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At the heart of general practice since 1960

Don't be caught out over your practice's standards of hygiene

In Scotland last month as many as 100 women were put at risk of HIV or hepatitis after their GP mixed sterilised and unsterilised vaginal speculae. This case of elementary human error has reinforced the reasoning behind recent NICE guidance. Prevention and control of infections are issues of very great practical importance in primary care. Within health care, hand washing remains the single most important measure to reduce the spread of infection2,3.

Hand care increases the efficacy of decontamination and includes keeping nails short and clean, avoidance of wearing jewellery (especially rings with stones), wrist watches and bracelets, artificial nails and nail polish. Hand drying is also important as wet surfaces transfer micro-organisms more effectively than dry ones; to add to this wet hands are prone to skin damage4.

It remains essential to decontaminate hands before direct contact with a patient and after any activity that contaminates hands3,4, but evidence suggests health care professionals, in primary and secondary care alike, rarely wash their hands to a satisfactory standard4.

All health care professionals understand hands must be washed with soap and water and dried thoroughly. There are many alcohol hand gels available that can offer an alternative to hand washing, but it must be remembered that alcohol is not a cleansing agent and therefore hands must be washed and dried prior to the use of alcohol ge · 5.

In addition to hand washing it is important the practitioner uses personal protective equipment (PPE). This remains important within infection control and management and within primary care it is vital that all health care workers are supplied with PPE if they are at risk of contact with blood, body fluids, secretions or excretions5-8. The use of gloves within health care has been a much-debated issue: which gloves should be used for which action?

It is recommended that when there is potential contact with non-intact skin or mucous membranes and if there is the risk of contact with blood or body fluids, latex (natural rubber latex) or nitril (cacryclonitrile) gloves must be worn. Vinyl gloves are not recommended for tasks that have a high degree of contact with blood or bloodstained body fluids.

Decontamination of equipment

Practices may use a variety of equipment. Some items may be single-use only, identified with this symbol: ??. These products must be used only once and then they must be thrown away.

Reusable items can be decontaminated in the practice for reuse but the practice must adhere to certain standards set out in HTM20109 to ensure a high standard of decontamination and sterilisation to protect the patients from acquiring infection.

The practice must be able to demonstrate how it is complying with HTM2010, which involves among other things regular servicing of the steriliser and daily monitoring of its performance.

The wise practice may well wish to balance the cost of using reusable equipment which includes purchase, plus the staff time for cleaning plus maintenance bills (and worry and possible legal action) against the cost of reusable items/using the local hospital sterile supply department.

Cleaning is the removal of organic matter, disinfection is the removal of some microbes not including spores, and sterilisation is the removal of all micro-organisms (see box below).

Cleaning

It is the first and most important part of any disinfection or sterilisation process. Inadequately cleaned equipment cannot be disinfected or sterilised effectively thus putting patients and staff at risk.

Cleaning can be achieved through manual cleaning or by placing instruments into an ultrasonic bath or washer (similar to a dishwasher, but specifically designed for medical instruments).

The advantage of using a mechanical washer is that staff are not put at risk of exposure to pathogens that might be present on the instruments via sharps injuries or inhalation of fine spray while scrubbing equipments.

It also has the advantage of being able to guarantee a higher standard of cleaning and is likely to be more consistent and can be validated.

All instruments should be checked during the cleaning stage to ensure they are still fit for purpose. Equipment that is broken or damaged should be taken out of circulation and should be condemned and replaced.

Disinfection

Where possible, instruments should be cleaned and then sterilised rather than disinfected to eliminate the need for chemicals to be used in the practice11. Where staff have identified equipment that is heat labile and disinfectants must be used they should seek guidance from the manufacturer and ensure they comply with the guidance and COSHH with regard to safe handling, PPE and storage.

Sterilisation

Practices that sterilise their own equipment must ensure the equipment is correctly maintained and monitored12.

