Welcome

Our IP&C team has responsibility for advice information and support for staff, patients and vistors regarding our infection prevention and control policies and procedures.

Alert

Alert

Policies, guidance documents and information leaflets

  • DCHS Infection Prevention and Control Policy
  • DCHS COSHH Operating Standards
  • DCHS Influenza Like Illness (ILI) Management Guidelines
  • DCHS Local Decontamination of Reusable Medical Devices -Dental & Podiatry
  • DCHS PPE Operating Standards
  • DCHS Prevention & Management of Sharps Injuries & Contamination Incidents Policy
  • DCHS SOP for Cleaning of patient Bed Space
  • DCHS SOP for Examples of Cleaning Clinical Equipment
  • DCHS Uniform and Dress Code Policy

Environmental/Food Safety Policies

  • DCHS Food Safety Policy
  • DCHS Waste Management Operational Standards
  • DCHS Water Safety Policy
  • DCHS Ventilation (buildings) Policy

*Coming soon  - Standard Operating Procedure for DCHS Complex Wound Care Clinics

Pathways/Flowcharts

  • Sepsis flowchart
  • Frailty pathway
  • Delirium pathway

Outbreaks/Barrier Nursing Documents

  • Patient Under Barrier Precuation Door Poster
  • Daily barrier cleaning schedule for individual patients form
  • Terminal barrier cleaning schedule for individual patients form
  • Norovirus outbreak chart - patients
  • Norovirus outbreak chart - staff
  • Norovirus outbreak daily barrier cleaning schedule
  • Norovirus outbreak terminal cleaning schedule
  • COVID outbreak form for patients
  • COVID outbreak form for staff

Other Documents

  • Bed space environment cleaning transfer/discharge checklist form
  • Management of deceased – Infection Control notification form
  • MRSA screening letter for GP
  • Record sheet for daily operation of drinking water fountains
Poster Name Link
ANTT - Do's and dont's poster Link
ANTT - Podiatry wound care procedure Link

ANTT - Wound care clinic procedure

Link
DCHS Management of In-Patients with Diarrhoea or suspected Clostridioides Difficile (Cdiff) Link
Don't be a dip stick Link
Dry hands Link
Management of blood and body fluid spillages Link
Myth Busters - Bare below the elbows (BBE) Link
Myth Busters - Diarrhoea and vomiting  Link
Myth Busters - Hand hygiene Link
Myth Busters - Personal Protective Equipment (PPE) Link
Myth Busters - Standard precautions for infection control Link
Myth Busters - Uniform poster Link
Myth Busters - Using face masks Link
Patient under barrier precautions poster Link
Preventing facial skin damage beneath PPE Link
Self-Isolation and testing - what you need to know now Link
Sore red hands Link
Top tips for hand hygiene Link

 

  • Clostridium difficile for inpatients patients leaflet
  • Clostridium difficile for community patients leaflet
  • ESBL and AMP C in urine leaflet
  • ESBL and AMP C in wounds and sputum leaflet
  • Influenza (Flu) in the community leaflet
  • Influenza (Flu) outbreaks in community hospitals leaflet
  • MRSA and MRSA screening information leaflet
  • MRSA decolonisation therapy information leaflet
  • Norovirus/winter vomiting bug leaflet
  • Scabies information leaflet
  • Shingles information leaflet
  • Staying Safe Booklet (includes sections on Sepsis, urinary tract and catheter associated infections)

Information for champions and students

Infection Prevention and Control Quality and Safe Care Champions (QSCC)

IP & C Quality & Safe Care Champions (QSCCs) are nominated members of staff who receive support to ‘embed’ best practice in relation to infection prevention and control within their clinical areas and support improvements to patient care within the Quality Always Clinical Assessment and Accreditation Scheme (CAAS) standards. The champions utilise the World Health Organisation's 5 moments of hand hygiene as the framework for the programme. Hand hygiene, including audit of practice, is a key focus for the champions.

Staff interested in becoming champions must read the agreement form with their manager. A QSCC nomination form must then be completed and submitted to Quality Always.

Please see Quality Always intranet page on MY DCHS for information on:

  • QSCC Role Overview
  • QSCC Agreement
  • QSCC Nomination Form
  • Support Sessions Timetable for Year
  • QSCC Register

Hand Hygiene Champions Training Pack

IP & C Self-assessment Tool for Quality & Safe Care Champions

  • Inpatient Wards
  • Community
  • Out Patients/Planned Care

PPE – Gloves, aprons & masks

Question Answer

Do I need to wear gloves for venepuncture (taking blood)?

Yes, Royal Marsden Manual recommends wearing well‐fitting gloves during venepuncture and cannulation to prevent contamination from potential blood spills.

Do I need to wear gloves for giving injections? No, World Health Organisation guidance - gloves should not be worn for routine intradermal, subcutaneous, or intramuscular injections providing your skin is intact.

