UNIVERSAL INFECTION CONTROL PRECAUTIONS.

1.1   Introduction

1.2   Risk Assessment 

1.3   Universal Infection Control Precautions 

1.4   Protective Clothing

1.5   Hand Hygiene

1.6   Isolation Facilities

1.7   Sterilization And Disinfection

1.8  UWP for procedures /hospital settings

1.9  Segregation and Disposal of Hospital waste

1.10 Handling and disposal of HIV bodies

1.11 Staff Protection and training

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UNIVERSAL INFECTION CONTROL PRECAUTIONS

- Minimising the risk of blood -borne infection

1.1   INTRODUCTION

Blood and body fluids may contain blood-borne viruses (eg. Hepatitis B and HIV) or other bacterial and other viral pathogens. These can present a risk to other patients and health care workers. As it is not always possible to know who is infected with these pathogens, emphasis on infection control effort should focus primarily on 'Universal Infection Control Precautions' (UICP) which prevent the exposure to blood and body fluids which are presumed to be potentially infective. 

These precaution apply to patients with:

• HIV; 

• hepatitis B,C, non-A non-B 

• syphilis 

• malaria 

• blood-borne viral and bacterial infections 

1.2    RISK ASSESSMENT

Transmission of HIV in health care settings can occur from patient to health care worker, between patients, or from health care worker to patients.

Procedures that carry risk to HCW :

• Examination of patient using common O.P.D. procedures e.g. P/R, P/V Invasive diagnostic & therapeutic procedures
• Wound dressing
• Operation theatre procedures
• Various ward activities
• Handling of blood/serum/body fluids & tissues
• Cleaning of hospital/clinic & disposal of waste
• Faulty sterilization Laundry; C.S.S.D.
• Post mortem/embalming

The risk to staff arises:

• from sharps and hollow needles;

• splashing of conjunctivae and mucous membranes with contaminated blood and body  fluids;

• heavy contamination of broken skin, eg. Abrasion,cuts, dermatitis etc.;

• handling of large quantities of blood and body fluids without  protective clothing.  

The risk to patients arises from:-

•  use of recycled hollow needles and syringes; 

•  contaminated blood transfusion;

•  heavy soiling of the environment; 

•  poor ward facilities and cleaning

1.3     UNIVERSAL INFECTION CONTROL PRECAUTIONS 

Universal Precautions assume that blood and body fluid of ANY patient could be infectious Application for universal infection control precautions means that all patients' body fluids should be treated as infectious, since it is not known who is infected and carry a virus. 

The purpose of these precautions is to prevent the exposure and infection of health care workers from blood-borne pathogens. The rationale for applying the precautions is that the health care worker may not know who is and is not infected, thereby making it important to treat all blood and body fluids as infectious.

Infection control precautions are intended to isolate the virus and the body fluids, not the patient.

Universal infection control precautions apply to:

Body fluids which may contain HIV or Hepatitis B:

•  Blood 

•  Blood-stained body fluids

•  Semen

•  Vaginal secretions  

•  Tissues

•  CSF, amniotic, pericardial, pleural fluids etc 

Body fluids which may contain other pathogenic micro-organisms:

•  Faeces  

•  Urine

•  Vomit

•  Sputm

Universal infection control precautions do not apply to: 

Body fluids which are unlikely to contain pathogens:

•  Tears  

•  Nasal secretions

•  Sweat 

•  Saliva

Note: Gloves should be worn for direct contact with mucous membranes, such as the mouth, stomas,.

1.4    PROTECTION CLOTHING

Definition of Personal Protective Equipment (PPE) is “specialized clothing or equipment worn by an employee for protection against infectious materials” eg. gloves, aprons etc.

Types of PPE Used in Healthcare Settings :

• Gloves – protect hands
• Gowns/aprons – protect skin and/or clothing
• Masks and respirators– protect mouth/nose
• Respirators – protect respiratory tract from airborne infectious agents
• Goggles – protect eyes
• Face shields – protect face, mouth, nose, and eyes

1.4.1    Gloves

Gloves should be worn for direct contact with blood or body fluids and for direct contact with non-intact skin or mucous membranes. Gloves should be made of latex and should fit well. Gloves should be discarded after each procedure. Alcohol dis-infection between patients is not recommended because the viruses can become 'fixed' to the latex by the alcohol.

1.4.2     Gowns / Aprons

These should be worn to protect staff from body fluids. Again, disposable aprons are preferable to recycled ones.

