Decontamination

Decontamination
This section is broken down into several sections and includes cleaning and disinfection of
healthcare equipment and the healthcare environment.
Definitions and application of processes
The term ‘decontamination’ refers to the combination of processes by which pathogenic
microorganisms, including bacterial spores, are removed from an item, making it safe
to handle, use or discard. Decontamination is a three-step process that involves cleaning,
disinfection and sterilisation (in that order).
CLEANING Cleaning is a process that uses detergent and water to remove visible
contamination.
It does not necessarily destroy microbes. Effective cleaning is essential
before disinfection or sterilisation. It is imperative that detergent is used to clean, not
disinfectant.
Detergent is crucial in cleaning as it breaks up dirt and grease, making it easier for the
water to remove any contamination. The combination of detergent and water removes
around 80% of microorganisms from surfaces.
Drying after cleaning is as important as cleaning itself in order to prevent growth of
microorganisms not removed during the cleaning process; this is true for hands and
surfaces.
DI S I N F E C T I O N Disinfection is a process that uses chemical agents or heat to eliminate
many or all pathogenic microorganisms on inanimate objects, with the exception of bacterial
spores.
Disinfectants should only be used when there is a risk of transmission of infection, e.g.
when a patient has an infection. They are not required routinely; cleaning with detergent
alone is adequate.
Disinfectants should be used to disinfect. They should be applied to clean surfaces – they
must not be used to clean (with the exception of products used for blood/body fluid
spillage management).
Alcohol is a disinfectant (not a cleanser) and should not be used for cleaning. Alcohol
acts as a fixative to proteins (which are present in blood and tissue) and makes them stick
to surfaces.
S T E R I L I S AT I O N This is the complete elimination or destruction of all forms of microbial
life, including bacterial spores.
I N F E C T I O N R I S K S A ND DECONTAMINATION REQUIREMENTS It is important
when buying equipment to check with the manufacturer how it should be decontaminated
and that the recommended method is achievable, as to deviate from manufacturer’s guidance
may invalidate the product warranty and transfer liability for the product (should it fail
or cause harm) to you as the user.
Decontamination of reusable medical devices should be undertaken in a dedicated facility
that ensures segregation of dirty and clean items, has a defined workflow, moving from
dirty to clean, and supports tracking and tracing of individual items, with documentation
that supports this, e.g. a sterile services department (SSD). Local decontamination at ward
level should be avoided.
The level of decontamination an item requires is dependent on how it is used – noninvasive
items require a lower level of decontamination than invasive items (see Table 2).
Table 2 Infection risks and decontamination requirements
Level of risk Application
Level of decontamination
required Examples
High Invasive items
Items in close contact with a
break in the skin or mucous
membrane
Items introduced into a sterile
body area
Sterilisation
High-level disinfection may
be adequate for some items
Surgical instruments
Dressings
Catheters
Prosthetic devices
Intermediate Items in contact with intact
mucous membranes, body fluids
Items contaminated with
particularly virulent or readily
transmissible organisms
Items for use on highly
susceptible patients or sites
Disinfection Endoscopes
Respiratory equipment
Low Items in contact with normal/
intact skin
Cleaning and drying
Disinfection is required if
there is a known risk of
infection
Washbowls
Toilets
Bedding
Minimal Items not in contact with the
patient/their immediate
surroundings
Cleaning and drying Floors
Sinks
Walls
S I N G L E U S E O N LY Items designated ‘single use only’ by the manufacturer must not be
reused under any circumstances, despite any cost concerns. Figure 2 shows the ‘single use
only’ symbol

When the ‘single use only’ symbol is seen on a medical device or its packaging the item
must be used once only and discarded. This is different from single-patient use items that
can be reused with the same patient.
If single-use items are reprocessed (decontaminated) and reused, the product liability is
transferred from the manufacturer to the reprocessor, who becomes responsible for the
item’s performance. This means that if a product fails to operate properly or causes harm or
injury it is the responsibility of the reprocessor.
Decontamination of healthcare equipment
• All items of equipment should be cleaned after each use/between patients.
• Manufacturer’s guidance must be adhered to when cleaning healthcare equipment.

Table 3 Healthcare equipment and decontamination methods
Item
Decontamination method – all items require
decontamination after each use
Beds Wash bed frame with detergent and water
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Bed cradles Wash with detergent and water
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Commode frame Clean with detergent wipes
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Commodes should be disassembled for cleaning and disinfection
Commode pan Wash with detergent and water
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Reusable bedpans Wash in an automated washer–disinfector with a heat disinfection cycle that
reaches 90 °C, or reaches 80 °C and maintains the temperature for 1 minute
OR
Wash in detergent and water then disinfect with a chlorine-releasing agent at
1000 parts per million available chlorine strength
Bedpan holder (used
with disposable liners)
Wash with detergent and water
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Blood pressure cuffs Wipe with a detergent wipe
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Dressings trolleys Wash with detergent and water
To disinfect wipe with 70% alcohol after cleaning
Incubator Wash with detergent and water
If disinfection is required use a chlorine-releasing agent at 125 parts per
million available chlorine strength or wipe surfaces with 70% alcohol
Mattresses Wash with detergent and water avoiding excess wetting
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Nailbrushes Sterilised by heat disinfection in SSD
Pillows Wash with detergent and water avoiding excess wetting
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength
Portable suction unit Wash bottle in detergent and water after emptying, after each use
If contents were blood stained, disinfect after washing with a
chlorine-releasing agent at 10 000 parts per million available chlorine
Sheets Send for laundering at patient discharge/when soiled/stained/contaminated/
creased, at least twice a week
Thermometers After removal of protective sleeve disinfect with an alcohol wipe
Toys Wash hard toys with detergent and water
If disinfection is required use a chlorine-releasing agent at 1000 parts per
million available chlorine strength and rinse or wipe with 70% alcohol
Urine bottles Wash in an automated washer–disinfector with a heat disinfection cycle that
reaches 90 °C, or reaches 80 °C and maintains the temperature for 1 minute
OR
Wash in detergent and water and then disinfect with a chlorine-releasing
agent at 1000 parts per million available chlorine strength
Wash bowls (plastic) Wash with detergent and water and dry thoroughly

