Cleaning

The physical removal (but not destruction) of contamination from, or with, blood, body fluids, dirt and dust from the environment and/or equipment is not just the responsibility of domestic or cleaning staff.

What is the healthcare worker's responsibility?

All healthcare workers have a responsibility for:

Cleaning equipment in between patient use and storing it appropriately (i.e. in a dedicated area; stored off the floor)
Ensuring that work and other surfaces (i.e. windowsills/shelves) are not cluttered

How can we help to maintain a clean environment?

In order to help maintain a clean environment, it is important that:

Floors, work surfaces and cupboards are of a good quality, washable and maintained appropriately
Walls, work surfaces and patient/bedside furniture (tables, lockers, chairs and foot stools) are intact

Routine day-to-day cleaning of the environment is undertaken using a neutral detergent and disposable cleaning equipment.

Cleaning following the discharge of patients with a known infection involves the use of disinfectants, chlorine or sporicidal agents
Cleaning following outbreaks of infections (often called 'deep-cleaning') may involve the use of hydrogen peroxide vapour or ultra-violet light in addition to disinfectants/chlorine
Cleaning equipment should be colour-coded to avoid the risk of cross infection

Every organisation will have specific standards for cleaning the environment and equipment. Let's look at some of the generic terminology and the standards for routine cleaning of both the environment and equipment.

Different terminology

Different hospitals and healthcare facilities have different terminology for the various types and levels of environmental clean, depending on why the cleaning is being undertaken, for example:

Red, amber or green clean
Level 1 or level 2 clean
Terminal clean
Clinical clean
Deep clean
Infection clean
Bed-space clean
Vacation clean

Routine cleaning

Routine cleaning within the general patient environment should be undertaken every day and there should be a service level agreement (SLA) or other document that describes the frequency of cleaning that includes (for example):

All high and low surfaces, including tables/lockers and work surfaces
Floors
Bed frames
Sinks/wash hand basins
Soap, alcohol hand rub/gel and moisturiser dispensers
PPE dispensers
Toilets/bathrooms
High-touch surfaces, for example door handles, call bells, bed controls

Non-invasive equipment

All patient equipment that is non-invasive (i.e. not in direct contact with sterile body cavities, the bloodstream, mucous membranes) must be cleaned in between each episode of patient use, for example:

Blood pressure machines (dinamaps/sphygmomanometers)
Monitors/pumps
IV stands
Wheelchairs/walking aids
Hoists
Commodes/bedpan shells
Dressing and equipment trolleys
Single-use disposable detergent/combined detergent-disinfectant wipes can be used. (Sporicidal wipes should be used for cleaning commodes)
Equipment should then be labelled as 'clean'

Single-use item

Some items or equipment can only be used once (single use). The packaging or item will be marked with a single-use sign.

This sign indicates that the item or equipment is disposable and that it cannot (and must not) be cleaned.

Equipment that is marked with the single-use symbol and that has a number next to it, indicates that the item can be reused on the same patient a specific number of times (single-patient use).

Fluid Spillages

It is everyone’s responsibility to:

Maintain good personal and hand hygiene
Keep a clean and safe working environment, including keeping clinical areas tidy, as the presence of unnecessary clutter interferes with the cleaning process. Even if surfaces have been cleaned thoroughly, they may still become contaminated with dust and dirt. Dust contains dead skin cells and fibres where micro-organisms can survive
Ensure that equipment used is clean and safe

The diagram below is a general overview of how to clean up different types of fluids and spillages. Please note that different products may be used in your organisation and it's your responsibility to know which products are available to use in your area, for example, many organisations now use specially-formulated wipes to clean up blood and bodily fluid spills.

What immediate actions should be taken following exposure to blood/body fluids?