1.4.3    Eye protection

Goggles or some sort of eye protection (visor) should be worn to (avoid conjunctival splash contamination. Spectacles are acceptable.

1.4.4     Masks

  These are recommended to avoid blood or body fluids splashing into the mouth and nostrils.

1.4.5       Respiratory Protection :

Respiratory Protection Purpose – protect from inhalation of infectious aerosols (e.g., Mycobacterium tuberculosis) e.g Particulate respirators, Half- or full-face elastomeric respirators, Powered air purifying respirators (PAPR).

1.4.6     Water proof dressing: Broken Skin

Cuts and abrasions on the hands and forearms should be covered with a waterproof dressing. 

1.5     Hand Hygiene :

1.5.1    Handwashing

Hands should be washed thoroughly and immediately with soap and water after contact with body fluids. Hands should be thoroughly washed even if gloves are worn.    Handwashing is the single most important procedure for the prevention of hospital-acquired infections after a non-sterile procedure

There are two types of hand washing:

1.   Social hand washing. This should be carried out:

•         routinely before and after coming into contact with patients;

•         when starting work;

•         when going off-duty; 

·         when they become visibly dirt y; 

•         when they are contaminated with body fluids or organic matter;

·         after visiting the toilet;   

·         after removing gloves; 

contact with patients during ward rounds or routine procedures such as bed-making or lifting should be followed by decontamination of the hands with alcohol chlorhexidine or a soap and water hand-wash. 

2.  Aseptic hand-washing. This type of hand washing should be used when as aseptic procedure is about to be performed on a patient (e.g. introducing central  venous pressure lines, peripheral cannulae or urinary Catheters). This requires meticulous cleaning of the hands and the use of a sustained action disinfectant. It is usually accompanied by the wearing of gloves.

Procedure for hand-washing: (Routine)

Remove all rings, jewellery (including watch) and roll up the sleeves.

Wet the hands under running water and apply a recommended amount of the hand-wash provided to the palms of the hands.

 Rub the hands together and then cup them around each other to massage all the finger tips properly, massaging the thumbs and the webs of the fingers.

Wash the wrist and backs of the hands.

Rinse the hands thoroughly under running water.

Dry thoroughly with several pieces of paper towel or single-use cotton towels.

If washing for an aseptic procedure:

Do not touch any non-sterile surface.

 Wear gloves.

Remove gloves after the procedure, wash hands and dry thoroughly.

1.5.2  Hand Disinfection

Sustained-action disinfectants with alcohol (rub) should be used:

•    When moving from one patient to another. 

•    After non-sterile duties not involving body fluids.

•    After handling or touching a potentially contaminated surface. 

All hand disinfection agents  should be kept in a sterile dispenser that delivers a known quantity of soap or disinfectant. The container and nozzle must be cleaned regularly to prevent contamination and blocking. Open containers of disinfectant and soap should not be left onward wash-hand basins as they can become contaminated with bacteria . When empty, the disinfectant containers should be returned to the pharmacy to be washed, cleaned and refilled. Defective pumps must be replaced immediately.

Soap and Water

Soap and water remove most organic contamination and are acceptable as a social-hand wash. However, bars of soap may be left Iying in pools of water, where they become contaminated with multiple antibiotic-resistant Gram-negative bacilli, which are then transferred to the hands  of staff and then to patients. If bar soaps are used they should be stored dry - either on a piece of string or fixed to the wall by magnet holders.

Soap and water should be supplemented with an alcohol-containing sustained action disinfectant prior to carrying out an aseptic technique. 

Sustained-action disinfectants

Sustained-action disinfectants (e.g. chlorhexidine and povidone iodine) remove organic contamination and with repeated use, maintain low bacterial hand-counts. They are recommended prior to an  aseptic technique. There is a reported level of allergy to these disinfectants, although the most common reason for 'allergy' is inadequate drying of the hands. Hand-creams may be applied after washing and drying the hands. Some users are genuinely allergic to chlorhexidine and alternative (e.g. povidone iodine) may be used. 

Alcohol-based sustained-action disinfectants

Alcohol-based sustained-action disinfectants are extremely useful and are an excellent means of providing hand disinfection in areas where washing facilities are lacking or where the staff are too busy to disinfect their hands between patients. A container of alcohol-based disinfectant beside each bed in a high dependency unit results in a significant increase in compliance with disinfection policy. A container placed on the clinical notes trolley is useful for hand disinfection between patients during ward rounds.

Alcohol-based disinfectants are also useful where hand-washing facilities are lacking and in remote regions when minor surgical procedures are performed outside the operating theatre.

