Control of Infection: How To Avoid Damaging Yourself And Your Patient

Clinical work exposes you to the risk of infection and injury. As well as illness or early death, your career could be affected. Infection with HIV or blood-borne hepatitis viruses could prevent you from working in any branch of surgery.

Patients are also at risk: careless hygiene practice by doctors & nurses are a major cause of wound infection. Hospital acquired infection costs the NHS £1 billion every year. 5,000 patients die every year from infections they contracted after admission.

You can avoid risk to yourself and your patient by:

• Getting & staying vaccinated
• Learn and always follow safe sharps practice
• Always following infection control procedures
• Report and get help with any needlestick accident.

Protecting Yourself

Clinical vaccinations

You must be vaccinated against hepatitis B, tuberculosis and rubella. Many teaching hospitals require students to have completed vaccinations before you are allowed to work with their patients.

You must attend the College OH clinic at South Kensington for vaccinations. Tel: 020 7594 9401 for appointments.

Always carry your vaccination card with you. You may not be allowed on the wards if you are unable to show you have completed your vaccination programme. If you don’t have one, contact the IC Clinic.

You need to get a hepatitis B booster every 5 years to maintain immunity. The College OH Service will send you a reminder (by email) when your booster is due

Preventing contact


Before going onto a ward:

• cover any broken skin— unhealed cuts or grazes— with an adhesive dressing.
  

• wear your white coat
• if you have active eczema on your hands, you should wear disposable gloves (vinyl are the best choice)
• always wear gloves for any internal examination
• always wear gloves for examination or dressing of wounds.
  

• dispose of used gloves etc into a clinical waste bin
• wash your hands after carrying out any internal examination or examination

Safe sharps practice

Your biggest risk of dangerous infections is through inoculation accidents— ‘needlesticks’— from hypodermic needles, scalpels etc. Always follow safe sharps practice, including when under pressure. The key points are:

DO:

• wear gloves. Even if they cannot prevent an accident, they reduce the risk of consequent infection
• use Vacutainers rather than needle & syringe
• discard into sharps bin immediately after use as a single unit (don’t unscrew the needle)
  
  

• re-sheath needles
• carry used sharps in your hand. Take the sharps bin to the bedside
• over-fill sharps bins. If you have to push, it’s full.
• try to retrieve anything from a sharps bin. Never put your hand inside a bin.
• bleed known high-risk patients

It takes time to become good at taking blood. It takes time to become proficient with Vacutainers. Learn from good teachers. Don’t be afraid to ask an experienced phlebotomist or doctor to supervise you— more than once—if you’re finding it difficult.

It is School policy that students must not take blood or carry out other procedures with sharps on patients known to be infected with HIV or other blood-borne viruses.

Needlestick action Hepatitis B, Hepatitis C and HIV can each be transmitted through accidents causing exposure to blood or other physiological fluids.

You are at risk of infection from:

• Any graze or puncture wound from a use sharp
• A bite from a violent patient if it breaks the skin
• splashing of or blood or other body fluid onto broken skin, or into your eyes or mouth
  

You need to:

• stop what your doing
• wash off the contaminating material immediately. Use tap water or normal saline to wash out an eye splash
• encourage bleeding by shaking. Don’t suck or squeeze a wound
• wash in running water
• report any injury to the hospital Occupational Health Department. Even if you think the patient involved is not an infection risk: they may be unknowingly infected with a blood-borne virus or have asked for their immune status not to be recorded in their notes.

You should also let the charge nurse for the ward or clinic know of an injury and complete an accident report form.

Post-exposure prophylaxis (PEP)

There is treatment available to prevent or reduce the risk of infection from HIV and Hepatitis B after a dangerous inoculation accident. The hospital’s occupational health department usually provides this. You should always seek their help to assess whether you were at risk and to decide whether PEP treatment is needed. Do not rely soley on your own or the ward doctor’s assessment.

For HIV, treatment is best started within one hour of an accident. At most hospitals, the senior doctor on duty in the A&E department, or the senior on-call physician, will provide help out-of-hours when occupational health is closed. You will be informed of the local arrangements for each hospital when you start an attachment. Information is also available on the College OH Service’s web site.

HIV post exposure prophylaxis.

The risk of HIV transmission from exposure incidents is small, but it can happen. The current treatment is to give a 28-day course of the drugs used to treat established HIV disease. They often cause unpleasant side effects and, rarely, have dangerous effects so you need to weigh up the risks and benefits before deciding on whether to take treatment. The OH physician or nurse will help you with this.

The statistical risk of infection from a patient who is HIV positive is:

• 1:300 for a needlestick injury with a hypodermic needle
• 1:3000 for a blood splash onto mucous membranes or broken skin.

• the patient is in the initial sero-conversion phase, or end-stage infection— ‘full-blown AIDS’.
• the injury was caused by a large bore needle e.g. IV cannula
• blood is injected in the accident.
• the injury is deep e.g. a puncture wound penetrating through the skin

Serum, CSF and other physiological fluids e.g. CSF are potentially infectious, especially if blood-stained. Faeces, saliva and urine are considered non-infectious unless visibly bloodstained.

More information on needlestick accidents.

Protecting Your Patient

Nosocomial infection: infection contracted during medical treatment is a huge problem in hospitals. Up to 5,000 patients die every year from nosocomial infections. Up to 30% are preventable through simple infection control procedures. Infections increase costs, waiting lists, and harm.

The most important control is also the simplest and cheapest— handwashing, to prevent accidental transmisson of infection from patient to patient via the hands of their carer: medical students includ ed! All hospitals have defined pr o cedures to try to prevent the spread of infection between patients and between patient and carer. They have to be followed to work. Don’t cut corners, don’t follow bad or careless practice you might see with others. Our first duty is always to the patient.

Infection control: hand-washing

Always wash your hands: 

BEFORE:

• contact with wounds, IV sites
• contact with susceptible patients
• carrying out any internal examination
• taking blood
• eating

• removing gloves
• contact with a patient suffering from infection
• changing or ‘lifting’ dressings
• going to the toilet
• assisting a patient with toiletting

• wear all protective equipment provided
• report missing equipment to the nurse-in-charge
• remove gowns, gloves & masks before leaving the room
• discard disposable clothing correctly
• close the door after entering and leaving
• wash hands immediately after examining the patient and before leaving the room, even if you have worn gloves

• You develop any possible infectious rash
• You are unwell with diarrhoea or vomiting
• You have been in contact with chickenpox or shingles (unless you have proven previous infection)
• You are unwell with a feverish illness

You should report contact with chickenpox to the Hospital or College OH Service. If you ever think you may have contracted HIV or other blood-borne infection, you have a duty, under GMC regulations, to report this in confidence to the School or the College OH Physician


Occupational Health Physician, Imperial College - Occupational Health Service

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