First Aid

For wounds:

Encourage bleeding by gently squeezing the site of injury
Wash the site of injury thoroughly with soap and water
Cover with a waterproof plaster

For mucous membranes:

Irrigate contaminated areas thoroughly with normal saline or tap water

Inform the person in charge

For all incidents, inform the person in charge immediately, so that they can:

Make a risk assessment of the exposure
Arrange for blood to be taken for testing for BBVs from the source of the exposure
Complete an accident/personal injury form

Inform Shared Services/On-Call Manager

Ring shared services within working hours or out of hours manager for further support and guidance.

Some staff will need to attend the emergency department and be seen and assessed as a matter of urgency in the following circumstances:

The HCW has not been immunised against hepatitis B or is unsure of their hepatitis B vaccination status
The HCW is a non-responder to the hepatitis B vaccine
The source patient is known or highly suspected to be HIV positive

Exposure to bloodborne pathogens can be through incidents such as a sharps injury, splash of blood to the eyes and mouth or a wound on your skin.

To reduce the risk, you must:

Handle and dispose of sharps safely
Wear face (including eye) protection if there is a risk of splashing
Cover wounds with a waterproof plaster
Wear Personal Protective Equipment (PPE)

If you get blood or bodily fluids in your mouth, eyes or a wound on the skin:

Thoroughly rinse with running water
Inform your manager
Ring the shared services or on-call manager - in case you need to attend A&E

Please make sure you follow your organisation's incident form procedure.

Linen

What precautions should be taken with linen?

Used linen

Used linen should be:

Handled carefully
Placed immediately into a white plastic laundry sack
Stored in a designated area
Not carried in the arms

In community care settings, where re-usable linen is used, the organisation must either contract with a laundry supplier that meets NHS standards or use disposable items. The use of domestic machines is not acceptable as they will not reach sufficiently high temperatures for soiled or infected linen. Remember that privacy curtains must be changed according to local procedure unless soiled, in which case they must be changed immediately.

Soiled/infected linen

When dealing with soiled or infected linen, you should:

Wear plastic apron/gloves
Handle carefully
Place in a red water-soluble bag and then into the white plastic laundry sack
Store in a designed area

Safe Waste Disposal

Waste products contaminated with blood or other bodily fluids are called ‘infectious/potentially infectious clinical waste’ and should be disposed of in a way that avoids potential harm to staff, patients or visitors.

All clinical staff are responsible for the safe and correct disposal of sharps. To facilitate this, small sharps bins should be located at the point of use, to ensure that used sharps can be disposed of immediately. Sharps should have safety features wherever possible and should be disposed of in the appropriate sharps bin.

You must NEVER overfill a sharps bin and NEVER try to re-sheath a needle.

Remember to refer to your local protocol and training regarding the safe disposal of sharps and the management of healthcare waste in your trust or organisation.

Aseptic Non-Touch Technique (ANTT)

Safe aseptic practice is paramount for protecting patients during invasive clinical procedures, for example, IV therapy, wound care, urinary catheterisation and cannulation.

What is ANTT?

Micro-organisms can easily be introduced into wounds and/or the bloodstream during invasive procedures such as:

Peripheral cannulation
Peripheral and central intravenous preparation and administration
Venepuncture
Blood culture collection
Wound care
Urinary catheterisation
PICC line insertion

Aseptic non-touch technique (ANTT) ensures that only uncontaminated equipment and fluids come into contact with sterile or susceptible body sites during certain procedures, and should be used for any procedure that bypasses the body’s natural defences.

Key parts and key (critical) sites

The fundamental concept of ANTT is the protection of key parts and key (critical) sites during an invasive procedure where there is a risk of contamination via the hands of healthcare staff and/or the environment.

Key parts are the aseptic (sterile) parts of equipment that come into direct contact with a key site and which, if touched either directly or indirectly, could result in infection
Key (critical) sites are any portal of entry for micro-organisms, such as wounds and insertion sites.

ANTT key principles

Always clean hands effectively (hand washing or alcohol hand rub)
Non-touch technique is used at all times to protect key parts
Touch non-key parts with confidence
Take appropriate infection prevention and control precautions

Only sterile items/equipment can come into contact with key sites. If a key part has to be touched, sterile gloves must be worn.

