Standard Precautions Policy

Reference Number

1.12

Version

Name of responsible (ratifying) committee

Infection Control Management Committee

Date ratified

17.09.2010

Document Manager (job title)

Consultant Infection Prevention

Date issued

15.10.2010

Review date

September 2011

Electronic location

Corporate Policies

Related Procedural Documents

See section 8 of this policy

Key Words (to aid with searching)

Risk Assessment; Standard Precautions; Universal

precautions potentially contaminated; HIV infections;
Staff; Visitor; Patient; Locum; Personal protection
equipment; (PPE): Risk assessment; Body fluids;
Occupational health and safety; Gloves; Aprons;
Clinical waste; Training; Infection control; Waste
disposal; Clinical guidelines; blood borne viruses

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CONTENTS

1.
2.
3.
4.
5.
6.
7.
8.
9.

INTRODUCTION........................................................................................................................... 3
PURPOSE.................................................................................................................................... 3
SCOPE......................................................................................................................................... 3
DEFINITIONS............................................................................................................................... 3
DUTIES AND RESPONSIBILITIES...............................................................................................3
PROCESS.................................................................................................................................... 4
TRAINING REQUIREMENTS.......................................................................................................7
REFERENCES AND ASSOCIATED DOCUMENTATION..............................................................7
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS............................................................................................................................... 7

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1. INTRODUCTION
Universal precautions resulted from recommendations from the Centers for Disease Control
(1987) in which it was stated that all blood and body fluids should be treated as being
potentially contaminated with HIV.
In the 1990s it was recognised that other pathogenic micro-organisms also had the potential to
cause nosocomial infections, and it was believed that universal precautions was open to many
interpretations. Therefore the term was superseded and became Standard Precautions.

2. PURPOSE
Standard precautions are fundamental in reducing the spread of infections within the healthcare
environment. Utilising standard precautions will protect patients, visitors and staff.
Standard precautions are basic infection prevention and control principles that should underpin
safe practice, in order to reduce the risk of infection to patients and staff. Standard precautions
should be used routinely to prevent forward transmission of micro-organisms to other patients,
staff and visitors.

3. SCOPE
This Policy applies to all PHT staff - health and non-healthcare including agency, bank and
locum staff as well as visitors to PHT and staff from other agencies who may deliver care at
PHT in the course of their duties.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety

4. DEFINITIONS
Standard precautions initially evolved from a two-tier isolation system. The first tier termed
standard precautions is designed for all patients and is the primary strategy to prevent the
spread of healthcare associated infection. The second tier termed transmission based
precautions is additional to standard precautions and protects patients from highly
transmissible pathogens Isolation Policy
The term standard precautions encompass all the infection prevention and control practices
that prevent the spread of infections from recognised and unrecognised sources. This reduces
the risk of potential transmission from pathogens that originate from moist body substances and
protects patients and/or staff from transmissible infections.
Personal Protective Equipment is defined as all equipment which is intended to be worn or
held by healthcare workers to promote personal and patient safety against infection risks. E.g
gloves/aprons/eye protection/masks.

5. DUTIES AND RESPONSIBILITIES

This applies to all PHT employees including agency, bank and locum staff who are performing
clinical procedures.

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6. PROCESS
The main elements of standard precautions are the following:
Hand Hygiene
Personal Protective Equipment & Risk Assessment
Sharps Safety
Management of blood and body fluid spillage
Aseptic technique
Linen and waste management.
Removal of Personal Protective Equipment.

Personal Protective Equipment & Risk Assessment.

The use of Personal Protective Equipment (PPE) in preventing cross infection is extremely
important given
The morbidity and mortality associated with healthcare acquired infections.
The cost of treating healthcare acquired infections.
The increasing problem of antibiotic resistant micro-organisms.
PPE is additional to normal clothing and uniforms to protect both the patient and healthcare
worker from the potential risks of cross infection. PPE is used to prevent the transfer of microorganisms to or from patients, staff or their uniforms and equipment.
Uniforms and clothing are not considered to be PPE.
The type of PPE worn is based on the assessed risk of the clinical intervention to be
undertaken.
Assess Risk before Performing a Task

No Protective
Clothing
(Exception * Aprons
to be worn for bed
making)

Gloves/Plastic Aprons

Gloves/plastic
aprons/eye
protection/face
masks/impervious
gowns

The following PPE should be available for staff as a minimum.

