropriate length of time before inserting the cannula.
•    Do not palpate the insertion site after the skin has been cleansed
    with antiseptic (this does not apply to maximum barrier
    precautions during which the operator is working in a sterile field).
•   Use either a transparent dressing or sterile gauze to cover the
    cannula site.
•   Replace cannula site dressings when they become damp, loosened,
    or soiled, or when the device is removed or replaced. Change
    dressings more frequently in diaphoretic patients.
•    Avoid touch contamination of the cannula insertion site when the
    dressing is replaced.
•   Do not routinely apply topical anti-microbial ointment to the
    insertion site of peripheral venous cannulas.
                Cannula Care
• Routinely flush peripheral venous locks with normal
  saline solution, unless they are used for obtaining
  blood specimens, in which case a diluted heparin (10
  units per ml) flush solution should be used.
• No recommendation for the routine use of topical
  venodilators (e.g., glyceryl trinitrate) or anti-
  inflammatory agents (e.g., cortisone) near the
  insertion site of peripheral venous cannulas to reduce
• No recommendation for the routine use of
  hydrocortisone or heparin in parenteral solutions to
  reduce phlebitis.
      Replacement of Administration Sets and
                    IV Fluids
• In general, administration sets include the area from the
  spike of tubing entering the fluid container to the hub of
  the vascular device. However, a short extension tube
  may be connected to the vascular device and may be
  considered a portion of the device to facilitate aseptic
  technique when changing administration sets. Replace
  extension tubing when the vascular device is replaced.
• Replace IV tubing, no more frequently than at 72-hour
  intervals, unless clinically indicated.
• No recommendation for the frequency of replacement of IV
  tubing used for intermittent infusions.

•    Replace tubing used to administer blood and blood products
    immediately after transfusion.

• Replace tubing used to administer lipid emulsions within 24
  hours of initiating the infusion.

• Intravenous Injection Ports
• Clean injection ports with 70% alcohol before accessing the
          Preparation and Quality
          Control of IV Admixtures
• Check all containers of parenteral fluid for visible turbidity
  (Haziness caused by the presence of particles and
  pollutants), leaks, cracks, particulate matter and the
  manufacturer’s expiration date before use.
• Use single-dose vials for parenteral additives or medications
  whenever possible.

• Refrigerate multi-dose vials after they are opened as
  recommended by the manufacturer.

• Cleanse the rubber diaphragm of multi-dose vials with 70%
  alcohol before inserting a device into the vial.
• Use a sterile device each time a multi-dose vial is accessed, and
  avoid touch contamination of the device before penetrating the
  rubber diaphragm.
• Discard multi-dose vials, when suspected or visible
  contamination occurs or when the manufacturer’s
  stated expiration date is due.
• In-line Filters
• Do not use filters routinely for infection control
           Surveillance for Cannula-related
• Palpate the cannula insertion site daily for tenderness
  through the intact dressing.

• Inspect the cannula site visually if the patient has
  evidence of tenderness at the insertion site, fever
  without obvious cause, or symptoms of local or
  bloodstream infection.

• In patients who have large, bulky dressings that prevent
  palpation or direct visualisation of the cannula insertion
  site, remove the dressing, visually inspect the cannula
  site at least daily and apply a new dressing.
• Record the date and time of cannula insertion in an
  obvious location near the cannula-insertion site (e.g.,
  on the dressing).

• Conduct surveillance for IV device-related infections
  to determine device-specific infection rates, to
  monitor trends in those rates, and to assist in
  identifying lapses in infection control practices within
  one’s own institution.

• Do not routinely perform surveillance cultures of
  devices used for IV access.
 Surgical wound infections (surgical site

• Factors which influence the frequency of surgical
  wound infection include
  – surgical technique
  – extent of endogenous contamination of the wound at
    surgery (e.g. clean, clean-contaminated)
  – duration of operation
  – underlying patient status
  – operating room environment
  – organisms shed by the operating room team.
• A systematic programme for prevention of surgical
  wound infections includes the practice of optimal

• surgical technique, a clean operating room
  environment with restricted staff entry and
  appropriate staff attire, sterile equipment, adequate
  preoperative preparation of the patient, appropriate
  use of preoperative antimicrobial prophylaxis, and a
  surgical wound surveillance programme.

• Surgical wound infection rates are decreased by
  standardized surveillance for infection with reporting
  of rates back to individual surgeons.
• Operating room environment
• Airborne bacteria must be minimized, and surfaces kept
• A recommended schedule for cleaning and disinfection of
  the operating theatre is:
• every morning before any intervention: cleaning of all
  horizontal surfaces
• between procedures: cleaning and disinfection of horizontal
  surfaces and all surgical items (e.g. tables, buckets)
• at the end of the working day: complete cleaning of the
  operating theatre using a recommended disinfectant
• once a week: complete cleaning of the operating room
  area, including all annexes such as dressing rooms,
  technical rooms, cupboards.

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