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Infection Prevention and Control Policy

INFECTION PREVENTION AND CONTROL POLICY
POLICY NO RATIFYING COMMITTEE DATE RATIFIED NEXT REVIEW DATE IC01 CORPORATE PROCEDURAL DOCUMENT REVIEW GROUP

NOVEMBER 2010 NOVEMBER 2012

POLICY STATEMENT:
This policy details the action required by all individuals directly employed by the Trust, contract staff, students, volunteers, locums and bank/agency staff, patients, carers and general public, which minimises the risk of infection, to patients, staff and visitors.

ACCOUNTABLE DIRECTOR:
Karen Wilson

Executive Director of Nursing and Care /Director of Infection Prevention and Control

POLICY AUTHOR: Infection Control Doctor/ Consultant Microbiologist Dr M M Rothburn

KEY POLICY ISSUES • • • • • • • • • • • The Transmission of Infection Hand Hygiene Policy -Decontamination of Hands Decontamination of the Environment, Cleaning, Body Fluid Spillages, Laundry and Clinical Waste Standard Principles for the use of Personal Protective Equipment Infectious Diseases, A-Z including Clostridium difficile Meningitis, MRSA and TB Policies Surveillance Policy Isolation Policy Major Outbreak Policy/Management of Outbreaks Blood Borne Virus Policy (HIV, Hepatitis B and Hepatitis C) Safe Use and Disposal of Sharps Aseptic Technique, Invasive Devices

This policy is available in other formats upon request.

Page 1 of 176

Infection Prevention and Control Policy

Index Section
1. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 2 2.1 2.2 2.3 2.4 3 3.1 3.2

Title Introduction

Page No
9 11 11 11 12 12 12 12 13

Rationale Scope of Policy Principles Infection Prevention and Control Risk Assessment Reporting Infection Prevention Control Related Incidents Training in Relation to Infection Prevention and Control Information for patients, and public in relation to Infection Prevention and Control Infection Control Assurance Framework

Policy
Duties Duty of Infection Control Committee Legislation and Guidance Professional Guidance

14
14 18 19 22

Infection Control Guidelines and Policies
Explanation of Terms and Risk Factors Common Risk Factors Predisposing to Infection Decontamination of hands - Hand Hygiene Policy Introduction Rationale Scope of Policy Principles Policy Duties Legislation and Guidance Standard Principles for Hand Hygiene Effective Hand Washing Technique Involves Five Steps Ayliffe Technique The 5 Moments for Hand Hygiene at the Point of Care Hand Cream and Skin Care Appearance and Workwear to support effective practice Process for Monitoring Compliance and Effectiveness Development and Consultation References Bibliography Glossary of Terms Decontamination of the Environment Standard Principles of Environmental Hygiene Walls, Ceilings and Floors Furniture and Fittings Sinks and Toilets

23
23 24 26 26 26 26 26 27 28 29 29 30 31 31 32 33 34 34 34 34 34 35 35 36 36 36

3.3

Page 2 of 176

Infection Prevention and Control Policy

3.4

3.5

3.6

Contamination Status Certificate 37 Bathrooms and Showers 38 Carpets 38 Domestic Rooms and Equipment 38 Body Fluid Spillages 39 Large Blood Spillages, Dried Blood and Faecal Smearing Dirty Protests 39 Daily and Terminal Cleaning of Infectious Rooms 40 Decontamination of Area, Facility Prior to Inspection and Repair 42 NHS Colour Coding 43 Decontamination of Linen (Laundry Policy) 43 Introduction 44 Rationale 44 Scope of Policy 44 Principles 44 Policy 44 Duties 44 Legislation and Guidance 45 Risks to Laundry Staff 45 Laundering of Linen 46 Linen Bagging Procedure 46 Process for Monitoring and Compliance of Effectiveness 46 Development and Consultation 46 References 46 Bibliography 46 Glossary of Terms 46 Clinical Waste 47 Categories of Waste 47 Non Hazardous Waste (European Code 18-01-04) 47 Hazardous Infectious Waste (Code 18-01-03) 48 Offensive Hygiene Waste (Code 18-01-04/ 20-01-99) 48 Sharps Yellow Top (European Waste Code 18-1-03) 48 Sharps Purple Top (European Waste Code 18-01-08) 49 Amalgam Waste (European...
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