• General purpose detergent and water/detergent wipes should be suitable for cleaning
the majority of items. Consult your infection control team and decontamination manager
for further advice and always follow manufacturer’s guidance when cleaning equipment
in order to avoid causing damage.
• Wear an apron and gloves when cleaning.
Table 3 sets out the cleaning and disinfection methods for items of healthcare equipment
commonly used at ward level. This guidance may differ from local policy – please refer to
infection control guidance in your place of work.
Note that disinfection is required if an item was used with an infectious patient. If contamination
with high-risk blood or body fluid occurs, a chlorine-releasing agent at 10 000
parts per million available chlorine strength should be used to disinfect. Check manufacturer’s
guidance beforehand for compatibility and refer to the subsection on management
of blood and body fluid spillages and splashes.
Decontamination of the healthcare environment
GENERAL S TANDARDS
• All areas must be kept free of unnecessary equipment and clutter to facilitate cleaning.
• The healthcare environment and all patient equipment must be visibly clean and free
from dust, dirt, debris and blood/body fluid contamination/ stains.
• The floor should not be used for storage – floors must be kept clear to facilitate cleaning.
• The fabric of the environment should be maintained and any damage or defects should
be repaired/replaced.
• Every bed space/single room should be cleaned with detergent and water when a patient
leaves before the next patient is admitted.
• Cleaning schedules should be displayed publicly.
I S O LATION ROOMS
• Isolation rooms should be cleaned last after all other areas in the ward to prevent the
spread of microorganisms and transmission of infection.
• The domestic should wear disposable gloves and an apron when cleaning in an isolation
room. These should be removed in the room immediately before leaving, discarded into
the clinical waste bag and hands should be washed.
• On a daily basis the room should be cleaned with detergent and water and then disinfected
using a chlorine-releasing agent at 1000 parts per million available chlorine
strength or cleaned and disinfected in one step with a chlorine-based detergent at 1000
parts per million available chlorine strength.
• After discharge of an infectious patient the room should be cleaned with detergent and
water and then disinfected using a chlorine-releasing agent at 1000 parts per million
available chlorine strength or cleaned and disinfected in one step with a chlorine-based
detergent at 1000 parts per million available chlorine strength.
• Curtains should be changed after the patient is discharged/transferred from the ward.
CURTA I N S
• Curtains should be changed when soiled/contaminated, after outbreaks of infection, after
discharge of an isolated patient and otherwise every three months as a minimum.
• Fabric curtains should be laundered every three months and disposable curtains should
be changed every three months as a matter of routine.
• If curtains become stained, contaminated or soiled they must be changed immediately.
• No curtain should be stained – curtains with old stains that are set into the fabric should
not be used.
E Q U I P M E N T U S ED F O R C LEANING
• The domestic should wear heavy-duty gloves for cleaning, not disposable clinical gloves,
unless working in an isolation room.
• Mops and buckets should be stored clean, dry and upside down to allow drying and to
avoid dust and debris from accumulating inside. Buckets should be stacked in a pyramid
style, not inside one another.
• Cleaning materials used by the ward domestic should be stored in the domestic service
room and not in any other area of the ward.
• Cloths used to clean and disinfect isolation rooms should be disposable or laundered immediately
after cleaning the isolation room. They must not be used to clean another area.
• All mop heads and cloths should be laundered daily.
COLOUR CODI N G F O R H Y G I E N E The following colour-coding scheme should be
applied to all cleaning materials (gloves, mop handles, buckets, cloths):
Red: bathrooms, washrooms, showers, toilets, basins and bathroom floors
Blue: general areas including wards, departments, offices and basins in public areas
Green: catering departments, ward kitchen areas and patient food service at ward level
Yellow: isolation areas
DO M E S T I C S E RVI C E R O O M ( C L E A N E R ’ S C U P B O A RD) The domestic service room
should be used solely to prepare and clean equipment used for cleaning; there should be no
personal belongings stored and food should not be consumed there. The domestic service
room is regarded as a dirty environment in the same way that the sluice room is, and to
consume food there presents a risk of infection to the member of staff.
CL E A N I N G F R E Q U E N C I E S
Blinds and curtains
In a hospital setting, curtains and blinds should be changed every three months and immediately
upon soiling, staining or contamination.
Floors
Floors should be washed daily with detergent and water. Spillages should be cleaned (and
disinfected if necessary) immediately.
Horizontal surfaces
All horizontal surfaces should be cleaned daily with detergent and water.
Lockers, bed tables
Lockers and bed tables should be washed daily with detergent and water. Spillages should
be cleaned (and disinfected if necessary) immediately.
Showers
Shower curtains should be cleaned daily with detergent and water and changed every three
months – sooner if contaminated.
Toilets
Toilets should be cleaned daily as a minimum and more frequently during outbreaks of
diarrhoeal illness, when they should be disinfected with a chlorine-releasing agent at 1000

