This site is intended for health professionals only

Infection control measures in primary care

Alison Fuller
RGN BSc(Hons)
Clinical Nurse Specialist
Infection Control
Bradford Health Authority

We all need to be aware of infection control measures. General practices are performing more minor surgery and invasive procedures, and primary care teams are dealing with an increasing number of patients with hospital-acquired infections.

Protective clothing
Protective clothing is essential to protect both patients and staff. As defined by the Health and Safety Executive, protective clothing ensures that skin, mucous membrane and healthcare workers' uniforms are protected from exposure to blood and body fluids.(1)

Aprons
Water-repellent disposable protection should be worn when there is anticipated contamination from blood or body fluids (eg, cervical cytology), or when close contact between the patient, materials or equipment may lead to contamination of clothing.(2)

Masks, visors and eye protection
These items are indicated when there is a procedure that is likely to cause body fluids or substances to splash into eyes, face and oral mucosa. Within general practice this may be: while manually cleaning instruments; while decontaminating invasive devices; during certain minor surgical procedures; and for cytotoxic therapy.

Gloves
Disposable gloves are advocated if direct contact with blood or body fluids is anticipated, or whenever there might be contact with mucous membrane or non-intact skin. These should be seamless, nonsterile and powder- free. It is essential that a risk assessment is conducted on the gloves' suitability to reduce latex exposure, and that gloves are fit for the purpose.(3) Gloves must be changed following each procedure, followed by a thorough handwash. A number of studies have identified that gloves used in clinical practice leak when apparently undamaged.(4,5) Therefore the integrity of gloves cannot be taken for granted, and hands may become contaminated during glove removal.(6)

Hand hygiene
Evidence supports handwashing as one of the single most effective procedures in the control and prevention of infection.(7,8) However, despite the evidence, inadequate handwashing is still an issue.
Routine handwashing removes most transient micro- organisms from soiled hands. The frequency of handwashing is determined by what you are doing - wash before and after direct patient contact. In most settings, handwashing with liquid soap and water is adequate for the purpose of the removal of dirt, organic material and most transient organisms found on the hands.(9) Before minor surgery or after invasive practices, a more intensive technique is required.
Liquid soap is preferred to bar soap. Hands must be washed thoroughly using a 10-15-second handwash technique, rinsed well and dried using disposable paper towels. Hand drying is extremely important as wet surfaces transfer microorganisms more effectively than dry ones.(10) Often terry towels continue to be used in clinical areas and are a potential risk for cross-infection.
Alcohol rubs are a quick and effective alternative when water or towels are not readily available. They are of particular value in homes where handwashing facilities are limited or not available, and within general practice between patient examinations.(11) All cuts and abrasions must be covered with a waterproof dressing.

Disposal of waste
Waste disposal within primary care is governed by the Environmental Protection Act and the publication Safe Disposal of Clinical Waste by the Health Services Advisory Committee.(12) It is essential that local policies are in place and reflect all aspects of waste management.
Employers have a responsibility to ensure that workers are trained in clinical waste disposal. Correct waste handling is imperative. For example: storage bags must be effectively sealed; waste bags should be handled by the neck only; all staff should know the procedure in the case of ­accidental spillage and to report accidents; the seal of any storage bag must be checked to ensure it is ­unbroken when movement is complete; the origin of the waste must be clearly marked on the bag; staff must be aware of the problems related to sharps disposal; different categories of waste must be ­segregated during storage; a sharp container must never be placed inside a clinical waste bag; and the waste carrier must be registered to ­collect clinical waste.
Further to this, waste must be stored in an allocated area that is not accessible to the public. The storage location for clinical waste awaiting collection must be secured and lockable if outside the health centre. Access to storage facilities should be limited to those responsible for handling, transporting or disposing of clinical waste.
 