The Health Technical Memorandum 201013 is the authoritative work on sterilisation and applies to all benchtop sterilisers. The aim of the guidance is to ensure the safety and efficiency of the machine. It sets out roles and responsibilities for the correct maintenance and use of the steriliser.

The management is defined as the person ultimately accountable for the operation of the premises in which the steriliser is being used. Usually in general practice this will be the GP. The management's main responsibility, apart from being ultimately accountable, is to ensure all the required maintenance and checks are done.

A company qualified to do such work can carry out the necessary three-monthly tests and there should be a record of all the tests and maintenance carried out so the practice can demonstrate that the regulations have been complied with.

In addition, because a steriliser is a pressure vessel, a yearly test must also be performed and recorded by a competent person to meet the requirements of the Pressure Equipment Regulations 199914.

The user is also responsible for daily tests to ensure the machine is still working between tests and these must also be recorded (see box left).

Finally, health care-acquired infections are much in the news at present and with the emergence of antibiotic-resistant organisms the importance of cleanliness in any health care setting is paramount.

To this end there has been recent guidance issued from NICE on infection control in the community and joint guidance from RCGP and the Community Infection Control Nurse Network specifically aimed at infection control in general practice15.

Daily steriliser check

 · Wipe out and clean chamber

 · Check and clean door seal

 · Check/fill water reservoir with sterile water

(this should be drained down at the end of each day and refilled at the beginning of the next session)

 · Run cycle and note:

·Temperature: 134°C when sterilising

·Pressure: 2.2 bar when sterilising

·Sterilisation hold time: 3.0-3.5 minutes

·Total cycle time: 15 minutes

 · Visual check for leaks or anything unusual

 · Record number of cycles where possible

 · Complete and sign the user sheet

 · Where machines have a printout this should

be filed or attached to patient notes as appropriate

Levels of decontamination

 · Instrument that will be in contact with normally sterile areas of the body

Must be sterilised after use and be sterile at the point of use

Surgical instruments

 · Instrument in contact with intact mucous membranes

Must be sterilised after use but does

not need to be sterile at point of use

unless using for intrauterine coil device insertion

Vaginal speculae

 · Instrument in contact with intact skin

Requires cleaning only

Stethoscope

Adapted from Wilson10

01Department of Health. The NHS Plan. London: Department of Health, 1999

02Department of Health. Standard principles for preventing

hospital-acquired infections:

J Hosp Infect 2001 47;21-37

03Infection Control Nurses Association. Guidelines for hand hygiene. London: ICNA and DEB Ltd.1999

04Larson E A. Causal link between handwashing and risk of infection? Examination of the evidence.

Infection Control and Hospital Epidemiology. 1998;9:28-36

05Department of Health (2001). The epic project: Developing national evidence-based guidelines for preventing health care-associated infection.

J Hosp Infect 47;6-37

06Department of Health. Management of health and safety at work regulations. London: HMSO, 1992

07Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. Guidance for clinical health care workers: Protection against infection with blood-borne viruses. London: Department of Health, 1998

08Health and Safety Executive. Personal protective equipment at work regulations SI 2966: guidance on regulations. London: HMSO, 1992

09National Institute for Clinical Excellence. Infection control prevention

of health care-associated infection in primary and community care.

London: NICE, 2003

10Wilson J. Infection Control in Clinical Practice. London: Bailliere Tindall 1995

11Health and Safety Commission. Control of Substances Hazardous to Health Regulation 1999 Approved Codes of Practice. HSE Books, 1999

12Medical Devices Agency. Guidance on the purchase, operation and maintenance of vacuum benchtop steam sterilisers.

MDA, 2000

13Health Technical Memorandum HTM2010 Part 3:Validation and verification. Part 4 :Operational Management. London:

The Stationery Office

14Pressure Equipment Regulations.

SI1999 No2001. London:

The Stationery Office, 1999

15Rayfield J et al. Infection Control Guidance for General Practice. Infection Control Nurses Association, 2003

Useful websites

www.icna.co.uk

www-micro.msb.le.ac.uk/335/prions.html

www.bmj.com/cgi/collection/mad_cow

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