parts per million available chlorine strength. Toilets should be cleaned at any time that
they are soiled.
Walls
In theatres walls should be cleaned every 6 months. In other areas there is no requirement
to wash walls with any specified frequency other than to spot-clean any areas that become
dirty using detergent and water.
Wash hand basins
Wash hand basins should be cleaned daily as a minimum and more frequently during outbreaks
of diarrhoeal illness, when they should be disinfected with a chlorine-releasing
agent at 1000 parts per million available chlorine strength.
Windows
Window cleaning is usually done by an external contractor and there is no recommended
frequency.
Managing blood and body fluid spillages and splashes
Blood and body fluids have different levels of risk in terms of their infectivity – see the
subsection on infectivity of body fluids.
In the event of a blood/body fluid spillage it is essential to disinfect the affected area as
described here in order to avoid transmission of bloodborne viruses. Hepatitis B can survive
on surfaces for at least seven days and it is possible to pick it up from inanimate objects;
therefore careful disinfection of spillages and contamination is essential.
HAND H Y G I E N E , G LOVE S , A P R O N S , VI S O R S A ND MASKS
• When disinfecting spillages gloves and an apron should be worn.
• If there is any risk of splashing to the face a surgical mask and eye protection should also
be worn.
• After dealing with the spillage the gloves, apron, etc., should be removed and hands
should be washed.
DI S I N F E C T I N G T H E S P I LLAGE Hypochlorite preparations should be used to disinfect
spillages, at the following concentrations:
• 1000 parts per million available chlorine for urine, vomit or faeces.
• 10 000 parts per million available chlorine for blood/body fluid spillages.
• If hypochlorite solution at 10 000 parts per million available chlorine has already been
prepared and the weaker solution has not, it is acceptable to use the stronger solution to
disinfect following spillage of urine, vomit or faeces – preparation of a separate solution
is not strictly necessary.
Hypochlorite granules should be used for fresh blood/body fluid spillages; these absorb the
spillage whilst disinfecting with 10 000 parts per million available chlorine.
• Do not apply hypochlorite granules to urine or vomit spillages, as the chemical reaction
that occurs causes chlorine gas to be released.
A wide range of products are available for managing blood and body fluid spillages,
including biohazard kits, impregnated wipes – make sure you are familiar
with the products available in your organisation and how to use them

20 DECONTAMINATION
BLOOD/ B LOOD- S TA I N ED B ODY F L U IDS
Fresh spillages
1. Apply hypochlorite granules to the affected area and leave for two minutes.
2. Clear up the spillage and granules with paper products, i.e. disposable items, and
discard into clinical waste.
3. Wash the affected area using general purpose detergent and water or detergent wipes
to remove residual hypochlorite.
4. Dry the affected area thoroughly.
Dried blood/blood-stained body fluids/splashes/
environmental contamination
1. Apply hypochlorite solution at 10 000 parts per million available chlorine strength to the
affected area using paper products. Allow two minutes contact time for disinfection
to take place. Where this is not practicable, e.g. splashes on equipment, hypochlorite
solution should be used to wipe the equipment to remove the contamination.
2. Discard all paper products used to clear up the spillage into a clinical waste bag.
3. Wash the affected area using general purpose detergent and water or detergent wipes
to remove residual hypochlorite.
4. Dry the affected area thoroughly.
U R I N E , VOMIT AND FAECES
1. Clear up the urine/vomit/faeces with paper products and discard into a clinical waste bag.
2. Disinfect the affected area using paper products and hypochlorite solution at 1000 parts
per million available chlorine strength.
3. Wash the affected area using detergent and water or detergent wipes to remove residual
hypochlorite and then dry thoroughly.
4. A chlorine-based detergent at 1000 parts per million available chlorine strength can be
used instead of steps 2 and 3.
I N F E C T IVI T Y O F B ODY F L U IDS Body fluids are regarded as being ‘high risk’ or
‘low risk’ in terms of infectivity. Urine, vomit and faeces are low risk; the following are
high risk:
• Blood/blood-stained body fluids
• Semen
• Vaginal secretions
• Synovial fluid
• Cerebrospinal fluid
• Amniotic fluid (liquor)
• Peritoneal fluid
• Pleural fluid
• Breast milk.
CARE WITH HYPOCHL O R I T E P R E PARAT I O N S
• Always prepare hypochlorite solution(s) in the container(s) provided by the manufacturer.
There should be two available to you – one for 10 000 parts per million available chlorine
concentration and another for 1000 parts per million available chlorine concentration.
• Follow manufacturer’s guidance on preparation of the solution(s).
• Prepare with cold water.

• Do not decant the solution into another vessel.
• Do not shake the container whilst waiting for the tablets to dissolve as to do so may lead
to the contents spraying out when the lid is removed.
• Hypochlorite solutions lose their strength after 24 hours – discard any unused solution(s)
after 24 hours and prepare a fresh batch the next time it is needed.
• Keep the lid of the container – the container should not be used without a lid.
• Hypochlorite solutions are COSHH substances and should be stored securely.
• Hypochlorite is corrosive to metal and therefore prolonged contact with metal should be
avoided.
• Manufacturer’s guidance should be consulted before applying hypochlorite solution to
any item of equipment.
• Do not apply hypochlorite to carpets and soft furnishings as it will strip out the colour;
instead clean with general purpose detergent and water and use steam to disinfect.
• Heavily soiled/contaminated items that cannot be cleaned and disinfected must be
discarded.
• The products used to clear up spillages must all be disposable – mops and buckets should
not be used.