Gloves (Sterile/non-sterile/latex free)
Aprons & fluid repellent gowns.
Goggles/face visors (face and eye protection)
Masks
Hats/Caps
Gloves
Gloves are not impervious but reduce penetration of blood and body fluids on to the hands.
Gloves should be worn whenever there might be contact with blood and body fluids, mucous
membranes or non intact skin. Gloves should not be worn unnecessarily as their prolonged and
indiscriminate use may cause adverse reactions and skin sensitivity. The choice of glove should

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be made following a suitable and sufficient risk assessment of the task, the risk to the patient
and risk to the health care worker.
Gloves should be readily available in all clinical areas, fit for purpose and fit well.
Gloves should be non-powdered and not made of latex, as latex allergies have serious
implications for patients and health care workers.
Gloves should be stored in a clean environment and not susceptible to gross contamination.
Gloves are single use only.
Boxed, clean non-sterile gloves are adequate for routine non-invasive nursing care.
Gloves must be changed between patients and between tasks on the same patient.
Non-sterile gloves should be available in a variety of sizes to suit the needs of the operator.
Gloves should not be washed or sanitised with alcohol gel. Gloves are not a replacement for
hand hygiene.
Gloves should be disposed of in clinical waste.
Sized sterile gloves should be available and used for all aseptic procedures.
It is important that the correct size is available for operator to reduce the risk of needle stick
injuries.
Aprons
The wearing of a plastic apron prevents the spread of micro-organisms from one patient to
another, protects clinical uniform and skin contamination. These should be worn whenever
there is a risk of contaminating clothing with blood and body fluids and when a patient has a
known infection, for example, direct patient care, bed making or when decontaminating
equipment (Note-Aprons worn for bed making should be changed between beds).
Disposable plastic aprons are cheap, impermeable to micro-organisms, easy to wear, protect
uniform from contamination and are single use.
Full body, fluid repellent gowns should be worn where there is a risk of extensive splashing of
blood, body fluids, secretions and excretions, with the exceptions of sweat, onto the skin of
health care workers. These may be sterile or non-sterile in nature depending on the intended
use.
Aprons should be available in roll dispensers for ease of access and use.
Aprons should be disposed of as clinical waste.
Hands should be washed with soap and water after removal of apron.
Staff are to wear a Yellow apron when caring for patients in a side room (Order No BTB269).
Goggles/face visors (face and eye protection).
Goggles and visors should be worn when a procedure is likely to cause blood and body fluids
or substances to splash the eyes and face.
Goggles and visors should be readily available.
If reusable equipment is used it should be decontaminated appropriately (link to
decontamination policy).
Equipment should only be used for one patient episode.
Goggles and visors should fit the wearer well.
Hands should be washed with soap and water on removal.
Clean or dispose according to the manufacturers instructions.
Masks
Two types of masks are used in clinical practice.

Surgical masks are used mainly in operating theatres. The main purpose of a mask is to help
prevent particles (droplets) being expelled into the environment by the wearer. Masks are also
resistant to fluids, and help protect the wearer from splashes of blood or other potentially
infectious substances. They are not necessarily designed for filtration efficiency, or to seal
tightly to the face. The mask should fit snugly over the face, with the coloured side out (some
masks have a coloured side, others do not) and the metal strip at the top. Position the strings
to keep the mask firmly in place over the nose, mouth and chin. Mould the metallic strip to the
bridge of the nose. Do not touch the mask again until it is removed. Healthcare workers
should discard the mask as clinical waste.

