Uniform • 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 procedures • 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 back • Keep fingernails short and no false nails or varnish (Liquid applied as a coating for protection and appearance) are permitted Uniform • 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 clothing. 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 patient. • 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 waste. Face Protection • Goggles and visors must be worn to prevent splashing of body fluids into the eye when performing risky procedures. Face Shield Goggles Masks • 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 Precautions: • 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 blood • Avoid sharps injuries • Clear up spillages (however small) properly • Follow safe procedures for the disposal of contaminated waste Infections associated with intravascular lines • Local (exit site, tunnel) and systemic infections may occur • They are most common in intensive care units. • Key practices for all vascular catheters include: • avoiding catheterization unless there is a medical indication • maintaining a high level of asepsis for catheter insertion and care limiting the use of catheters to as short a duration as possible • preparing fluids aseptically and immediately before use Foley Catheters INTERMITTENT CATHETERS Urinary tract infections (UTI) • Urinary tract infections are the most frequent nosocomial infections 80% of these infections are associated with an indwelling urethral catheter • Interventions effective in preventing nosocomial urinary infection include: • avoiding urethral catheterization unless there is 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. Cystoscopy) • hygienic handwash or rub prior to insertion and following catheter or drainage bag manipulation • sterile gloves for insertion • perineal cleaning with an antiseptic solution prior to insertion • non-traumatic urethral insertion using an appropriate 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 catheters • appropriate staff training in catheter insertion and care • 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 used. 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 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 infection. • 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 valve. 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 procedure. • 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 guidelines/policy. • An appropriate lubricant from a single- use container should be used during catheter insertion to minimise urethral trauma and infection. 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 dilution. • 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 used. • 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 catheters 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 subsequent catheter dressings require a surgical hand wash or rub. • Follow appropriate aseptic care in accessing the system, including disinfecting external surfaces • 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 cover 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 infection prevention. • Antibiotic lock solutions should not be used routinely to prevent catheter-related bloodstream infections (CRBSI) • 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 documented. • 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. • 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 • 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 dry. • An aqueous solution of chlorhexidine gluconate should be used if the manufacturer’s recommendations prohibit 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 Peripheral Venous Cannulation... Peripheral intravenous device-related infections • INTERVENTIONS AND PRACTICES CONSIDERED • 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 catheters • 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 intralipids, • A dressing change is not normally necessary. Management Maintenance • 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% alcohol) • 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 phlebitis. • 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 system. 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 purposes. Surveillance for Cannula-related Infection • 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 infections) • 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 clean. • 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 cleaner • once a week: complete cleaning of the operating room area, including all annexes such as dressing rooms, technical rooms, cupboards.
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