Do I need to change my gloves & apron between wounds or tasks on the same patient?

Yes, you need to change your gloves, but you do not need to change your apron unless it is contaminated or damaged.

Do I need to wear a sterile apron for wound care? No, as the apron should not come into contact with key parts.

When do I need to wear a visor/face protection?

Where there is a risk of splashing to the face/eyes with blood or body fluids and for patients on the respiratory pathway or patients with Monkey Pox or Chicken Pox.
When do I need to wear and FFP3 mask? You only need to wear an FFP3 mask when carrying out an Aerosol Generating Procedure (AGP) on patients on the respiratory pathway and when caring for patients with Monkey Pox or Chicken Pox.
When do I need to wear a long-sleeved coverall/gown?

You only need to wear a long-sleeved gown/coverall when carrying out an Aerosol Generating Procedure (AGP) on patients on the respiratory pathway and when caring for patients with Monkey Pox or Chicken Pox.

Patient Care
Question Answer
Can I use Clinell Universal Wipes on patient’s skin?

No, Although Clinell Universal wipes are dermatologically tested and are “skin kind” they are designed to be used for cleaning surfaces and equipment. Other more suitable skin cleansing wipes are available from Clinell.

Do I need to clean patient’s skin prior to venepuncture?

Yes, in line with the Royal Marsden Manual of Clinical Nursing Procedures - Chapter 10.1 "Clean the patient's skin carefully for 30 seconds using an appropriate preparation, such as skin cleansing wipes containing “Chlorhexidine 2% and alcohol 70%”, and allow to dry. Do not re-palpate or touch the skin” “This is to maintain asepsis, minimize the risk of infection and to prevent pain on insertion.”

A link to suitable products available on NHS Supply Chain can be found here. For further information contact EDCHST.infectioncontrol@nhs.net.

Cleaning equipment and the environment

Question Answer
Can I use Clinell Universal Wipes for cleaning surfaces/ equipment between patients?

Yes, as long as surfaces are not visibly dirty, contaminated with blood or body fluids or the patient has a known or suspected infection.

Do I need to wear gloves when using Clinell (green) universal wipes?

Yes, the manufacturers of Clinell recommend wearing gloves when using the wipes as the products used in their manufacture may over time lead to irritation, allergies and skin conditions.
When do I need to use chlorine base solutions e.g. Actichlor? You need to use chlorine based solutions as part of the “5 step cleaning process” if equipment or surfaces are visibly dirty, contaminated with blood or body fluids and for patients with gastrointestinal infections such as Norovirus or C. Diff.

How often do fabric and disposable curtains need to be changed in DCHS?

Every 3 months, curtains should be dated when the next curtain change is due.

Do the Laerdal pocket masks in rigid plastic containers have an expiry date?

Yes, the expiry date is recognised to be 5 years after manufacture.  

However masks should be checked regularly and if they look old, worn and out of date then they should be replaced.

Can portable be fans be used in clinical and non-clinical areas?

Yes, portable fans may be used in both clinical and non-clinical areas but must not be allowed to blow air directly onto areas where clinical procedures such as wound care are taking place. They must also be on regular cleaning schedules and have a cage surrounding the blades that can be unclipped for cleaning.
Can portable air conditioning units be used in any areas of DCHS?

No, due to the risk from Legionella and issues around maintenance DCHS do not support the use of portable air conditioning units. Contact Estates for further information - dchst.estateshelpdesk@nhs.net.

Sharps and sharps containers

Question Answer

How long may sharps containers be used for once started?

Once opened sharps containers may only be used for 3 months. This does not apply to sharps containers on the resus trolley, these should be closed, disposed of and replaced once used.

Hand hygiene, Uniform & Bare Below the Elbows

Question Answer

Can I wash my hands with cold water?

Yes, although it is preferable to use warm water, if this is not available then cold water may be used. It is the use of liquid hand soap and the mechanical action of hand washing that loosens dirt and microorganisms and allows them to be removed.
When can I use alcohol hand gel? When hands are not visibly contaminated or when patient has a known or suspected infection, including diarrhoeal infection.
When do I need to wash my hands with soap and water?

When hands are visibly soiled, when caring for patients with a known or suspected infection, when there is an obvious build-up of alcohol hand gel on hands, when caring for patients with diarrhoea and/or vomiting.

What can I do if I have dry or sore red hands?

See DCHS leaflets on “dry hands” and “sore red hands” and if necessary contact Occupational Health dchst.occupationalhealth@nhs.net for advice and support.

Do I need to wash my uniform separate from other laundry and at 60 degrees?

Yes, extensive literature searches and research has concluded that washing uniforms at 60 degrees is the safest option as it removes all microorganisms, including Clostridioides difficile (C. diff) to as safe level.

What jewellery can I wear as part of DCHS Uniform and Dress Code Policy?

You may wear one plain, smooth wedding band and one pair of plain stud earrings.
Can I wear a bangle e.g. Kara for religious reasons?