Visors and goggles (eye protection), headwear and footwear

Visors and goggles (eye protection), headwear
and footwear
CHOOSING Goggles should protect you against splashes to your eyes. They should wrap
around the eye area to ensure side areas are protected.
Visors may be worn instead of a mask and goggle combination when there is a high risk
of splattering or spray of blood or other body fluids.
USING
• Visors/goggles should be worn to protect the eyes whenever there is a risk of splashing
to the face. They should be removed when no longer required.
• Visors/goggles should be worn during aerosol generating procedures (intubation, oro/
nasopharyngeal suctioning, tracheostomy care, chest physiotherapy, bronchoscopy/
cardiopulmonary resuscitation).
• Visors/goggles should be worn by all theatre staff directly participating in an invasive
procedure where there is a risk of splashing to the face.
• Torn or otherwise damaged face protection should not be used and should be removed
immediately (safety permitting) if this occurs during a procedure.
REMOVI N G Remove goggles/visors promptly after use, avoiding contact with most likely
contaminated areas, e.g. the front surface. This should be done by handling the straps/ear
loops/goggle legs only (manufacturers’ instructions should be followed).
HEADWARE Theatre hats should be worn in theatres, sterile services departments and
clean rooms. They should cover the hair entirely and should be changed between sessions
or if contaminated with blood or body fluids.
FOOTWARE Footwear should be clean and well maintained. It should support and
cover the whole foot to protect from dropped sharps and blood/body fluid spillages.
Footwear dedicated to a specific clinical area, such as theatre, should be removed before
leaving that area.
Summary of when to use PPE
The guidance contained within Table 1 is not exhaustive; it offers examples of common care
activities where blood/other body fluid exposure may occur and protection must be worn.
As standard, a risk assessment must be undertaken to consider the risks of blood/other
body fluid exposure prior to activities. For further information refer to your local infection
control team/policy.
Table 1 Summary of when to use PPE
Activity
Aprons/gowns
(depending on
significant splashing/
exposure)
Face, eye, mouth
protection
(surgical masks,
goggles) Gloves
Contact with intact skin – no
visible blood/ body fluids, rashes
Not required Not required Not required
Sterile procedures Required Risk assessment Required
Contact with wounds, skin lesions Required Risk assessment Required
Managing spillages of urine and
faeces
Required Risk assessment Required
Potential exposure to blood/other
body fluids, e.g. performing
suctioning, cleaning up spillages,
taking specimens
Required Risk assessment Required
Venepuncture/cannulation Required Not required Required
Vaginal examination Required Not required Required
Applying topical creams, etc. Not required Not required Required
Touching patients with unknown
skin rash
Risk assessment Not required Required
Emptyichanging urinary catheter
bags, urinals, bedpans, etc.
Required Risk assessment Required
Handling specimens Required Not required Required
Handling used instruments Required Not required Required
Using disinfectants, cleaning
agents
Required Risk assessment Required
General cleaning of clinical
areas and equipment
Risk assessment Not required Risk
assessment
Bed making, dressing patients Risk assessment Not required Risk
assessment
Oral care Risk assessment Risk assessment Required
Feeding patient Required Not required Risk
assessment
Handling waste Risk assessment Risk assessment Required

Masks CHOOSING

Masks
CHOOSING
• A wide range of masks are available: reusable and disposable surgical and FFP3 masks;
masks with visors; masks without visors, etc. Make sure you know what is available in
your place of work, how to wear it and how to use it – always follow the manufacturer’s
guidance on use, make sure each item fits comfortably and check expiry dates.
• If there is any possibility that blood, body fluids, medications or fluids of any type may be
splashed in your face, you should wear a surgical mask.
• If you are caring for someone with an infection that is transmitted via the airborne route,
e.g. influenza, and will be performing an aerosol generating procedure such as intubation,
oro/nasopharyngeal suctioning, tracheostomy care, chest physiotherapy, bronchoscopy/
CPR, etc., you should wear an FFP3 mask.
• Manufacturers’ instructions should be adhered to while donning masks to ensure the
most appropriate fit and optimum protection.
USING The purpose of wearing a mask is to prevent splashes from going in your mouth
or up your nose. Specialist masks also filter the air you breathe. Torn or damaged masks
should not be worn as they may not provide the desired level of protection.
SURGICAL MASKS These provide a physical barrier against splashes to the mouth and
nose. They do not filter the air you inhale and are not an effective barrier for fine aerosol
droplets that float through the air and are inhaled. Care should be taken to ensure that
surgical masks fit snugly around the nose and chin.
Surgical masks are single-use, disposable items and should be removed when no longer
required. They should not be worn around the neck and should be changed when moist/
wet/contaminated.
F I LT E R I N G FA C E P I E C E M A S K S ( F F P M A S K S ) These provide a physical barrier
against splashes to the mouth and nose and also filter the air you inhale. They are capable
of filtering fine aerosols. FFP3 masks are the mask of choice, providing a higher level of
filtration than FFP2 masks.
FFP3 masks should be worn when aerosolising procedures are underway with patients
with infections transmitted via the airborne route, e.g. influenza, tuberculosis, etc. They
must be fitted to ensure the best possible fit on to your face. A ‘fit test’ should be carried
out to check how well the mask fits (Box 1).
Box 1 Fit test for masks
FFP3 mask fit testing
• Fit testing is a one-off test but should be repeated if facial shape changes/following
significant weight gain/loss.
• FFP3 fit testing is a legal requirement.
• The wearer must achieve an adequate fit with each specific model of FFP3.
Factors affecting face seal
• Jewellery – may need to be removed.
• Facial markings, e.g. scar/mole.
• Safety or prescription glasses (should be worn during fit test).
• Facial hair. A small goatee or beard than will be covered by the mask may be okay,
otherwise staff must be clean shaven for a proper fit and face seal. Otherwise,
those with facial hair should shave/do not perform aerosolising procedures/use a
hood with powered extraction.
Carry out a fit check before the fit test
• Cover the mask surface with flat hands. For valved masks inhale sharply and for
unvalved masks exhale sharply. If leaks around the seal are detected, correctly fit
the mask before entering a hazardous area

