Good practice in infection

prevention and control

Guidance for nursing staff
 …effects [from
hospital acquired infection]
vary from discomfort for
the patient to prolonged or
permanent disability and a
small proportion of patient
deaths each year are
primarily attributable to
hospital acquired
infections.
(National Audit Office, 2000)

Note about language

The term ‘patient’ has been used throughout this text
but this can also be understood to mean client or
resident.

This publication contains information, advice and guidance to

help members of the RCN. It is intended for use within the UK
but readers are advised that practices may vary in each country
and outside the UK.
The information in this booklet has been compiled from
professional sources, but its accuracy is not guaranteed. Whilst
every effort has been made to ensure the RCN provides accurate
and expert information and guidance, it is impossible to predict
all the circumstances in which it may be used. Accordingly, the
RCN shall not be liable to any person or entity with respect to
any loss or damage caused or alleged to be caused directly or
indirectly by what is contained in or left out of this website
information and guidance.
Published by the Royal College of Nursing, 20 Cavendish Square,
London, W1G 0RN
© 2005 Royal College of Nursing. All rights reserved. No part of
this publication may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means electronic,
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not be lent, resold, hired out or otherwise disposed of by ways of
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is published, without the prior consent of the Publishers.
 ROYAL COLLEGE OF N URSI NG

Good practice in infection

prevention and control
Guidance for nursing staff

Contents
Foreword 2
Introduction 3
The general principles of infection prevention and control 3
1. Hand hygiene 4
2. Using personal protective equipment 4
3. Safe handling and disposal of sharps 5
4. Safe handling and disposal of chemical waste 6
5. Managing blood and bodily fluids 6
! Spillages 6
! Collecting, handling and labelling of specimens 6
6. Decontaminating equipment 7
! Cleaning 7
! Disinfection 8
! Sterilisation 8
7. Achieving and maintaining a clean clinical environment 9
8. Appropriate use of indwelling devices 9
9. Managing accidental exposure to blood-borne virus 10
10. Good communication 11
11. Training 11

Variant Creutzfeldt Jakob Disease (vCJD) 12

Methicillin-resistant Staphylococcus aureus (MRSA) 12
References 12
Useful reading 13
Useful websites 15
Glossary 15
Appendix 1 Infection control checklist 16
10-Step handwashing guide Inside Back Cover

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GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

Foreword

Infection prevention and control is deservedly high on the agenda

for patients, nurses and decision makers. The RCN Wipe it Out
campaign is part of our mission to promote excellence in practice.
This updated guidance will be a valuable tool to help you and your
team reduce the prevalence of health care associated infections
(HCAIs). Use it together with the other Wipe it Out leaflets and
posters to promote good practice. It will help you to spare patients’
anxiety, pain, inconvenience, disability and even death.
Infection control is an essential component of care and one which
has too often been undervalued in recent years. The frontlines of
twenty-first century care combine tremendous technology and
expertise side by side with staff shortages and concerns about
hygiene. Patients and their families are concerned about whether
we are getting the basics right – nutrition, dignity, hygiene.
Hand washing is far less glamorous than hi-tech interventions, but
it is known to be the single most important thing we can do to
reduce the spread of disease. By encouraging good practice among
members of the health care team – and visitors – you will be
helping patients.
A safe working environment is a safe caring environment. This
guidance covers important issues including disposing of waste,
managing sharps, blood and bodily fluids as well as achieving and
maintaining a clean clinical environment.You will be able to
appreciate how to put the guidance into practice whether you
nurse in hospital, in general practice or in patients’ homes.
You may also appreciate that improvements need to be made in
infection prevention and control in your workplace. This is an
opportunity for you to share evidence on best practice, build
support from colleagues, patients, other departments and other
organisations and present the convincing case for change. It is part
of transforming the culture of health care through raising
standards and designing person-centred services. It is as central
to patient care as effective hand washing.
The RCN is calling for a number of improvements, including
training in infection control for all health care staff, 24 hour
availability of cleaning teams and onsite provision of staff
uniforms and changing facilities. By campaigning together, we
can bring about significant positive improvements for patients,
the public and the health care team.

Beverly Malone RN PhD FAAN

General Secretary

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 ROYAL COLLEGE OF N URSI NG

Introduction The general

As part of its Wipe it out campaign the Royal College
principles of
of Nursing has revised its guidance on good practice
in infection prevention and control. This new updated infection prevention
guidance emphasises the key roles that nursing staff
and other health care workers in the NHS and
independent sector have in helping to reduce the
and control
prevalence of health care associated infections
(HCAIs). (standard precautions)
Every health care worker plays a vital part in helping
to minimise the risk of cross infection – for example, Standard precautions (formerly known as universal
by making certain that hands are properly washed, precautions) underpin routine safe practice,
the clinical environment is as clean as possible, protecting both staff and clients from infection. By
ensuring knowledge and skills are continually applying standard precautions at all times and to all
updated and by educating patients and visitors. patients, best practice becomes second nature and the
This publication includes information on the general risks of infection are minimised. They include:
principles of infection prevention and control,
including standard infection prevention and control 1 achieving optimum hand hygiene
practice, decontamination, achieving and
2 using personal protective equipment
maintaining a clean clinical environment, what to do
in the event of an invasive injury/accident, and the 3 safe handling and disposal of sharps
importance of good communication. Two small
sections give guidance on variant Creutzfeldt Jakob 4 safe handling and disposal of clinical waste
Disease (vCJD) and methicillin-resistant
Staphylococcus aureus (MRSA). There is also a Useful 5 managing blood and bodily fluids
information section with signposts to initiatives and
policies being implemented around the UK. 6 decontaminating equipment

7 achieving and maintaining a clean clinical

environment

8 appropriate use of indwelling devices

9 managing accidents

10 good communication – with other health care

workers, patients and visitors

11 training/education.