The two types of ANTT

There are two types of ANTT:

Standard ANTT is used for invasive procedures in which it is technically straightforward not to have to touch key parts and key sites directly. Typical procedures include cannulation, IV therapy, venepuncture, simple wound care
Surgical ANTT is used for invasive procedures that are technically complex, long in duration and more invasive. Examples include: surgery and central venous catheter placement and complex or large-scale wound care

All staff undertaking procedures where ANTT is required must undergo training and competency assessment by a dedicated ANTT trainer within their organisation.

Bloodborne Infections

Exposure to bloodborne pathogens can be through incidents such as a sharps injury, splash of blood to the eyes and mouth or a wound on your skin. To reduce the risk, you must:

Wear Personal Protective Equipment (PPE)
Cover wounds with a waterproof plaster
Wear face (including eye) protection if there is a risk of splashing
Handle and dispose of sharps safely

All healthcare staff are responsible for the care that they give, and are accountable (answerable) to someone else for their actions. They have a legal obligation (duty of care) to ensure that patients in their care do not come to any harm as a result of any acts or omissions.

Staff need to be compliant with infection prevention and control (IP&C) clinical practice standards, and act in accordance with policies and guidelines. Non-compliance increases the infection risk to patients.

If IP&C policies/guidelines and practice are not followed and a patient develops an avoidable infection, the care provided could be viewed as negligent, meaning that harm has been caused to the patient as a result of careless omission.

Bacterial Infections

Remind yourself of the bacterial infections that could occur in a hospital or community setting.

Clostridioides difficile (C-Diff)

C. difficile (Clostridioides difficile) is a diagnosis in its own right and must be treated as a separate condition to any other conditions/illnesses affecting the patient. Its spectrum of illness/symptoms ranges from mild to potentially life threatening. It is transmitted by the ingestion of spores, which are shed from colonised or infected patients. Those most at risk are older patients and those who have had a recent course of antibiotics.

Pathogenesis of disease

For the disease to occur there must be disturbance of normal flora (loss of colonisation resistance). This happens especially when our 'good bacteria' are killed off by a broad-spectrum antibiotic, for example, Cefuroxime, Ciprofloxacin, Co-amoxiclav. This leaves room for other 'bad bacteria' such as C. difficile to flourish. C. difficile might start to produce toxins. Toxins act on the gut wall to produce disease. Some antibiotics are worse than others at disturbing the 'good bacteria'; also some strains of C. difficile are more aggressive than others.

C. difficile is found in up to 5% of healthy adults.

MRSA

MRSA stands for Meticillin-Resistant Staphylococcus aureus (S.aureus). MRSA are Staphylococcus aureus bacteria that have become resistant to certain antibiotics. People may be colonised or infected with S.aureus.

Colonisation means that the S.aureus is present in or on the body but is not causing illness.

Infection means that the S.aureus is present and is causing illness.

How is MRSA spread?

MRSA is transmitted primarily by contact with a person who has an infection or is colonised with the bacteria
Skin scales may contaminate the environment
Sputum droplets/aerosols may contaminate if they become airborne through coughing and sneezing
Equipment and environment may contribute to the spread of infection if it has not been cleaned effectively

Dealing with MRSA in a hospital

Standard precautions are essential in preventing cross-infection
Patients must be managed as per your Trust Policy
Patients may be commenced on topical treatment which might consist of body wash, nasal ointment and/or mouth wash

In the community:

MRSA in the community seldom poses a risk; some patients in the community will remain colonised indefinitely. MRSA will live harmlessly on the skin; however, it may pose a risk if a patient needs an invasive procedure or develops a new medical condition. Patients with those with wounds or invasive devices will be at risk of developing infection. For that reason, healthcare workers are reminded to ensure that they record on patients' records their MRSA status and make sure that they communicate it to all healthcare colleagues who are supporting that patient
In the community, the application of standard precautions for all patients is sufficient to stop the transmission of MRSA between patients. This includes application of hand hygiene, correct use of PPE and effective cleaning between patients
In the community, there is rarely a need to apply decolonisation treatments for patients unless an invasive procedure is planned - please see local policies

Who should be screened?