Home waste
Householders who generate small amounts of clinical waste are exempt from the "duty of care", and therefore can, for example, dispose of dressings freely into their normal household waste.
Where community staff provide healthcare to a client in their own home and produce clinical waste as a result, they should conduct a risk assessment on the individual requirements of the client. Some areas have a system in place that has been ratified by the local authority and infection control team. Small quantities of waste deemed as low risk are double bagged and disposed of with normal domestic waste. Where waste is identified as excessive or high risk, arrangements should be made with the local authority for collection and proper disposal. It must be stressed that permission to dispose of clinical waste into the householder's own waste needs the client's consent.
All cytotoxic waste at present must be disposed of carefully in a specifically designated container for cytotoxic waste. A consignment note must accompany this waste, and it is required to be moved as a separate consignment.

Management of sharps
The safe handling and disposal of needles and other sharp instruments should be an integral part of policy development. As with other infection control strategies, management and implementation of safe working practices are paramount. This ensures that risks are identified and procedures are in place to minimise those risks. All staff should be immunised for hepatitis B and made aware of other bloodborne viruses, such as hepatitis C.
A local sharps policy must be made available, incorporating information on how to access medical intervention in the event of potential occupational exposure.
Accidental inoculation is defined as a puncture of the skin caused by:

  • All penetrating sharps/needle injuries.
  • Contamination of abrasions with blood or body fluids.
  • Scratches/bites involving broken skin - causing bleeding or other visible skin puncture.
  • Splashes of blood/body fluids into eyes or mouth.

In the event of a sharps injury, the area should be encouraged to bleed, washed immediately under running water and covered. Accidents must be reported immediately to the manager. This may be the practice manager or GP.
A bulletin issued by the Medical Devices Agency identified continuing reports of sharp injuries occurring as a result of the inappropriate sharps disposal.(12)

Management of sharps

  • Needles must never be resheathed and always ­disposed of as a complete unit into a sharps ­container.
  • Sharps must not be passed directly from hand to hand, and movement must be kept to a minimum.
  • If it is necessary to remove a needle from a syringe, such as transferring blood to a specimen bottle, the needle must be placed in the sharps container before transferring the blood.
  • Needle forceps or other suitable devices must be used when the needle is disposable from a reusable syringe (eg, local anaesthetic in dentistry).
  • Cuts and abrasions of exposed skin must be ­covered with a secure waterproof dressing.
  • Sharps containers should comply with British ­standards.
  • Sharps containers should be only three-quarters full before sealing and disposal.
  • Sharps containers must be correctly and ­adequately sealed.
  • Sharps boxes should be labelled with source of origin and date.
  • Sharps containers are not placed in yellow bags.
  • Wear appropriate protective clothing (such as aprons, gloves, protective glasses, masks) when involved in any procedure likely to lead to spillage of blood or body fluids.
  • Never leave sharps lying around following use. It is the responsibility of the user to ensure ­immediate safe disposal.

Decontamination and sterilisation
The demand for minor surgery and screening procedures has increased in general practice. Procedures and the understanding of the decontamination of instruments and equipment are often inadequate.(14-16) All equipment must be adequately decontaminated in between use and between patient use by cleaning, disinfecting and sterilising. The method will depend on a risk assessment of the procedure and the item being used. Medical equipment can be categorised according to the risk that the particular procedure poses to the patient.(17)
Low risk  Any item in contact with: healthy skin or nondirect contact with patients; furniture surfaces. Minimum standard clean or single use.
Intermediate risk  Any item in contact with: intact mucous membranes or contaminated with body fluids; before use on immunocompromised patients; ear syringing. Items used in the vagina or cervix must be sterilised.
High risk  Any item in contact with a break in the skin or mucous membrane or that is introduced into an area identified as sterile; instruments used for surgical/operative procedures.

Cleaning

  • Clean before disinfection or sterilisation is carried out.
  • All items must be fully immersed if washing by hand in an identified dirty sink.
  • Ultrasonic baths are an alternative.
  • Use single nonshedding cloths rather than ­
  • reusable ones.
  • Do not store brushes in disinfectant solutions.
  • All cleaned equipment must be dried thoroughly before storage.