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GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

1. Hand hygiene inappropriately placed facilities to the notice of their

managers (or matron). They also have a duty of care
Hand hygiene is widely acknowledged to be the single to patients and themselves and must use facilities
most important activity for reducing the spread of provided to prevent cross infection.
disease, yet evidence suggests that many health care
professionals do not decontaminate their hands as Hand drying
often as they need to or use the correct technique Improper drying can recontaminate hands that have
which means that areas of the hands can be missed. been washed.Wet surfaces transfer organisms more
The diagram on page 5 demonstrates the hand effectively than dry ones and inadequately dried
hygiene procedure that should be followed when hands are prone to skin damage. Disposable paper
washing with soap and water or using an alcohol hand towels of good quality should be used to ensure
hand gel or rub. hands are dried thoroughly. Hand towels should be
CTICEININFECTIONCONTROL conveniently placed in wall mounted dispensers close
Hands should be decontaminated before direct to hand washing facilities.
contact with patients and after any activity or
contact that contaminates the hands, including
following the removal of gloves. While alcohol hand 2. Using personal protective
gels and rubs are a practical alternative to soap and equipment
water, alcohol is not a cleaning agent. Hands that are
visibly dirty or potentially grossly contaminated Personal protective equipment (PPE) is used to
must be washed with soap and water and dried protect both yourself and your patient from the risks
thoroughly. Hand preparation increases the of cross-infection. It may also be required for contact
effectiveness of decontamination.You should: with hazardous chemicals and some
pharmaceuticals. PPE includes items like gloves,
! keep nails short, clean and polish free aprons, masks, goggles or visors. In certain situations
! avoid wearing wrist watches and jewellery, such as theatre, it may also include hats and footwear.
especially rings with ridges or stones
Disposable gloves
! artificial nails must not be worn Gloves should be worn whenever there might be
! any cuts and abrasions should be covered with a contact with blood and body fluids, mucous
waterproof dressing. membranes or non intact skin. They are not a
substitute for hand washing. They should be put on
Remove your wristwatch and any bracelets and roll immediately before the task to be performed, then
up long sleeves before washing your hands (and removed and discarded as soon as the procedure is
wrists). In addition, bear in mind the following completed. Hands must always be washed following
points: their removal.
Facilities The choice of glove should be made following a
Adequate hand washing facilities must be available suitable and sufficient risk assessment of the task, the
and easily accessible in all patient areas, treatment risk to the patient and risk to the health care worker
rooms, sluices and kitchens. Basins in clinical areas (ICNA, 2002). Nitrile or latex gloves should be worn
should have elbow or wrist lever operated mixer taps when handling blood, blood-stained fluids, cytotoxic
or automated controls and be provided with liquid drugs or other high risk substances.
soap dispensers, paper hand towels and foot-operated Polythene gloves are not suitable for use when dealing
waste bins (NHS Estates, 2002).Alcohol hand gel with blood and/or blood and body fluids, ie. in a
must also be available at ‘point of care’ in all primary clinical setting. Neoprene and nitrile gloves are good
and secondary care settings (National Patient Safety alternatives for those who are sensitive to natural
Agency (2004). rubber latex. These synthetic gloves have been shown
All health care workers should bring any lack of, or to have comparable in-use barrier performance to

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 ROYAL COLLEGE OF N URSI NG

natural rubber latex gloves in laboratory and clinical 3. Safe handling and disposal
studies.Vinyl gloves can be used to perform many of sharps
tasks in the health care environment, but are not
appropriate when handling blood, blood-stained Sharps include needles, scalpels, stitch cutters, glass
fluids, cytotoxic drugs or other high risk substances. ampoules and any sharp instrument. The main
Please check the local policy for your workplace. hazards of a sharps injury are hepatitis B, hepatitis C
and HIV. Second only to back injuries as a cause of
Disposable plastics aprons
occupational injuries amongst health care workers,
These should be worn whenever there is a risk of between July 1997 and June 2002, there were 1,550
contaminating clothing with blood and body fluids reports of blood-borne virus exposures in health care
and when a patient has a known infection, for workers – of which 42 per cent were nurses or
example, direct patient care, bed making or when midwives.
decontaminating equipment.You should discard
them as soon as the intended task is completed and To reduce the risk of injury and exposure to blood-
then wash your hands. They must be stored safely so borne viruses, it is vital that sharps are used safely
that they don’t accumulate dust which can act as a and disposed of carefully, following your workplace’s
reservoir for infection. Impervious gowns should be agreed policies on safe working procedures.Your
used when there is a risk of extensive contamination employer should provide targeted education and
of blood or body fluids. awareness training for all health care workers.
Some procedures have a higher than average risk of
Masks, visors and eye protection causing injury. These include intra-vascular
These should be worn when a procedure is likely to cannulation, venepuncture and injection. Devices
cause blood and body fluids or substances to splash involved in these high-risk procedures are:
into the eyes, face or mouth. Masks may also be ! IV cannulae
necessary if infection is spread by an airborne route –
! winged steel – butterfly – needles
for example, multi drug resistant tuberculosis or
severe acute respiratory syndrome (SARS) – see ! needles and syringes
information on the Health Protection Agency website ! phlebotomy needles.
(www.hpa.org.uk).You should ensure that this
You should ensure that:
equipment fits correctly, is handled as little as
possible and changed between patients or operations ! sharps are not passed directly from hand to hand
(see Figure 1). Masks should be discarded ! handling is kept to a minimum
immediately after use. ! needles are not broken or bent before use or
Figure 1: Nurse wearing a mask in the correct position disposal
! syringes or needles are not dismantled by hand
and are disposed of as a single unit
! needles are never re-sheathed
! staff take personal responsibility for any sharps
they use and dispose of them in a designated
container at the point of use. The container should
conform to UN standard 3291 and British
Standard 7320
! sharps containers are not filled by more than two
thirds and are stored in an area away from the
public
! sharps trays with integral sharps bins are in use
! sharps are disposed of at the point of use