Some patients will be screened for MRSA.
Remember that in the community, patients rarely require screening for MRSA unless requested by an infection prevention and control expert

Gram-negative bloodstream infections

Gram-negative bloodstream infections (BSIs) are a healthcare safety issue. Since April 2017, there has been an NHS ambition to halve the numbers of healthcare-associated Gram-negative BSIs by 2021.

Key healthcare-associated risk factors

This is not an exhaustive list but should be used as a basis to classify Gram-negative BSIs as healthcare associated:

Indwelling vascular access devices (insertion, in situ, or removal)
Urinary catheterisation (insertion, in situ with or without manipulation, or removal)
Other devices (insertion, in situ with or without manipulation, or removal)
Invasive procedures (e.g. endoscopic retrograde cholangio-pancreatography, prostate biopsy, surgery including, but not restricted to, gastrointestinal tract surgery)
Neutropenia (<500/mL at time of bacteraemia)
Antimicrobial therapy within the previous 28 days
Hospital admission within the previous 28 days
E.coli

What to do When Ill

All staff will be personally accountable for their actions and responsible for ensuring that they comply with infection prevention and control policies of their place of work.

Staff must understand their legal duty to take reasonable care of their health, safety and security and that of other persons who may be affected by their actions and for reporting untoward incidents and areas of concern.

Any breach in infection control policies or practice will place staff, patients and visitors at risk and subsequently the completion of a clinical incident form will be required.

All staff are obligated professionally, contractually and legally to adhere to policies of their place of work that will help to prevent and control infections

If you are unwell, then refer to your local local policies. Shared services can advise you about fitness to work if you are suffering from infections such as coughs, colds, flu, diarrhoea or vomiting. It is normally advised that if you have been unwell with an infectious illness, you should not return to work for 48 hours after symptoms have cleared.

Although it is widely believed that flu is very like the common cold, this is not the case. Flu has symptoms that differ from those of a cold, including a high temperature, headache, shivery feelings, lack of energy and aching limbs. Having the flu vaccine yearly will keep you well and protect patients.

You should ask shared services for advice if you suffer from skin conditions such as psoriasis or eczema, especially if this is on your hands. To reduce the risk of infection it is important to use moisturiser to avoid hands becoming dry and cracked.

Session Summary

Please ensure you are aware of your organisation's infection prevention policies and procedures. This information may be found on your organisation's intranet or website. For further information please contact your organisation's infection prevention and control lead. National guidance includes:

National Resource for Infection Control (www.nric.org.uk)
Infection Control Services (www.infection-control-services.co.uk)
World Health Organization (www.who.int/)
Infection Prevention Society (www.ips.uk.net)
Centres for Disease Control (www.cdc.gov)
Public Health England (www.gov.uk/government/organisations/public-health-england)
NHS Improvement (https://improvement.nhs.uk)
Aseptic Non-Touch Technique (www.antt.org/)
Health and Safety Executive – Health Surveillance (www.hse.gov.uk/health-surveillance)

Organisations already undertake health surveillance for staff on known employment risks to health. As part of this work all organisations should undertake monitoring of sharps injury patterns and incidents in order to inform ongoing risk assessments and evaluate changes to practice. This should be reported within the organisation as part of broader health and safety reporting.

Key Points

The prevention and control of healthcare-associated infections are everybody’s responsibility
It is a legal requirement that all registered providers of health and social care register with the Care Quality Commission (CQC), and it is a requirement of registration that providers comply with the Health and Social Care Act 2008, Code of Practice on the prevention and control of infection
HCAIs are largely preventable and all staff are responsible for ensuring that they comply with IP&C policies/guidance and that they protect patients/clients in their care as far as is practically possible

Next Steps

Continue to the Infection Prevention and Control Level 2 eAssessment. This should be completed to demonstrate the required knowledge and understanding and to complete the training. Remember to also familiarise yourself with local procedures.

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