• Key Points
• Keep sleeves rolled above the wrist
• Do not wear a wrist watch or any jewellery
• Use non-sterile gloves to protect yourself
• Use sterile gloves to protect the patient
• Scrub properly before performing aseptic
• 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,
• 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
Protective Clothing Guidance
• 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
• Goggles and visors must be worn to
prevent splashing of body fluids into the
eye when performing risky procedures.
• 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...
• 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
• 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
• 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
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
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
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
• 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
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
• 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
• 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
• Urine samples must be obtained from a
sampling port using an aseptic technique.
• The meatus should be washed daily with soap
• 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
• 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
• 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
• 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
• 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 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
• 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
• 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
• 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
• If a patient has profuse perspiration, or if the
insertion site is bleeding or oozing, a sterile gauze
dressing is preferable to a transparent,
• 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.
• 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
• INTERVENTIONS AND PRACTICES
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
• 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
• 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.
• 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
Replacement of Administration Sets and
• 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
• 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
• 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
• 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
• 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.