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GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

! sharps boxes are signed on assembly and disposal 5. Managing blood and
! sharps are stored safely away from the public and
bodily fluids
out of reach of children
Spillages
! staff are aware of inoculation injury policy.
These should be dealt with quickly, following your
If you notice that any of the above procedures are not workplace’s written policy for dealing with spillages.
being followed properly by colleagues you should The policy should include details of the chemicals
seek advice from your infection control team who will staff should use to ensure that any spillage is
provide education for staff on safe use and disposal of disinfected properly, taking into account the surface
sharps. where the incident happened – for example, a carpet
Innovative products are available that can reduce the in a patient’s home or hard surface in a hospital.
risk of sharps injuries.While they may be more
Collecting, handling and labelling specimens
expensive, their cost can be offset against the savings
achieved in reducing sharps injuries. Guidance on the A written policy should be in place for the collection
most appropriate evaluated safety devices is available and transportation of laboratory specimens.You
from the NHS Purchasing and Supply Agency – see should:
sources of further information for more details. For ! be trained to handle specimens safely
information on what to do in the event of an invasive ! collect samples (wearing protective clothing) in
sharps injury, see page 11 of this guidance. an appropriate sterile and properly sealed
container
4. Safe handling and disposal of ! complete form using patient labels (where
chemical waste available) and check that all relevant information
is included
Your workplace should have a written policy on waste ! take care not to contaminate the outside of the
disposal, which provides guidance on all aspects, container and the request forms
including special waste, like pharmaceuticals and
! ensure that specimens are transported in
cytotoxic waste, segregation of waste and an audit
accordance with the Safe Transport of Dangerous
trail. This should include colour coding of bags used
Goods Act 1999
for waste, for example:
! make sure specimens are sent to the laboratory as
! yellow bags for clinical waste
soon as possible. Under no circumstances should
! black bags for household waste specimens be left on window sills or placed in
! special bins for glass and aerosols staff pockets
! colour coded bins for pharmaceutical or cytotoxic ! once results are available check and enter into the
waste. patient’s records.Any results outside normal
All health care and support staff should be instructed limits should be highlighted to the patient’s
in the safe handling of waste, including disposal and clinician.Act on any infection control issues
dealing with spillages. Trusts should consider systems immediately.
for segregating waste that can be recycled. If you feel you need further training in any of the
If any of the above, speak to your infection control team who will
above are not be able to provide you with advice and training.
being
implemented
health care
staff should
lobby their
employers.

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 ROYAL COLLEGE OF N URSI NG

6. Decontaminating Cleaning
equipment This uses water and detergent (enzymatic cleaner) to
remove visible contamination but does not
As inadequate decontamination has frequently been necessarily destroy micro-organisms, although it
associated with outbreaks of infection in hospitals, it should reduce their numbers. Effective cleaning is an
is vital that re-usable equipment is scrupulously essential prerequisite to both disinfection and
decontaminated between each patient. To ensure that sterilisation.
control of infection is maintained at a high level, all
Manual cleaning should be performed with extreme
health care staff must be aware of the implications of
care and only if no other method or device is available.
safe decontamination and their responsibilities to
It is more efficient to use an automated/validated
their patients, themselves and their colleagues.
method, for example, an automated washer-disinfector
Use table 1 to make an appropriate choice of or ultrasonic bath. For more detailed information, see
decontamination method. A protocol for the local decontamination of surgical
Decontamination is the combination of processes – instruments (NHS Estates, 2004a).
cleaning, disinfection and sterilisation – used to ensure Disinfection
a re-usable medical device is safe for further use.
This uses chemical agents or heat to reduce the
Single use equipment (where the item can only be number of viable organisms. It may not necessarily
used once) should not be reprocessed or re-used. inactivate all viruses and bacterial spores.Where
Devices designated for single patient use (where the equipment will tolerate sterilisation disinfection
item can be repeatedly used for the same patient) will should not be used as a substitute.
be clearly marked by a symbol. Such devices include
Washer-disinfectors should be used only by those
nebulisers, disposable pulse oximeter probes and
with the correct training and in conjunction with a
certain specified intermittent catheters.
suitable detergent that has been recommended by the
Figure 2: Symbol for
single use equipment
manufacturer or trust policy. Following the rinse
cycle, items should be checked for cleanliness.
Machines must be maintained, validated and comply
with HTM 2030.
If an ultra sonic cleaner is used the machine should

Table 1: decontamination according to associated risks

Equipment description Level of cleaning needed Examples

High risk Equipment that: Equipment must be cleaned Examples include surgical
and sterilised – fully instruments.
! enters a sterile body cavity decontaminated – after each
! penetrates the skin patient use. It should be left
in a sterile state for
! touches a break in the skin subsequent use.
or mucous membranes.