Aprons and gowns CHOOSING

Aprons and gowns
CHOOSING
• Aprons and gowns should be water repellent and should allow you a full range of movement
when worn and not interfere with your clinical activity.
• Check expiry dates on sterile gowns before use – never use an out of date gown.
USING
• An apron or gown should be worn when contamination of your clothing or uniform
might occur.
• Disposable aprons and gowns are single-use items and should be disposed of via the
clinical waste stream immediately after use.
• Disposable, single-use plastic aprons should be worn when there is a risk of contact with
blood/body fluids.
• An impermeable gown should be worn rather than a plastic apron when there is a risk
of significant splashing of body fluids, e.g. in an operating theatre or during invasive
procedures.
• Disposable long-sleeved gowns should be worn when caring for patients known or
suspected to have scabies or any other parasitic skin infestation.
• Colour-coded aprons and gowns are often worn for different tasks in a ward setting, e.g.
a specific colour may be worn when patients are isolated and another for serving meals –
ensure that you wear the correct colour for the task in hand in accordance with local policy.
• Reusable gowns, such as those worn in operating theatres, should be worn once and
then laundered. They must be changed between patients.
• Disposable aprons and gowns must never be cleaned and reused.
• An apron or gown should be worn for one patient and then removed. It may be necessary
to change your apron or gown between tasks on the same patient to prevent
cross-contamination.
• A torn or damaged apron or gown should not be used and should be removed immediately
(safety permitting) if this occurs during a procedure.
• An apron or gown should be removed as soon as the task for which it was worn is complete,
before touching non-contaminated and clean areas, items, environmental surfaces
and contact with other patients and staff.
REMOVI N G
• When removing an apron or gown you should avoid touching the most heavily soiled/
contaminated areas. You should also take care not to touch your clothing or uniform
worn underneath to avoid contamination.
• Turn the outer contaminated side of the gown inward, roll the aprons or gown into a ball
and dispose of it via the clinical waste stream.

Gloves

Gloves
CHOOSING Gloves are a medical device and should be treated as such:
• Choose the right size to ensure a good fit in order to avoid friction, excessive sweating,
finger and hand muscle fatigue and interference with dexterity.
• Check the expiry date of the gloves you use – never use gloves that are out of date
(glove material can deteriorate over time and an out of date glove might not perform
as well).
• Never use disposable latex gloves containing powder (due to the risks associated with
aerosolisation and latex allergies).
USING
• Gloves should be donned before commencing a procedure where you might come into
contact with blood/body fluids/chemicals/therapeutic creams/lotions and as required for
the preparation of medications.
• Gloves should be changed if they become punctured, damaged or torn, or if damage to
the glove is suspected.
• Two pairs of gloves should be worn (double gloving) during some exposure prone procedures
(EPPs), e.g. orthopaedic and gynaecological procedures.
• Gloves should be removed promptly after use (as soon as the procedure is complete)
before touching non-contaminated/clean areas/items, environmental surfaces or other
persons (including yourself), with hands washed immediately afterwards.
• Gloves being worn for a procedure/activity should not be worn to handle or write on
charts, or to touch any other communal, clean surfaces.
• Gloves should not be decanted from the original box to ensure the expiry date is known
and the integrity maintained.
• Gloves should never be washed or have alcohol handrub applied to them. Instead, 
should be removed, hands cleansed and a new pair of gloves donned, if required.
• Wearing gloves does not mean that hands do not need to be washed – hands should be
washed before donning gloves and after removing them.
• Jewellery should not be worn under gloves. Plain metal bands are generally tolerated
but stoned rings may tear the glove material and should not be worn during clinical
activity.
REMOVI N G Care should be taken when removing used gloves to avoid contamination.
Holding the wrist end of the glove, pull it down over itself so that it goes inside out as you
pull it down your hand. Hold the removed glove in the hand that pulled it down. Now using
the ungloved hand, slowly pull the other glove down, inside out, in the same way, over the
fingers and the first glove and dispose of them into the clinical waste as a wrapped
package.
• Gloves should be changed between patients and between procedures on the same
patient to prevent cross-contamination.
• Torn, punctured or otherwise damaged gloves should not be used and should be
removed immediately (safety permitting) if this occurs during a procedure

Gloves, aprons, visors and masks – personal protective equipment (PPE)

Gloves, aprons, visors and masks – personal
protective equipment (PPE)
This section is broken down into smaller sections on general principles of PPE use – gloves,
aprons and gowns, masks, visors and goggles, headwear and footwear – and a summary
of when to use PPE is included.
General principles
The principles described here apply to all situations and all clinical settings. The term PPE
refers to gloves, aprons, gowns, masks, goggles and visors. The appropriate use of PPE is
essential for infection control. The benefit of wearing PPE is twofold in that it provides
protection to both the wearer and the patient.
Before donning PPE you should risk assess the situation – which items are most appropriate
for the task/situation, depending on what you might be exposed to, e.g. blood/other
body fluids? Not all items will be required each time.
You should also consider sensitivities and the risk of latex allergy (your infection control
team and occupational health department will be able to advise you on local policy).
ORDE R O F A P P L I C AT I O N A ND REMOVAL The order of applying PPE is less critical
than the order of removal – remember that when removing PPE each item is contaminated
and it is important to take each item off in the correct order for your protection.
PPE should be applied in the following order:
1. Apron/gown.
2. Mask.
3. Goggles.
4. Gloves.
PPE should be removed in the following order:
1. Gloves.
2. Apron/gown.
3. Goggles.
4. Mask.
After removing PPE you must wash your hands. This is necessary to ensure that any microorganisms
that may have got on to your hands when wearing and removing PPE are not
transmitted to other surfaces/patients/staff that you come into contact with.
PPE should be appropriate, fit for purpose and suitable for the person using/wearing it,
with supplies located close to the point of use. It is your responsibility to ensure you have
what you need, that it fits you properly and you know how to wear/use it.
PPE should be worn only when required and removed when no longer required, with
hands washed immediately afterwards.
PPE should not be worn by staff when transferring patients.
Disposable gloves, aprons, gowns and masks are single-use items and their packaging
will clearly state this. They should never be reused. They should be removed and disposed
of when the task for which they were worn is completed, with hands washed immediately
afterwards.
Reusable masks and visors must be cleaned after each use. Soapy water or a detergent
wipe may be used unless blood/body fluid contamination has occurred, in which case disinfection
with hypochlorite solution at 10 000 parts per million available chlorine strength
is required. See the section on spillage management
Face protection should not be touched whilst being worn as this can lead to hand
contamination.

Manufacturer’s guidance on the use of PPE should always be adhered to.