1.6   ISOLATION FACILITIES 

Single cubicles should be provided only for patients who need high-dependency nursing. If a special ward or unit is available, all patients should be treated as high risk and isolation is not necessary.

Requirements

Protective clothing  - gloves and aprons are essential. Masks should be used if indicated.

1.7   STERILIZATION AND DISINFECTION

1.7.1 Safe decontamination of instruments and equipments:

Cleaning—removing all foreign material (i.e., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object. Disinfection—a process that eliminates many or all microorganisms except spores, and is done with liquid chemicals or by pasteurizing objects.

 Sterilization—a process that completely eliminates or kills all microorganisms, and is done by using sterilizers that provide steam under pressure, dry heat, ethylene oxide (ETO) and other gases, or by using some liquid chemicals for prolonged soaking times.

Safe decontamination of Critical Devices: E.g. Equipments that Enters sterile tissue or vascular system (includes dental instruments) Implants, scalpels, needles, other surgical instruments dental instruments, and endoscopic accessories Sterilization :- Steam under pressure , Dry heat, Ethylene oxide (ETO) gas High level disinfection - Glutaraldehyde based formulations (2%)

Safe decontamination of Semi-Critical Devices: – Touches mucous membranes or broken skin E.g. Flexible endoscopes, laryngoscopes, endotracheal tubes, respiratory therapy and anesthesia equipment, diaphragm fitting rings, and other similar devices. High-level disinfection( exposure time - 20 minutes) :- Glutaraldehyde based formulations (2%)- commonly used - Cidex.

Safe decontamination of Non-Critical Devices: - Touches intact skin Stethoscopes, tabletops, floors, bedpans, furniture, etc. Low-level disinfection (exposure time - 10 minutes) : - Ethyl or isopropyl alcohol (70% to 90%) Phenolic germicidal detergent (dilute per label) Iodophor germicidal detergent (dilute per label) Quaternary ammonium germicidal detergent(dilute per label) Household bleach (sodium hypochlorite 5.25%)

1.7.2  Disinfectant & Concentration : -

Alcohol( Ethyl/Iso-propyl) - 60- 80%

Glutaraldehyde (cidex) - 2% alkaline solution

Povidone iodine( Betadine) - 2.5%

Sodium hypochlorite – (0.1 -1%) Blood spills - 1% (10,000 ppm of chlorine), Surface cleaning - 0.1%(1000 ppm of chlorine) ,Contaminated instruments - 0.2%

Preparing Sodium Hypochlorite solution from Household bleach (5.25%):- Contains 52,500 ppm of available chlorine 1:10 dil contains - 5000 ppm 1:100 dil contains - 50 ppm Organism Chlorine Time for inactivation Mycoplasma - 50 ppm seconds Vegetative bacteria - 5ppm minutes Most bacteria -100 ppm 10 minutes Viruses -200 ppm 10 minutes Hepatitis B Virus -500 ppm 10 minutes HIV - 50 ppm 10 minutes Note: Freshly prepared, no organic matter.

1.7.3  Safe decontamination of Linen:- Soiled linen should be handled with minimum of agitation. Linen soiled with blood and body fluids should be transported in leak proof bags. Linen should be washed with detergent and hot water ( 70 degrees centigrade) for 25 minutes.

1.7.4 Handling Blood Spills :-Wear Gloves Avoid direct contact of gloved hand with spill Cover the spill with paper towel/absorbent material Pour hypochlorite 1% (10 gm/litre) Leave for 10 minutes Clean with absorbent material Wipe the surface with disinfectant Sweep broken glass/fractured plastic with dust - pan and brush

1.8   UWP For Procedures / Hospital settings:

1.8.1 INTRAVENOUS PROCEDURES

These must be performed with great care by an experienced practitioner:

Gloves and aprons should be worn; eye protection is optional.

A closed system (Vacutainer) is recommended but if a hypodermic needle and syringe must be used the whole unit must be discarded in a sharps container. DO NOT RESHEATH NEEDLES.

1.8.2 Collection and transportation of blood from patients

•  Perform an absolute minimum of test on high -risk patients.

• Collect specimens (using a closed system, see above) in secure containers, label clearly and put in a leak –  proof bag with request form. 

•  Venepuncture should only be performed by an experienced phlebotomist.

• Transferring the blood to an appropriate container should be  done slowly and carefully and without creating an aerosol. There is to be NO pipetting of specimens by mouth. Mechanical pipettors should be used.    