Medium risk Equipment that touches Equipment does not need to Examples include a bedpan.
intact skin or mucous be sterile at the point of use
membranes. but must be cleaned and
sterilised (decontaminated)
between each patient.

Low risk Equipment that does not Equipment must be cleaned Examples include an
touch broken skin or mucous and/or disinfected after use. ophthalmoscope receiver;
membranes, or is not in a bedframe
contact with patients.

Adapted from the Medical Devices Agency publication, Sterilisation, disinfection and cleaning of medical equipment (1996).

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GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

be drained, cleaned, dried, covered and left dry until ! a bench top vacuum steam steriliser. These must
required for further use. Requirements for testing can be installed, validated and maintained
be found in HTM 2030. Log books and records must appropriately according to HTM 2010; MDA DB
be kept by the designated person for both types of 9804 and MDA DB 2002(06).
machines
All steam sterilisers are subject to the Pressure
Chemical disinfectants are classified generically Systems Safety Regulations 2000 and must be
and their biocidal capabilities vary. While most are examined annually by a competent person.
capable of inactivating bacteria and enveloped
The following table shows the times and
viruses, many are not so effective against non
temperatures usually used for steam sterilisation:
enveloped viruses – for example, the hepatitis
viruses and also cysts and bacterial spores. Efficacy
depends on choosing and using the disinfectant Table 2: steam sterilisation times and temperatures
correctly. Chemical disinfection is not as effective as
Sterilising Approximate Minimum hold
heat disinfection. For further information on the temperature pressure (bar) time in minutes
most appropriate disinfectants to use in a range in
community setting, see Infection control guidance for centigrade
general practice (Infection Control Nurses min – max

Association and Royal College of General 134 – 137 2.25 3

Practitioners, 2003). Trusts will have their own policy
for the use of appropriate disinfectants and all health 126 – 129 1.5 10
care staff who use chemicals must receive
education/training before handling. 121 – 124 1.15 15

The use of disinfectants is governed by the Control of

Substances Hazardous to Health (COSHH) regulations,
which ensure that employers must provide staff with
information, instruction and training.
The Medical Devices Agency bulletin DB 2002 (06)
Sterilisation provides guidance on purchase, operation and
This ensures that an object is free from viable micro- maintenance of bench top steam sterilisers (2002). It
organisms, including bacterial spores. Both acute and draws attention to the need for:
primary care trusts should actively work towards ! daily testing by the user
achieving central sterilising of reusable equipment, ! periodic testing by a qualified engineer
using local sterile services department (SSD) where
! operator training
available.
! knowledge of the legal and insurance aspects of
All SSDs that supply re-sterilised instruments to
ownership and use
other organisations are bound by a European
directive (93/42/EEC), which safeguards standards of ! comprehensive record keeping of testing.
quality.Advantages include having a cost-effective
Finally, bear in mind that the effectiveness of
system that is quality controlled, has a tracking
decontamination may be hindered at any stage of the
system and is managed and operated by trained staff
process by:
in a purpose-built environment.
! poor choice of method
Where using your SSD is not possible, alternatives
are: ! poor technique

! using pre-sterilised, single-use, disposable items. ! lack of maintenance of equipment

The advantages include convenience and
! inadequate monitoring
suitability for use in areas where decontamination
could be hard to achieve. ! poor handling or storage of equipment.

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 ROYAL COLLEGE OF N URSI NG

7. Achieving and maintaining a schedule that details the items and environments to
clean clinical environment be cleaned:
! before and after each clinic session
A dirty clinical environment is one of the factors that
! daily
may contribute towards infection rates. Conversely,
high standards of cleanliness will help to reduce the ! weekly
risk of cross-infection. Good design in buildings, ! monthly
fixtures and fittings is also important to allow
! annually.
efficient cleaning. According to guidance published
by NHS Estates – an agency of the Department of Additionally, cleaning equipment such as vacuums,
Health – health care facilities should be patient floor scrubbing machines and polishers should be
friendly and offer a safe environment for care (NHS cleaned and properly maintained. Information on
Estates, 2004b). recommended methods of cleaning and disinfection
should be available for staff. Detailed guidance is
Cleaning removes contaminants, including dust and
available from Infection control guidance for general
soil, large numbers of micro-organisms and the
practice (Infection Control Nurses Association and
organic matter that may shield them, for example,
Royal College of General Practitioners, 2003).
faeces, blood and other bodily fluids.