Hand hygiene equipment

Hand hygiene equipment
SOAP AND WAT E R Plain liquid soap and water are adequate for hand washing for the
majority of clinical care activities – the technique used to clean the hands is more important
than the type of soap used. The six-step technique for hand washing is already discussed.
It is also important that hands are washed under running water and not in static water, as
the objective is to remove microorganisms from the hands and flush them down the drain;
washing hands in static water, i.e. in a hand washbasin with a plug in, does not clean the
hands as effectively as washing under running water.
A N T I B A C T E R I A L S O A P S Antibacterial soaps are not required for general clinical activity;
they are most useful in surgery due to their ability to lower the number of bacteria on
the skin to a lower level than washing with plain soap would achieve, plus they have a
residual effect, which means that it takes longer for the number of bacteria on the skin to
return to normal.
Antibacterial soaps also have a cumulative effect in that the more often they are used,
the greater the number of bacteria removed. Subsequently it takes longer for the number
of bacteria on the skin to return to normal.
ALCOHOL HANDRUB Alcohol handrub can be used to decontaminate the hands providing
they look and feel clean. It should not be used on hands that are soiled or contaminated,
as it will have no effect. Alcohol handrubs sanitise the hands by killing microorganisms
on the skin’s surface; they do not remove soil or organic matter from the skin.
• Alcohol is a disinfectant and is inactivated by dirt and organic matter. As such, if applied
to a soiled or dirty hand it will not have the desired effect.
• Alcohol handrub should be applied to all surfaces of the hands and the hands rubbed
until dry in order to be effective.
• The six-step technique for hand washing should be used when applying alcohol handrub.
• After 4–5 applications of alcohol handrub, hands should be washed using soap and water.
• Alcohol handrub can be used to clean the hands after removing gloves providing hands
look and feel clean.
• Alcohol handrub is not reliable against the bacteria and viruses that cause diarrhoea and
should not be used whenever patients have diarrhoea symptoms. Hands should be
washed with soap and water at these times.
• Alcohol handrub should be applied directly to the skin – it should not be applied to
gloves. Gloves should be removed and a new set donned. Gloves are single-use items
and should not be cleaned and reused under any circumstances.
N A I LBRUSHES Nailbrushes should not be used as they can tear and damage the skin,
creating more places for bacteria to accumulate on the hands. If used for theatre scrubbing
they should be used once and discarded or returned to sterile services for decontamination
before being used again.
S K I N C A R E
• Any cuts or abrasions on the hands should be covered with a waterproof dressing.
• Hand cream should be applied during breaks and when off duty.

• Shared tubs or pots of hand cream should not be used, as they can become contaminated
and lead to hand contamination. Pump dispensers and tubes are ideal.
• Hand creams that make it more difficult to clean the hands after application should not
be used.
• Hand creams that cause any type of deterioration in glove material should not be used.
HAND E T I Q U E T T E Clinical staff should have short clean nails free from dirt, nail varnish,
false nails or nail attachments in order that hands can be cleaned effectively. (False
nails are known to harbour more bacteria than natural nails.)
B A R E B E LOW THE ELBOW It is Department of Health policy in the United Kingdom
for clinical staff working with patients to be ‘bare below the elbow’ during clinical care
activities, in order that hands can be cleaned most effectively, which is best achieved in the
absence of long sleeves and hand and wrist jewellery. A plain metal band (wedding ring)
can be worn but should be moved up and down the finger during hand washing in order
to cleanse the skin underneath.
HAND WASHBASINS To support effective hand washing, hand washbasins in clinical
areas should have the following features:
• Mixer taps.
• Elbow/wrist/pedal/knee/sensor-operated taps, i.e. hands-free operation.
• No plug and not capable of taking a plug.
• No overflow.
• The water from the tap should not flow directly into the drainage aperture.
• Hand washbasins and taps should be wall mounted, not countersunk.
Hand washbasins in clinical areas should be used exclusively for hand washing, as using
them for other activities such as emptying basins and cleaning equipment or crockery
allows the sink to become contaminated, which can lead to contamination of the hands
during hand washing.

Hand hygiene

Hand hygiene
Washing the hands is the most effective way to prevent the spread of infection. This section
is broken down into two subsections: the first covers when to wash the hands and the
technique for doing so effectively; the second section discusses hand hygiene equipment,
including soap, nailbrushes and hand washbasins.
When and how to clean the hands
WHEN Hands should be cleaned at the ‘five moments for hand hygiene’:
1. Before touching a patient.
2. Before a clean/aseptic procedure.
3. After exposure to blood/body fluids.
4. After touching a patient.
5. After touching a patient’s surroundings.
More broadly speaking, this includes:
• Before and after handling invasive devices (moments 1, 2 and 3).
• Before and after dressing wounds (moments 1, 2 and 3).
• Before and after contact with immunocompromised patients (moments 1 and 4).
• After contact with equipment contaminated with blood/body fluid (moment 3).
• After contact with blood/body fluid (moment 3).
• After handling used laundry and clinical waste (moment 3).
• After glove removal (moment 3).
• Before leaving the clinical area (moments 4 and 5).
• After using the toilet (not specific to healthcare, but essential).
• Before and after handling food/drink (not specific to healthcare, but essential).
HOW Using the six-step technique for hand washing (below) described by Ayliffe et al.
(1978) should take approximately 15–20 seconds and allows all surfaces of the hands to be
cleaned effectively. The mechanical action of rubbing the hands together is important in
hand washing to dislodge bacteria from the skin’s surface.
Hands should be wet before soap is applied in order to get a better lather and spread of
the soap and to avoid the irritation that can occur when soap is applied directly to the skin,
repeatedly.
1. Rub hands together palm to palm.
2. Rub hands together, palm to palm with fingers interlaced.
3. Rub left hand over right hand with palm of left hand rubbing back of right hand, with
fingers interlaced, and then right hand over left hand with palm of right hand rubbing
back of left hand, with fingers interlaced.
4. Rub fingertips of left hand into right palm and fingertips of right hand into left palm.
5. Rub hands together with backs of fingers to opposing palms.
6. Grip thumb of left hand with right hand and rub in a rotational manner and then repeat
on the other side.
The hands should then be rinsed and dried thoroughly.
Surgical scrubbing/rubbing
Surgical scrubbing/rubbing involves using the six-step technique described above to wash
the hands, including the forearms. An antibacterial soap is used and the process takes
around two minutes.
• Surgical scrubbing/rubbing is essential before donning sterile theatre gowns, gloves, etc.
• All hand and wrist jewellery must be removed.