Yes, in agreement with your line manager, however you must remove it or ensure it is secured up your arm to enable effective hand hygiene to take place.

Can I wear an SOS medic alert bracelet?

Yes, in agreement with your line manager, however you must remove it or ensure it is secured up your arm to enable effective hand hygiene to take place.

I work in the community can I use patient’s own fabric towels or kitchen roll for drying my hands?

No, to standardise practice and minimise the risk of infection you should use your own stock of paper hand towels. These can be obtained for your service via the NHS Supply Chain.
Can I use patients own liquid hand soap or bar of soap when carrying out hand hygiene?

No, to standardise practice and minimise the risk of infection you should use your own stock of liquid hand soap or alcohol hand gel. These can be obtained for your service via the NHS Supply Chain.

Can I work clinically if I have a wound with a dressing on my hand or arm below the elbows?

No, if the dressing is not waterproof then you would be unable to carry out effective hand hygiene in order to minimise the risk of cross infection.

Can I work clinically if I need to wear a splint, brace or support to the hand or arm below the elbow for clinical activities?

No, unless the appliance can be removed to enable you to carry out effective hand hygiene and is fully wipeable to reduce the risk of cross infection.

Diarrhoea & vomiting

Question Answer

 What type of stools on the Bristol Stool chart do I need to send for testing if a gastro-intestinal infection such as Norovirus or Clostridium difficile is suspected?

True diarrhoea consists entirely of liquid/water and takes the shape of the container it is in and a pipette used to obtain a sample for testing, Type 5, 6 and 7 on the Bristol Stool Chart.

How long do patients with diarrhoea and vomiting need to remain isolated following symptoms of diarrhoea and vomiting?

Patients need to remain isolated for 48 hours after symptoms have subsided.

How long do I need to stay off work if I have symptoms of diarrhoea and vomiting?

You need to be free of symptoms for 48 hours before returning to work.

Can I come into work with symptoms of diarrhoea and vomiting if I am not working clinically or work in an office environment?

No, you must not attend work with symptoms of diarrhoea and vomiting whatever environment you work in.

Specific infections & barrier nursing

Question Answer

Do patients with shingles or chickenpox need barrier nursing?

Yes, until blisters/spots have scabbed over and are dry.

Do patients with scabies need barrier nursing?

No, patients may be nursed in an open ward however linen should be treated as infectious until all treatment is completed. Standard precautions apply for use of gloves and apron.

MRSA swabbing

Question Answer
Do we routinely swab patients for MRSA within DCHS?

No, only patients having podiatric surgery or nail surgery where the nails appears to be infected or patients have a history of MRSA and have not been swabbed within the last 6 weeks are swabbed for MRSA within DCHS.

AMaT Audits and IP & C Champions

Question Answer
How often do AMaT audits need to be carried out?

AMaT audits need to be carried out on a quarterly basis, the number of returns depends on the size of the team and refers to the number for the whole quarter. “One audit cycle” refers to a quarter.

Why do AMaT audits need to be carried out even in non-clinical areas/teams?

We need to ensure work areas and teams are working safely and correctly to minimise the risk of infections and outbreaks. The AMaT audits provide evidence that staff are complying with local and national guidance and this in turn provides assurance for the Trust board and external bodies such as NHSEI in the event of any outbreaks.

What can we do if it difficult to observe members of our team e.g. due to remote working?

In this case a scenario based observation can be completed e.g. at a base for example at handover, team meetings or time out days.

Can non-clinical staff become IP & C Champions?

Yes, non-clinical staff can receive information and training by contacting the Quality Always Team -  dchst.qualityalways@nhs.net.

How can I receive training, advice or support on using the AMaT tools?

Training, advice and support, including the answers to queries related to the AMaT can be obtained via the Improvement, Innovation and Effectiveness Team - dchst.cet@nhs.net.

Equipment and supplies

Question Answer

Do the IP & C Team carry supplies that other staff can access e.g. Lateral Flow Tests (LFT), gloves, aprons, hand wash and gel?

No, the IP & C Team only have a small supply of resources for their own use and order their own supplies via the PPE Team as all other areas - dchst.covid19ppe@nhs.net.

Is the IP & C Team able to provide product information or order codes for equipment and supplies such as gloves, wipes, masks etc?

No, the IP & C Team do not have access to information on products or order codes. Staff need to access the PPE Team dchst.covid19ppe@nhs.net or Procurement Queries - dchst.procurementqueries@nhs.net.

  • World Hand Hygiene Day – World Health Organisation (WHO) – held annually, 5th May each year
  • Global Handwashing Day - Held annually, 15 October.
  • Royal College of Nursing (RCN)  - Glove Awareness Week - held annually to coincide with World Hand Hygiene Day
  • World Sepsis Awareness Day - Held annually on 13th September
  • International Infection Control Week - Held annually in October
  • World Antimicrobial Awareness Week - Held anually in November