In hospitals
8. Appropriate use of
NHS Estates has published a variety of guidance
indwelling devices†
under its clean hospitals programme, which began in
2000. National standards of cleanliness for the NHS Make sure you use the correct technique when using
(NHS Estates, 2002b) provides trust cleanliness indwelling devices as it is vital to reduce the risk of
scores.An implementation toolkit and audit materials patients acquiring infection. 80 per cent of urinary
are also available. The NHS healthcare cleaning infections can be traced back to indwelling urinary
manual (NHS Estates, 2004c) acts as a resource to catheters. These infections arise because catheters
assist in training traumatise the urethra as well as providing a pathway
and setting for bacteria and other organisms to enter the bladder.
About nine per
standards to help The longer such catheters are in place, the higher the
cent of inpatients risk of infection.
promote high
have a hospital quality and Similarly, over 60% of blood infections are introduced
acquired infection consistent service by intravenous feeding lines, catheters or similar
at any one time, levels. Patient devices. This is because micro-organisms on the
equivalent to at Environment patient’s skin (either those naturally present or those
least 100,000 Action Teams acquired whilst in hospital) can gain entry to deeper
(PEATs) regularly tissues or the bloodstream when a cannula or
infections a year
inspect hospitals catheter is inserted into a vein.
(National Audit
to assess a wide Follow your work place policy on the use of
Office, 2000) range of indwelling devices.You can access further
cleanliness issues information on use of intravenous feeding lines;
in wards, reception and waiting areas,A&E, corridors, urinary catheters; peripheral intravenous cannulae
furnishings, linen and external appearance. and central venous lines at www.rcn.org.uk/mrsa

In general practices
† Adapted from: Department of Health, Winning Ways -
Nurses who work in a GP practice should have a Working together to reduce healthcare associated infection
regular planned, written and monitored cleaning in England, December 2003

9
GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

Figure 3: managing accidents

9. Managing accidental
exposure to blood-borne Immediately stop what you are
virus doing and attend the injury
Encourage bleeding of the wound by applying
Accidental exposure to blood and body fluids can gentle pressure – do not suck.
occur by:
! percutaneous injury – for example, from needles,
instruments, bone fragments or significant bites Wash well under running water.
that break the skin
! exposure of broken skin – for example, abrasions,
Dry and apply a waterproof
cuts or eczema dressing as necessary.
! exposure of mucous membranes, including the
eyes and the mouth.
Figure 3 illustrates the action that should be taken
immediately following accidental exposure to bodily If blood and body If blood and body fluids
fluids, including blood. fluids splash splash into your mouth,
into eyes, irrigate do not swallow. Rinse
Managing the risk of HIV with cold water. out several times with
If there has been exposure to blood, high risk blood cold water.
and body fluids or tissue known or strongly suspected
to be contaminated with HIV, the Chief Medical
Officer’s Expert Advisory Group on AIDS recommends
the use of antiretroviral post exposure prophylaxis
Report the incident to your occupational
(PEP). Ideally, this is given within an hour of exposure
health department – or A&E out of hours –
and the full course lasts for four weeks.Where
and your manager.
treatment is delayed but the source person proves to be
HIV positive, PEP can be given up to two weeks from
the time of the injury. Advice and follow-up care
from your occupational health department are Complete an accident form.
essential.

Managing the risk of hepatitis B (HBV)

Seek help to initiate an investigation into the
The risk of contracting HBV from needlestick
cause of the incident and risk assessment.
exposure in a health care setting is much higher than
HIV because the virus is both more infectious and
has greater prevalence.As a result, the RCN
recommends that all nurses should be vaccinated
against hepatitis B with monitoring of antibody titre In the case of an If the injury is from a used
levels and boosters, where inoculation injury occurs injury from a needle or instrument, risk
and titres are low. Staff should take responsibility for clean/unused assessment should be
this and should contact the occupational health instrument or carried out with a
department if there are any concerns. needle, no further microbiologist, infection
action is likely. control doctor or consultant
for communicable disease
control. Consent is required
if a patient’s blood needs to
be taken.

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 ROYAL COLLEGE OF N URSI NG

10. Good communication The RCN has produced leaflets for patients and
visitors as part of its Wipe it out campaign.You can
Anxiety about HCAIs, including MRSA, is often based obtain copies of these by downloading them from the
on ignorance about the risks of infection and the RCN website at www.rcn.org.uk/mrsa
precautions to prevent transmission. Nurses can do a
great deal to allay fears by communicating effectively,
without breaking confidentiality. For example, nurses 11.Training
should:
All health care professionals who have a clinical
! provide information leaflets for patients, visitors responsibility for patients must include infection
and staff prevention and control as part of their every day
! provide notices which describe the precautions practice. The RCN believes all health care staff should
needed receive mandatory infection control training as part
! talk to patients about how they can help of their induction and on an ongoing annual basis. It
themselves is particularly important that knowledge and skills
are continually updated.
! include support staff in team meetings during
outbreaks The training should cover all the general principles of
infection prevention and control (as outlined in this
! tell the patient how their care might be affected by
publication), to emphasise the key role that health
a HCAI and how long precautions will be needed
care professionals play in minimising the spread of
! ensure that other staff understand the actions infection; to highlight what can happen as a result of
they need to take – for example, if the community bad practice and underline the importance of good
nurse needs to continue care at home communication.
! inform general practitioners on discharge or Training should include:
transfer if their patient has acquired a HCAI.
! practical hand washing sessions/use of alcohol
hand sanitizer
! aseptic technique

! the importance of environmental/equipment

cleaning and whose responsibility
! who to go to for advice/ more information

! trust infection and prevention policies

! what you can do to help yourself, your colleagues

and your patients (uniform, hair, general
hygiene).
Please refer to the RCN infection control checklist
(Appendix 1) as a reminder of the key steps.You may
want to photocopy this and display it in your
workplace.