• Nailbrushes should not be used but nail picks can be used if the nails appear dirty.

Standard principles of infection prevention and control

Standard principles of infection prevention

and control

These principles were originally referred to as ‘universal precautions’ and are often referred

to as ‘standard precautions’.

To break the chain of infection the standard principles of infection control should be

applied, which are:

1. Hand hygiene.

2. Correct use of personal protective equipment (gloves, aprons, visors and masks).

3. Control of the environment, which incorporates:

°°decontamination (of healthcare equipment and the healthcare environment; management

of blood and body fluid spillages);

°°isolation and cohorting;

°°respiratory hygiene;

°°safe management of sharps and splash injuries;

°°safe sharps practice;

°°safe disposal of clinical waste;

°°safe handling of linen and laundry.

The aseptic non-touch technique is included here, as it is essential for infection prevention

and control.

Whooping cough

Whooping cough
Whooping cough is a respiratory infection caused by the bacterium Bordetella pertussis.
Whooping cough is a notifiable disease.
SPREAD B Y Close direct contact with an infected person, by droplet spread. It is highly
contagious – up to 90% of susceptible household contacts will develop the disease.
I N F E C T I O U S P E R I OD The incubation period is usually 7–10 days (rarely it can be up
to 21 days). The infectious period is up to 3 weeks after the onset of symptoms. Beyond
3 weeks, risk of transmission of infection is minimal, even if the cough persists.
I N F E C T I O U S C O N T R O L P R E C A U T I O N S
1 Isolation Required
2 Hand washing Required
3 Gloves Required
4 Apron Required
5 Mask Required
6 Eye protection Not required
The risk of transmission is minimal after 3 weeks of illness, but in a few cases (up to 20%)
infectivity can persist for up to 6 weeks. Therefore the above infection control precautions
should be taken in all hospitalised cases. Discuss with your Infection Prevention and Control
Team if required.
S TA F F All staff looking after a patient with whooping cough should have had a full
course of whooping cough vaccination. If vaccination history is incomplete or unknown,
arrange for other staff to care for the patient and discuss with Occupational Health.
VI S I T O R S Visitors should be kept to a minimum number and should be limited to adults
with a history of vaccination against whooping cough. Children under the age of 1 year
should not visit under any circumstances. Visitors should comply with all above
precautions.
PAT I E N T T R A N S F E R Patient transfer should be kept to a minimum. The patient should
wear a mask during transfer. The receiving ward/department should be informed in advance
of the diagnosis.
MORE INFORMAT I O N Whooping cough may occur at any age. Young infants are
the most at risk because they are not yet vaccinated and because infection at this age can
cause severe illness with breathing difficulties.
Epidemics of whooping cough occur every 3 to 4 years, and the highest number of cases
is usually in July–September annually.
Whooping cough is a vaccine-preventable disease. In the UK it is given as part of the
routine childhood immunisation programme and is also given to high-risk groups as
needed, e.g. to pregnant women during the 2012–2013 national outbreak. Immunity
wanes over time and it is possible to catch whooping cough even if you have previously had
the illness or a course of vaccinations.
The illness begins with coryzal symptoms and progresses to a dry cough, which may
occur in paroxysms (outbursts of coughing) and may end with vomiting or with an intake
of air, which makes a ‘whooping’ sound. The cough may go on for weeks or months

Whooping cough is treated with antibiotics (usually erythromycin, clarithromycin or
azithromycin) within the first 3 weeks of symptoms. Treatment is not necessary later in the
course of the illness. Treatment duration used to be 14 days but has now been reduced
to 7 days (3 days if taking azithromycin). Unvaccinated/partially vaccinated cases up to
10 years of age should complete their course of primary immunisation and booster vaccine
once they have recovered from their acute illness.
Contacts of cases may be offered antibiotic prophylaxis and/or vaccination if identified
promptly.
Laboratory confirmation is possible by culture or PCR of pernasal swab or nasopharyngeal
aspirate, or by serology. Discuss with your microbiologist or Health Protection Unit to
ascertain the most appropriate test.

Viral haemorrhagic fevers (VHFs)

Viral haemorrhagic fevers (VHFs)
Viral haemorrhagic fevers (VHFs) are imported infections caused by a range of viruses. VHF
infection is uncommon but is important because it is difficult to diagnose, has a high casefatality
rate with no effective treatment and it can spread rapidly within the hospital setting
unless correct precautions are taken. All units admitting returning travellers should have
policies in place to risk assess and identify possible cases. Standard principles of infection
control should be used while the assessment is carried out. Following the assessment, the
patient is categorised as one of the following: highly unlikely to have VHF, possibility of VHF,
high possibility of VHF or confirmed VHF. Further management, including the level of infection
control precautions, depends on the outcome of the risk assessment. Always inform
the Infection Prevention and Control Team and a consultant microbiologist of any suspected
case of VHF. VHF is a notifiable disease: notify high possibility/confirmed cases
urgently.
SPREAD B Y
• Direct contact – if blood or body fluids come into contact with broken skin or mucous
membranes.
• Indirect contact – with an environment contaminated with splashes or droplets of blood
or body fluids.
I N F E C T I O U S P E R I OD The incubation period ranges from 3 to 21 days. The patient is
considered potentially infectious until an alternative diagnosis is confirmed or until there
has been a negative VHF screen and the patient has been afebrile for 24 hours. If VHF is the
confirmed diagnosis, the patient is considered infectious for an indefinite period (seek
expert guidance).
I N F E C T I O N C O N T R O L P R E C A U T I O N S
For patient highly unlikely to have VHF (no risk/ minimal risk)
1 Isolation Not required
2 Hand washing Required
3 Gloves Required
4 Apron Required
5 Mask Not required
6 Eye protection Not required
If possibility of VHF
1 Isolation Required. Should have dedicated en suite facilities
or dedicated commode
2 Hand washing Required
3 Gloves Required
4 Apron Required
5 Mask Not generally required, but if patient is bruising or
bleeding wear a fluid-repellent surgical facemask
for routine care and FFP3 mask for aerosol- or
splash-generating procedures
6 Eye protection Not generally required, but disposable visor
recommended if patient is bruising or bleeding