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Respiratory masks provide protection from airborne transmission. Respirators are intended to
help reduce the wearers exposure to airborne particles. They are made to defined national
standards, such as the United States NIOSH-approved N95 respirator, or the similar European
standard EN149:2001 FFP3 respirator. The standards define the performance required of the
respirator, including filtration efficiency. When worn correctly, they seal firmly to the face, thus
reducing the risk of leakage.
Surgical masks may be used in clinical environments outside theatres to protect the facial
mucous membranes against splashes and airborne particles. Surgical masks worn in operating
theatres should be removed and disposed of by the wearer before leaving the department.
All masks should fit correctly, be handled as little as possible and changed between patients or
operations.
Respiratory masks should be used only when clinically indicated.
Management of blood and body fluid spillage
Aseptic technique
An aseptic technique is the practice of preventing microbial contamination of living tissue/fluid
or sterile materials by excluding, removing or killing microorganisms, in order to prevent sepsis.
This can be achieved by using sterile equipment and fluids during invasive patient procedures.
Linen and Waste
All PPE should be disposed of at the point of care in the nearest clinical waste bin. PPE should
not be disposed of via the domestic waste stream.
Removal of Personal Protective Equipment
PPE should be removed in an order that minimises the potential for cross-contamination. On
completion of a task/procedure, gloves, gown and eye goggles should be removed (in that
order) and disposed of as clinical waste. If wearing a mask, this should be removed last, to
minimise contamination of the face.
1. Gloves
Grasp the outside of the glove with the opposite gloved hand; peel off.
Hold the removed glove in gloved hand.
Slide the fingers of the ungloved hand under the remaining glove at the wrist.
Peel the second glove off over the first glove and discard.
2. Gown or apron
Unfasten or break ties.
Pull gown/apron away from the neck and shoulders, touching
the inside of the gown only.
Turn the gown/apron inside out, fold or roll into a bundle and discard.
3. Goggles or face shield
To remove, handle by the headband or earpieces and discard.
4. Respirator or surgical mask
Untie or break bottom ties, followed by top ties or elastic and
remove by handling ties only and discard. To minimise
cross-contamination, the order outlined above should be applied
even if not all items of PPE have been used. On completion
hand hygiene should be undertaken.

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7. TRAINING REQUIREMENTS

All Trust staff clinical and non-clinical must be aware of the contents of this policy. Infection
prevention and control is a key essential training course with annual mandatory attendance
for clinical staff (Refer to Training Matrix). All clinical staff are required to attend annual
infection prevention and control updates, which would include practical and theoretical
training. Staff must have dedicated time to maintain infection control competencies through
education and peer support.

Infection prevention and control training is available in number of formats including formal
taught sessions, e learning and local training via the local infection control link advisor.
Non-attendance at infection prevention and control training will be monitored via the quarterly
reports to Departmental Heads from the Divisional Training Groups. Departmental Heads will
be required to develop action plans to target non-attendance and report the outcomes
(quarterly) to the Strategic Learning and Development Committee.

8. REFERENCES AND ASSOCIATED DOCUMENTATION

References
Advisory Group on Infection. (1998) Scottish Infection Manual. Edinburgh, Scottish Office
Department of Health.
Centers for Disease Control. (1987) Recommendations for the prevention of transmission of
HIV transmission in health care settings. MMWR.36:2S.
Department of Health (1995) Hospital Infection Control. Guidance on the control of infection in
hospital. London, Department of Health.
Garner, JS. (1996) Hospital Infection Control Practices Advisory Committee. Guideline for
isolation precautions in hospitals. Infection Control and Hospital Epidemiology.17(1):54-80.
Health and Safety Executive (1992) Personal Protective Equipment at Work. Guidance on
regulations. L25. London, Health and Safety Executive.
House of Lords Select Committee on Science and Technology (1998) Resistance to antibiotics
and other microbials. Seventh Report. London, The Stationary Office.
Infection Control Nurses Association (2002) Protective clothing:Principles and guidance.
Bathgate, ICNA.
National Audit Office (2000) The management and control of hospital acquired infection in
acute trusts in England. HC230 Session 1999-00. London, National Audit Office.
Plowman et al (1999) The socio-economic burden of hospital acquired infection. London,
PHLS.
Pratt, R.J., Pellowe, C.M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones, S.R.L.J., McDougall,
C., and Wilcox, M.H.
(2007). Epic2: National Evidence-Based guidelines for Preventing
Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection
65S, S1-S64.
Royal College of Nursing (2005) Good practice in infection prevention and control. Guidance for
nursing staff. Wipe it out. RCN campaign on MRSA.

9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,

PROCEDURAL DOCUMENTS
Detail how this document will be monitored to ensure it is effective and being complied with.
The effectiveness in practice of all procedural documents should be routinely monitored
(audited) to ensure the document objectives are being achieved. The process for how the
monitoring will be performed should be included in the procedural document.
The details of the monitoring to be considered include:
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The aspects of the procedural document to be monitored: it may be useful to identify

standards or key performance indicators (KPIs);

The methodology for monitoring e.g. spot checks, observation audit, data collection;

Frequency of the monitoring e.g. quarterly, annually;

Who will be responsible for monitoring and reporting on compliance; and

The committee or group who will be responsible for receiving the results and taking
action as required. In most circumstances this will be the committee which ratified the
document.

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