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GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

Variant Creutzfeldt-Jakob References

Disease
Advisory Committee on Dangerous Pathogens and
Thorough cleaning of instruments is extremely Spongiform Encephalopathy Advisory Committee
important in reducing the possible transmission of all (2003) Transmissible spongiform encephalopathy
micro-organisms – in particular the abnormal agents: safe working and the prevention of infection.
protein prion that is known to cause variant London: Department of Health.
Creutzfeldt Jakob Disease (vCJD). Research shows Department of Health (2003) Winning Ways -
that these prions are resistant to all common methods Working together to reduce Healthcare Associated
of decontamination. For information and advice on Infection in England. London: Department of Health.
vCJD, risk assessment and how to handle instruments
that may have been used on people who have this Health and Safety Commission (2000) Safety of
condition, you should consult your local: pressure systems: pressure systems safety regulation.
London: HSC.
! consultant in communicable disease control
Health and Safety Commission (2002) The control of
! microbiologist substances hazardous to health regulations (fourth
! infection control nurse. edition). Sudbury: HSE Books.

Further guidance can also be obtained from: Infection Control Nurses Association (2002) A
Transmissible spongiform encephalopathy agents: safe comprehensive glove choice. Bathgate: ICNA
working and the prevention of infection (Advisory Infection Control Nurses Association and Royal
Committee on Dangerous Pathogens and Spongiform College of General Practitioners (2003) Infection
Encephalopathy Advisory Committee, 2003). control guidance for general practice. Bathgate: ICNA.
(Tel: 01506 811077 for copies)
Methicillin-resistant Medical Devices Agency (1996) Sterilisation,
Staphylococcus aureus disinfection and cleaning of medical equipment,
London: MDA.
For information related Medical Devices Agency (1998) The validation and
‘Mortality rates for specifically to MRSA periodic testing of bench top vacuum steam sterilisers.
deaths involving please read the RCN’s London: MDA (DB 1998/4).
MRSA increased guidance Methicillin-
over 15-fold during resistant Medical Devices Agency (2002) Bench top steam
the period 1993- Staphylococcus aureus sterilisers - guidance on purchase, operation and
2002.’ (Office of (MRSA): guidance for maintenance. London: MDA (DB 2002/6).
National Statistics, nursing staff (2005). National Audit Office (2000) The management and
2005) RCN members can control of hospital acquired infection in acute NHS
order copies by calling trusts in England. London: The Stationery Office.
RCN Direct on 0845
772 6100 and quoting National Patient Safety Alert (2004) Clean hands help
publication code 002 to save lives. London: NPSA (Patient Safety Alert
740.Alternatively, No.4).
members and non- NHS Estates (2004a) A protocol for the local
members can find out decontamination of surgical instruments, London:
more about MRSA by Department of Health.
visiting
NHS Estates (2004b) Lighting and colour for hospital
www.rcn.org.uk/mrsa
design. A report on an NHS Estates funded research
project. London: The Stationery Office.

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 ROYAL COLLEGE OF N URSI NG

NHS Estates (2004c) The NHS healthcare cleaning Hand hygiene

manual. London: Department of Health. National Institute of Clinical Excellence (2001)
www.nhsestates.gov.uk Standard principles for preventing hospital acquired
NHS Estates (2002a) Infection control in the built infections. London: NICE.
environment (second edition). Norwich: The National Institute of Clinical Excellence (2003)
Stationery Office. Infection control, prevention of healthcare-associated
NHS Estates (2002b) National standards of cleanliness infection in primary and community care. London:
for the NHS. London: The Stationery Office. NICE.
NHS Executive (1997) Washer-disinfectors. London: Pellowe C, Pratt R, Loveday H, Harper P, Robinson N
HMSO (Health Technical Memorandum 2030). and Jones S (2004) The epic project: updating the
evidence-base for national evidence-based guidelines
Office for National Statistics (2005) ‘Deaths involving for preventing healthcare-associated infections in
MRSA: England and Wales, 1999-2003,’ Health NHS hospitals in England: a report with
Statistics Quarterly Spring 2005 No 25. London: ONS. recommendations, British Journal of Infection
Royal College of Nursing (2005) Methicillin-resistant Control, 15(6), Dec., pp.10-16.
Staphylococcus aureus (MRSA). Guidance for nursing Royal College of Nursing (2005) Methicillin-resistant
staff. London: RCN. Publication code: 002 740. Staphylococcus aureus (MRSA). Guidance for nursing
staff. London: RCN. Publication code: 002 740.
Useful reading NHS Estates (1997) In-patient accommodation:
options for choice. London: HMSO (Health Building
General Note 4). www.nhsestates.gov.uk
Chief Medical Officer (2003) Winning ways: working National Patient Safety Agency (NPSA)
together to reduce health care associated infection in Cleanyourhandscampaign, www.npsa.nhs.uk
England, London: Department of Health.
Environment and equipment
Department of Health (2004) Towards cleaner
hospitals and lower rates of infection. A summary of Department of Health (2004) Towards cleaner
action. London: Department of Health.Available to hospitals and lower rates of infection. A summary of
download from www.dh.gov.uk action. London: DH.Available to download from
www.dh.gov.uk
Health, Social Services and Public Safety – Northern
Ireland.Available to download from Infection Control Nurses Association and Royal
www.dhsspsni.gov.uk College of General Practitioners (2003) Infection
control guidance for general practice. Bathgate: ICNA.
Jones E (2004) A matron’s charter: an action plan for www.icna.co.uk
cleaner hospitals. London: Department of Health.
Available to download from www.nhsestates.gov.uk Jones E (2004) A matron’s charter: an action plan for
cleaner hospitals. London: Department of Health.
National Audit Office (2004) Improving patient care by Available to download from www.nhsestates.gov.uk
reducing the risk of hospital acquired infection: a
progress report. London: The Stationery Office. NHS Estates (2002) National standards of cleanliness
for the NHS. Norwich: The Stationery Office.
Scottish Executive. Health Department (2004) The www.nhsestates.gov.uk
NHSScotland Code of Practice for the local
management of hygiene and healthcare associated NHS Estates (2004) The NHS healthcare cleaning
infection (HAI), Edinburgh: SE. manual. London: Department of Health.
www.nhsestates.gov.uk
Welsh Assembly Government (2004) Healthcare
associated infections: a strategy for hospitals in Wales.
Cardiff: WAG. www.nphs.wales.nhs.uk

