2.5 TRUST POLICY AND PROCEDURES FOR BLOOD AND BODY FLUID SPILLAGE

Transcription

1 2.5 TRUST POLICY AND PROCEDURES FOR BLOOD AND BODY FLUID SPILLAGE Reference Number CL-RM/2013/051 Version 2.1 Status Final Author: Helen Forrest Job Title Lead Nurse Infection Prevention and Control Version / Amendment History Version Date Author Reason 2 October June 2016 J. Toplass H. Forrest Reviewed and Updated Review and updated Intended Recipients: All medical and clinical staff, Associate Directors, Service Managers, Divisional Nurse Director, Clinical Governance Facilitator, Matrons. Training and Dissemination: Dissemination via the Trust Intranet. Included in Infection Control Mandatory Training To be read in conjunction with: Trust Policy for Standard Infection Control Precautions; Trust Policy and Procedure for Hand Hygiene; Trust Policy for Personal Protective Equipment; Trust policy for the management of inoculation incidents, Trust Waste policy. Trust policy for Cleaning and Disinfection In consultation with and Date: Health and Safety (June 2016) Infection Control Operational Group ( ), Infection Control Committee ( ) EIRA stage one Completed Yes Stage two Completed N/A Procedural Documentation Review Group Assurance Approving Body and Date Approved Infection Control Committee Management Executive Date of Issue July 2016 Review Date and Frequency May 2019 (then every 3 years) Contact for Review Lead Nurse Infection Prevention and Control 1

2 Executive Lead Signature Approving Executive Signature Chief Nurse Chief Nurse 2

3 Contents Section 1 Introduction 2 Purpose and Outcomes 3 Managing the Policy for Blood and Body Fluid Spillage 3.1 General Principles 3.2 Methods of Treating Blood and Body Fluid Spills Blood, high risk body fluids and body fluids with visible blood present: Vomit, diarrhoea, infective urine, no visible blood present. (Fluids potentially infectious but not known to contain blood borne viruses). General body fluid spillages (spillages of urine and faeces, which do not appear to have blood present): Carpeted areas Soft Furnishings 4 Definitions Used 5 Key Responsibilities 6 Monitoring Compliance and Effectiveness 7 References 3

4 1 Introduction Contamination of the environment / equipment with blood and body fluids may provide a reservoir of pathogens, which could result in cross-infection to patients, staff and visitors. 2 Purpose and Outcomes As part of standard infection control precautions all staff should be aware of the procedure for cleaning of blood and body fluid spillages, to prevent cross-infection Any staff responsible for decontamination of spillages and equipment has a duty, under the Health and Safety at Work Act, to do so safely and correctly to ensure the workplace is free from hazards. Adherence to this policy will result in a safe clean environment following a blood / body fluid spillage. 3 Managing the Policy for Blood and Body Fluid Spillage 3.1 General Principles Body fluid spillages must be cleaned up promptly following the methods outlined below. If the member of staff is unable to do this immediately, then the area must be made safe, including the use of a floor safety sign and it must be reported urgently to an appropriate person to be actioned. Disposable gloves and aprons must be worn and fresh solutions in clean containers should be used and discarded after each use. Mop buckets if used should be washed with detergent and water and stored dry after use. Mop heads should be changed after each use. Spillages onto linen/ curtains etc must be managed in line with the Trust linen policy. 3.2 Methods of Treating Blood and Body Fluid Spills Blood, high risk body fluids and body fluids with visible blood present: Cleaning agents: 1% Sodium hypochlorite (10,000ppm av. Chlorine) and detergent 1. Collect protective personal equipment and other equipment (mop, bucket, paper towels, offensive / infectious waste bags etc.) 2. Put on personal protective equipment, protect eyes and mouth with goggles/visor and mask or full face visor if splash or spray is anticipated. 3. Soak up excess spillage with paper towels and discard into offensive waste bag according to waste policy. 4