•  Needles should not be resheathed but discarded in the sharps container. However, if resheathing is absolutely  necessary, use a mushroom device, which holds the cap so the needle  can be introduced safely. Alternatively, lay the cap on the table with the closed end against anything that offers resistance and insert the needle carefully  - NEVER hold the cap while resheathing.  

1.8.3   Renal dialysis unit / Operation Theatre:

The same basic principle apply to the dialysis unit as to the operating theatre and delivery room:

i.                    Staff should be immunized against hepatitis B before starting work in the unit.

ii.                  All patients should be screened and immunized against hepatitis B. 

iii.                Disposable tubing and heat -labile equipment are recommended for dialysis.

iv.                The outer surfaces of the renal dialysis machine should be cleaned with warm water and detergent.

v.                  The inside of the machine should be cleaned with 1 per cent chloro  (hypochlorite) and rinse thoroughly before further use.

vi.                Disposable filters should be used to prevent contamination with blood.

vii.              Disposable administration lines, dialyser and needles should be used.

viii.            Equipment to be recycled should be able to withstand autoclave temperatures of 121ºC. 

1.9    Segregation & Disposal of hospital waste  :

Waste should be segregated & suitably disinfected before disposal

Classification of Hospital waste:

Infectious/Hazardous : Human Anatomical waste: Human tissues, organs, parts, Blood, Blood bags

Sharps –Needles, syringes, scalpels, blades, glass etc

Soiled –Wound dressings, swabs, mops , bandages

Laboratory - Pathology ,Microbiology

Non Infectious: General waste - paper, plastic bags , bouquets Kitchen waste

Segregation of hospital waste :

Segregation must be done in colour coded containers

Red: All plastics-Disposable syringes, Blood bags, IV tubings, Urine bags etc

Yellow: Body parts, Histopathology specimens, human tissue, organs, microbiology waste, soiled waste, swabs, dressings , mops ,bandages etc

Green : General waste, Kitchen waste

White Puncture proof Containers :Needles, glass ampoules, nails, blades, lancets etc

1.9.1 Disinfection methods :1%Sodium hypochlorite, Autoclaving, Incineration.

1.9.2 Disposal of Waste : Methods of disposal:

Green Bag	Red Bag	Yellow Bag	White container
Non infectious	Infectious	Infectious	Sharp (Infectious/Non infectious)
Municipal Waste	Autoclave & Shredding	Incineration	Drop in 1% Sodium Hypochlorite
			Autoclave & Shredding
Landfill	Landfill	-	Landfill

Limlug

W'here incineration facilities are not available, clinical waste can be treated with lime and buried in the hospital grounds. To do this safely:

1.  Dig a pit, approximately 2.5 m deep. 

2.  Spread a layer of up to 75 cm of clinical waste across the bottom of the pit.

3.  Add a layer of lime. 

4.  Continue layering every 75 cm until the pit is filled to within 0.5 m of the ground.

5.  Fill the pit with earth before starting another.

Limlug is the cheapest and most effective means of getting rid of clinical waste in areas where incineration facilities are not available. Care should be taken not to bury non -biodegradable products, e.g. plastic bags. Tins containing sharps should be buried. Use paper bags when liming. 

    

1.10 Handling & Disposal of HIV positive dead body:

Observe UPs :Avoid direct contact with blood and body fluids. Wear protective gear- gloves, apron. Disinfect with 1% sodium hypochlorite all needle puncture holes, wound drainage and dress with impermeable dressings. Plug all orifices with swabs soaked in 1% sodium hypochlorite solution. Wash and disinfect the body with 1% sodium hypochlorite solution.

Do not embalm the body. Cover the body with robust plastic sheet (150um thick) and cover it tightly with tapes or zipper. Clean the outside plastic sheet with 0.1% sodium hypochlorite if soiled. Soiled linen should be bagged and sent to laundry.It should be disinfected with sodium hypochlorite before washing. Hands should be washed thoroughly after removing gloves and protective clothing.

1.11 Protection and training of staff

• That clear policies of safety, covering inoculation accidents must be available.
• All inoculation accidents must be reported and documented. 
• All staff must be provided with adequate protective clothing.
• All staff must be immunized against hepatitis B.
• Staff should have adequate training in the care of patients who are HIV or hepatitis B - positive and should be aware of the risks involved.  
• All staff handling clinical waste must be adequately trained and aware of the protocol for action in the event of accidental inoculation or body contamination. 
• Frequent lectures are essential to allay fear and promote good morale.