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GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

Scottish Executive Health Department (2004) The Blood-borne virus

NHSScotland national cleaning services specification: Department of Health (1991) Decontamination of
healthcare associated infection task force. Edinburgh: equipment, linen or other surfaces contaminated with
SE. Hepatitis B and /or HIV. London: DH (HC(91)33).
NHS Estates (2001) Infection control in the built Department of Health (1993) Protecting healthcare
environment: design and planning. London: The workers and patients from hepatitis B, London: DH
Stationery Office. www.nhsestates.gov.uk (HSG(93)40) (plus addendum EL(96)77).
Uniform Department of Health (1998) Guidance for clinical
Royal College of Nursing (2005) RCN Guidance on health care workers: protection against infection with
uniforms / clothing worn for delivery of patient care. blood-borne viruses. London: DH (HSC(98)63).
London: RCN. Publication code 002 724 Department of Health (1998) Guidance on the
www.rcn.org.uk/mrsa management of AIDS/HIV infected healthcare workers
Royal College of Nursing (2005) A uniform approach. and patient notification. London: DH (HSC(98)226).
A checklist for nursing staff. London: RCN. Publication Department of Health (2000) Hepatitis B infected
code 002 723 www.rcn.org.uk/mrsa health care workers. London: DH (HSC(2000)20).
Clinical waste Laundry
Department of the Environment (1991) Department of Health (1995) Hospital laundry
Environmental protection act 1990: waste arrangements for used and infected linen. London: DH
management: the duty of care: a code of practice. (HSG(95)18).
London: HMSO.
NHS Estates (2002) Infection control in the built
Department of the Environment (1992) The environment (second edition). Norwich: The
environment protection act 1990: parts II and IV: the Stationery Office.
controlled waste regulations. London: DE.
Resources available from the RCN
Department of the Environment (1996) The
environment protection act 1990: part II: special waste As part of its Wipe it out campaign, the RCN has
regulations 1996. London: HMSO. produced a range of leaflets and posters to help
nursing staff, patients and visitors promote good
Health and Safety Commission (2002) The control of practice in infection control. To obtain copies and to
substances hazardous to health regulations (fourth find out more about infection control go to
edition). Sudbury: HSE Books. www.rcn.org.uk/mrsa
Health Service Advisory Committee (1999) Safe The RCN has also produced a wealth of other
disposal of clinical waste (second edition). Sudbury: information and guidance as part of its Working Well
HSE Books. Initiative. Titles – including the following – are
NHS Estates (1994) A strategic guide to clinical waste available to members by calling RCN Direct on 0845
management for general managers and chief 772 6100 and quoting the publication code.
executives. London: NHS Estates. ! Royal College of Nursing (1999) Losing your
Parliament (1990) Environmental protection act 1990. touch? Avoid latex allergy, London: RCN.
London: HMSO. Publication code: 000 948
Parliament (1992) The management of health and ! Royal College of Nursing (2002) Is there an
safety at work regulations, London: HMSO (SI no. alternative to glutaraldehyde? A review of agents
2051). used in cold sterilisation (second edition).
London: RCN. Publication code: 001 362