164 VIRAL HAEMORRHAGIC FEVERS (VHFs)
For high possibility of VHF in a stable patient
1 Isolation Required. Should have dedicated en suite facilities
or dedicated commode
2 Hand washing Required
3 Gloves Required
4 Apron Required
5 Mask Required: fluid-repellent surgical mask generally
adequate, FFP3 mask for aerosol- or splashgenerating
procedures
6 Eye protection Required – disposable visor
For high possibility of VHF in patient with bruising, bleeding or uncontrolled diarrhoea/
vomiting
1 Isolation Required. Should have dedicated en
suite facilities or dedicated commode
2 Hand washing Required
3 Gloves Double gloves required
4 Apron Fluid-repellent disposable gown
required
5 Mask FFP3 mask required
6 Eye protection Disposable visor required
EQUIPMENT Equipment used in high-possibility/confirmed cases of VHF should be
single
use and disposable.
S TA F F If there is a high possibility of VHF, or a confirmed case, the number of staff caring
for the patient should be restricted to essential staff only and a record of these staff should
be kept. Remember to inform the laboratory of a suspected case of VHF so that laboratory
staff can take appropriate precautions when handling specimens.
VI S I T O R S Visitors should not be allowed if there is a high possibility or confirmed case
of VHF.
PAT I E N T T R A N S F E R Patient transfer should not take place unless absolutely essential
for medical reasons. The receiving department should be informed in advance of the possibility
of VHF. The Infection Prevention and Control Team should also be informed of any
planned patient movement.
MORE INFORMAT I O N Symptoms include fever, sore throat, headache, muscle or joint
pain, diarrhoea and vomiting. Obvious bleeding occurs at a late stage of the illness. Cases
of VHF are rare in the United Kingdom and are always imported from other countries. Any
patient with high-possibility VHF, or with possible VHF with bruising or bleeding, must be
discussed with an infectious disease unit. Any patient with confirmed VHF must be transferred
to a high-security infectious disease unit. Management of a confirmed VHF case is a
highly specialist subject and is not within the scope of this book
Whooping cough
Whooping cough is a respiratory infection caused by the bacterium Bordetella pertussis.
Whooping cough is a notifiable disease.
SPREAD B Y Close direct contact with an infected person, by droplet spread. It is highly
contagious – up to 90% of susceptible household contacts will develop the disease.
I N F E C T I O U S P E R I OD The incubation period is usually 7–10 days (rarely it can be up
to 21 days). The infectious period is up to 3 weeks after the onset of symptoms. Beyond
3 weeks, risk of transmission of infection is minimal, even if the cough persists.
I N F E C T I O U S C O N T R O L P R E C A U T I O N S
1 Isolation Required
2 Hand washing Required
3 Gloves Required
4 Apron Required
5 Mask Required
6 Eye protection Not required
The risk of transmission is minimal after 3 weeks of illness, but in a few cases (up to 20%)
infectivity can persist for up to 6 weeks. Therefore the above infection control precautions
should be taken in all hospitalised cases. Discuss with your Infection Prevention and Control
Team if required.
S TA F F All staff looking after a patient with whooping cough should have had a full
course of whooping cough vaccination. If vaccination history is incomplete or unknown,
arrange for other staff to care for the patient and discuss with Occupational Health.
VI S I T O R S Visitors should be kept to a minimum number and should be limited to adults
with a history of vaccination against whooping cough. Children under the age of 1 year
should not visit under any circumstances. Visitors should comply with all above
precautions.
PAT I E N T T R A N S F E R Patient transfer should be kept to a minimum. The patient should
wear a mask during transfer. The receiving ward/department should be informed in advance
of the diagnosis.
MORE INFORMAT I O N Whooping cough may occur at any age. Young infants are
the most at risk because they are not yet vaccinated and because infection at this age can
cause severe illness with breathing difficulties.
Epidemics of whooping cough occur every 3 to 4 years, and the highest number of cases
is usually in July–September annually.
Whooping cough is a vaccine-preventable disease. In the UK it is given as part of the
routine childhood immunisation programme and is also given to high-risk groups as
needed, e.g. to pregnant women during the 2012–2013 national outbreak. Immunity
wanes over time and it is possible to catch whooping cough even if you have previously had
the illness or a course of vaccinations.
The illness begins with coryzal symptoms and progresses to a dry cough, which may
occur in paroxysms (outbursts of coughing) and may end with vomiting or with an intake

of air, which makes a ‘whooping’ sound. The cough may go on for weeks or months.
Whooping cough is treated with antibiotics (usually erythromycin, clarithromycin or
azithromycin) within the first 3 weeks of symptoms. Treatment is not necessary later in the
course of the illness. Treatment duration used to be 14 days but has now been reduced
to 7 days (3 days if taking azithromycin). Unvaccinated/partially vaccinated cases up to
10 years of age should complete their course of primary immunisation and booster vaccine
once they have recovered from their acute illness.
Contacts of cases may be offered antibiotic prophylaxis and/or vaccination if identified
promptly.
Laboratory confirmation is possible by culture or PCR of pernasal swab or nasopharyngeal
aspirate, or by serology. Discuss with your microbiologist or Health Protection Unit to

ascertain the most appropriate test.