Disinfection

  • Using a washer or disinfector is preferred.
  • All chemical disinfectants must be correctly ­selected and used.
  • The Control of Substances Hazardous to Health (COSHH) regulations must be adhered to.(18)
  • When diluting disinfectants they must always be measured (no guesses).
  • Always wear disposable gloves, apron and eye ­protection, if indicated, when using disinfectants.
  • Rinse equipment with water after disinfection.
  • Discard the disinfectant solution after use, clean the ­container and store dry.

Sterilisation

  • Autoclaving is the preferred method.
  • Instruments used in high-risk procedures must be sterile at the point of use.
  • Following autoclaving, equipment must be stored correctly (ie, dust-free environment).
  • Autoclaves must have daily and weekly checks and maintenance checks. A documented record must be maintained and kept of the checks.
  • Any test failures must be reported and the machine withdrawn from use.
  • Benchtop steam sterilisers are designed for the processing of equipment for immediate use within a clinical environment.(19)
  • Nonvacuumed benchtop steam sterilisers should not be used to process equipment with lumens or cavities.
  • Never resterilise single-use devices.(20)
  • Instruments must be separated in the chamber of benchtop sterilisers to allow all surfaces exposure to the steam.
  • Ensure all hinged equipment is open before ­sterilisation (eg, open forceps).
  • Staff must be appropriately trained in the operation and maintenance of a benchtop steam steriliser.

Conclusion
The control and prevention of infection is an integral part of all clinical practice. Consequently it is important that systems are in place to ensure that staff possess the skills, knowledge and training necessary to protect both themselves and their patients.

References

  1. Health and Safety Executive. Personal protective equipment at work regulations: guidance on regulations. London: HMSO; 1992.
  2. Griffiths-Jones A, Ward K, editors. Principles of infection control practice. London: Scutari Press; 1995.
  3. ICNA. Glove usage guidelines. London: ICNA; 1999.
  4. Korniewicz DM, et al. Leakage of virus through used vinyl and latex examination gloves. J Clin Microbiol 1990;28:787-8.
  5. De Groot, et al. Permeability of latex and vinyl gloves to water and blood. Am J Infect Control 1989;17:196-201.
  6. Pratt RJ, et al. The epic project: ­developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: Guidelines for preventing hospital-acquired infections. J Hosp Infect 2001;47 Suppl:S3-82.
  7. Larson E, et al. Efficacy of alcohol-based hand rinses under frequent-use conditions. Antimicrob Agents Chemother 1986;30:542-4.
  8. Ayliffe GA, et al. Hygienic hand disinfection tests in three laboratories. J Hosp Infect 1990;15:141-9.
  9. Ward V, et al. Preventing hospital acquired infection - clinical guidelines. London: PHLS; 1997.
  10. Hoffman PN, Wilson J. Hands, hygiene and hospitals. PHLS Microbiol Digest 1994;11(4):211-61.
  11. McFarlane A. Why do we forget to remember handwashing? Prof Nurse 1990;5:250-2.
  12. Health Service Advisory Committee. Safe disposal of clinical waste. London: HMSO; 1999.
  13. Medical Devices Agency. Safe use and disposal of sharps. MDA safety warning. London: MDA; 2001.
  14. Hoffman PN. Decontamination of equipment in general practice. Practitioner 1987;231:1411-5.
  15. Morgan DR, et al. Decontamination of instruments and control of cross-­infection in general practice. BMJ 1990;300:1379-80.
  16. Coulter WA, et al. Autoclave performance and operator knowledge of autoclave use in primary care - a survey of UK practices. J Hosp Infect 2001;48:180-5.
  17. Royal College of Nursing. Good ­practice in infection control: guidance for nurses working in general practice. London: RCN; 2000.
  18. COSHH Regulations. Statutory instrument number 1657. London: HMSO; 1988.
  19. Medical Devices Agency. The purchase operation and maintenance of benchtop steam sterilisers. DB 9605. London: MDA; 1997.
  20. MDA. Single use medical devices: implications and consequences of reuse. DB 2000(04).London: MDA; 2000.

Resources
Infection Control Nurses Association
W:www.icna.co.uk
Medical Devices Agency
W:www.medical-devices.gov.uk
Public Health Laboratory Service
W:www.phls.co.uk