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 ROYAL COLLEGE OF N URSI NG

Useful websites Glossary

You may find the following websites useful: COSHH – Control of Substances Hazardous to Health
! The Department of Health: www.dh.gov.uk Creutzfeldt-Jakob Disease (vCJD) – a disease in
which rapid progressive degeneration of brain
! The Health Protection Agency (HPA):
tissue results in dementia and eventually death
www.hpa.org.uk
HAI – hospital acquired infection – any infection
! The Hospital Infection Society: www.his.org.uk
acquired while undergoing treatment,
! Infection Control Nurses Association: investigation or rehabilitation in hospital
www.icna.co.uk
Hand washing – washing the hands with an
! The Medical and Healthcare products Regulatory unmedicated detergent and water (or water
Agency: www.mhra.gov.uk alone), to remove dirt and loose transient flora in
order to prevent cross-infection
In April 2003, the Medical Devices Agency merged
with the Medicines Control Agency to form the HBV – Hepatitis B
MHRA. This executive agency of the Department HCAI – health care associated infection – any
of Health produces a variety of bulletins and infection acquired while undergoing treatment,
alerts including advice on single use items, bench investigation or rehabilitation in any health care
top sterilisers and the decontamination of setting or in community care settings
endoscopes.
MRSA – Staphylococcus aureus which is resistant to
! The National Institute for Clinical Excellence an antibiotic called methicillin are referred to as
(NICE): www.nice.org.uk methicillin-resistant Staphylococcus aureus or
In 2001, NICE produced Standard principles for MRSA. Methicillin-resistant means
prevention of hospital acquired infection and in flucloxacillin resistant
2003, Infection control – prevention of health care PEAT – patient environment action team
associated infection in primary and community
care. PEP – post exposure prophylaxis

! National Patient Safety Agency www.npsa.nhs.uk PPE – personal protective equipment

SARS – severe acute respiratory syndrome
The NPSA has developed the cleanyourhands
campaign which targets hand hygiene as a key Sterile – free from any living organisms, for example,
patient safety issue. sterile gloves, sterile catheter
www.npsa.nhs.uk/cleanyourhands SSD – sterile services department
! NHS Estates: www.nhsestates.gov.uk

For information on their clean hospitals

programme and downloadable copies of advice,
guidance and audit materials.
! NHS Purchasing and Supply Agency:
www.pasa.nhs.uk
This website offers guidance on safety devices.
! The Safer Needles Network:
www.saferneedlesnow.net and
www.needlestickforum.net

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 GOOD PRACTICE IN INFECTION PREVENTION AND CONTROL

Appendix 1

Infection control checklist

Standard precautions underpin safe protection and should be used at all times
with every patient. Use the following checklist to guide you.

Have you washed your hands? Do you scrupulously decontaminate

equipment?
Hand washing is the single most important step in
reducing the spread of disease. Use the six-step Meticulously clean, disinfect and sterilise re-usable
technique before direct contact with patients and equipment, as appropriate, to ensure it is safe for
after any activity that contaminates the hands. Dry future use.
thoroughly afterwards, using disposable towels.
Are you maintaining a clean
Do you need to use personal environment?
protective equipment? Ensure your workplace has a regularly planned,
Carry out a risk assessment if potential written and monitored cleaning schedule, which
contamination by blood or body fluid is likely. Use details both the items and environments to be
disposable gloves, aprons, masks, goggles or cleaned and how often this should happen.
visors to protect yourself and your patient from
these risks of cross-infection, and when handling
Do you know what to do in the event
these substances or hazardous chemicals and of an accident?
some pharmaceuticals. Attend the injury, washing it well in cold running
water. If bodily fluids have splashed into eyes,
Are you preventing sharps injuries? irrigate with cold water. If they have splashed into a
mouth, do not swallow and rinse out several times
Keep handling to a minimum and never re-sheath. with cold water. Report the incident and seek
Dispose of sharps carefully in a special container at expert advice.
the point of use.
And finally, do you know your
Are you disposing of waste safely? workplace’s procedures?
Ensure that you have been instructed in how to Ensure that you understand and follow your
dispose of waste safely, including the colour coding workplace’s written policies and procedures on all
of bags used for different types of waste. aspects of infection control.

Do you deal promptly

with spillages?
Spillages must be dealt with quickly, using
appropriate chemical disinfectants as necessary.
Ensure you have a thorough knowledge of chemical
disinfectants.

16
 *
10 steps to effective hand hygiene
1 2 3 4 5
Wet hands and forearms Soap up rubbing palm to palm Rub with fingers interlaced Massage between fingers, Scrub with fingers locked
right palm over back of left hand, including finger tips
left palm over back of right hand
6 7 8 9 10
Rub rotationally with Rinse thoroughly Dry palms and backs of hands Work towel between fingers Dry around and under nails
thumbs locked using a paper towel to help
remove remaining bacteria
Importance of hand washing
Hands are usually considered to be one of the most common ways that cross contamination occurs. Effective, timely hand hygiene
can contribute significantly to reducing the risks of cross contamination.
* The hand washing technique adopted must ensure that all areas of the hands are covered. Particular attention should be paid to the
Dispensers finger tips, between the fingers and to the outside and back area of the thumbs, which are often missed.
Once rinsed thoroughly, dry the hands carefully with paper towels and apply an appropriate hand cream.
Inspired by nature. Created for superior hygiene. *Trademark: Kimberly-Clark Corporation/©Copyright 2000 Kimberly-Clark Corporation/Publication no. 2244.01 GB 11-2000
 April 2005

Published by the Royal College of Nursing

20 Cavendish Square
London
W1G 0RN

Tel 020 7409 3333

www.rcn.org.uk/mrsa

The RCN represents nurses and nursing,

promotes excellence in practice and
shapes health policies
002 741