5 4. If there is broken glass in the spillage DO NOT pick it up with your fingers use a scoop of cardboard or dust pan and brush and dispose of into Sharps container (a large container will be needed for dustpan and brush). 5. Wipe spillage area with undiluted 1% sodium hypochlorite (10,000ppm available chlorine) using disposable paper towels. 6. Wash off with hot water and detergent, dispose of the towels offensive waste (infectious waste if patient is known or suspected to have an infection) according to the waste policy. 7. Leave the spill area clean and dry. 8. Remove apron and gloves and discard offensive waste bag according to waste policy. 9. Wash hands Vomit, diarrhoea, infective urine, no visible blood present. (Fluids potentially infectious but not known to contain blood borne viruses). Cleaning agent: Actichlor plus (1,000ppm av. Chlorine) 1. Collect protective personal equipment and other equipment (mop, bucket, paper towels, infectious waste bags etc.) 2. Put on personal protective equipment, protect eyes and mouth with goggles/visor and mask or full face visor if splash or spray is anticipated 3. Soak up excess spillage with paper towels and discard into infectious waste bag according to waste policy. 4. If there is broken glass in the spillage DO NOT pick it up with your fingers use a scoop of cardboard and dispose of into Sharps container. 5. Clean the area using Actichlor plus diluted to 1000ppm av. Chlorine, (this does not need rinsing off). 6. Leave the spill area clean and dry. 7. Remove apron and gloves and discard into infectious waste bag according to waste policy. 8. Wash hands General body fluid spillages (spillages of urine and faeces, which do not appear to have blood present): Cleaning agent: neutral detergent 1. Collect protective equipment and equipment (mop, bucket, offensive waste bags etc.) 2. Put on personal protective equipment, protect eyes and mouth with goggles/visor and mask or full face visor if splash or spray is anticipated 3. Soak up excess spillage with disposable paper towels; discard into offensive waste bag according to waste policy. 4. Clean area with detergent and hot water, dry thoroughly. 5. Remove apron and gloves and discard into offensive waste bag. 6. Wash hands. 5

6 3.2.4 Carpeted areas Where a spillage has occurred in a carpeted area, treat according to the type of spillage outlined above. Contact the facilities help desk as soon as possible in order that the carpet can be domestically cleaned after the spillage has been treated. If the carpet is unable to be cleaned then the carpet must be replaced/discarded Soft Furnishings (cushions, floor mats etc) Soft furnishings are not recommended for use in clinical areas. Infection Prevention and Control must be contacted prior to purchase of such items to determine their suitability. If such items are present and become soiled advice must be sought from the infection prevention and control team regarding decontamination. Items that cannot be decontaminated will be discarded. Definitions Used Pathogens High Risk Body Fluids Low risk Body Fluids Micro-organisms with the ability to cause disease. Blood, breast milk, cerebral spinal fluid, amniotic fluid, pleural fluid, semen, vaginal secretions, synovial fluid, body fluids containing visible blood, saliva associated with dentistry, wound exudates. Vomit, diarrhoea, urine, with no visible blood present 5 Key Responsibilities/Duties 5.1 Infection Prevention and Control Team Will review and update the policy in line with up to date guidance Will provide on-going support and advice as required Will ensure blood spillage procedure is covered in Mandatory training. Will ensure COSHH data sheets are provided to divisions when new products are introduced. 5.2 Divisional Nurse Directors / Clinical Governance Facilitators/ Matrons/Clinical Leads / Sisters / Charge Nurses Will ensure all staff are aware of and adhere to this policy. Will ensure that COSHH data sheets are easily accessible to all staff. Are responsible for ensuring adequate stock levels of appropriate disinfectants are available in clinical areas. Are responsible for ensuring any equipment purchased is compatible prior to purchase with the procedure to manage a blood spillage. Will ensure staff are released to attend appropriate training. 6

7 5.3 Employees Are responsible for ensuring their own practice complies with this policy and for encouraging others to do so. 6 Monitoring Compliance and Effectiveness Monitoring Requirement : The IPCT and Facilities Management will monitor compliance with Environmental cleanliness Any non compliance issues will be reported to the divisional Matron / Head of Nursing as appropriate. Monitoring Method: Environmental cleanliness and the presence of blood / body fluids spillages will be monitored as part of the annual infection control audit programme, individual area cleanliness auditing and by the Patient Led Assessment (PLACE) Team. Report Prepared by: Lead Nurse Infection Prevention and Control Monitoring presented to: Report Non-compliance will be reviewed through the Infection Control Operational Group Frequency of Report As required 7 References Department of Health (1992) Management of Health and Safety at Work Regulations. Department of Health (1998) Guidance for clinical health care workers: protection against infection with blood-borne viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. 7