spillage procedure

Document Type: PROCEDURE

Unique Identifier: CORP/PROC/468

Version Number: 1

Title: Blood and Body Fluid Spillage

Status: Ratified

Scope: Trust Wide

Classification: Organisational

Author/Originator and Title: Johanne Lickiss Clinical Infection Control Nurse

Responsibility: Control of Infection Clinical Governance Directorate

Replaces: All previous Blood Spillage Policies

Description of amendments: Throughout the Document comply with Trust format

Name of Committee/Directorate/ Working Group: Decontamination

Date of Meeting:

Risk Assessment: Not Applicable

Validated by: Clinical Governance Management Team Meeting

Validation Date: 23/02/2007

Ratified by: Clinical Effectiveness Committee

Ratified Date: 05/03/2007

Date of Issue: 05/03/2007 Review Date: 01/09/2009

Review Dates: Review dates may alter if any significant changes are mad

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Does this document meet with the Race Relation Amendment Act (2000) Age Discrimination Act , Disability Discrimination Act and Gender Equality Regulations? Not Applicable

Blackpool Fylde and Wyre Hospitals NHS Trust

Revision No: 1 Review Date: 01/10/2009

I.D. No: CORP/PROC/468

Title: Blood and Body Spillage Do you have the up to date version? See the intranet for the latest version

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1 PURPOSE.

The purpose of this procedure is to ensure that all staff groups follow the Blood and Body Fluid Spillage Procedure in conjunction with the Blood and Body Fluid Spillage Policy. (See Section 7)

2 SCOPE.

This procedure applies to all staff employed by Blackpool Fylde and Wyre Hospitals NHS Trust the Trust (BFWH).

3 PROCEDURE

3.1 Management of Blood and Body Fluid Spillage

When dealing with Blood and Body Fluid Spillage all staff must wear personal protective clothing (gloves and aprons) at all times. All Personal Protective Clothing must be disposed of into Clinical Waste bags. Further Personal Protective Equipment must be used appropriately when there is a risk of extensive splashing of blood and body fluids e.g. body fluid repellent gowns, face visors and footwear. Never use mops to clear up body fluid spillages. All body fluid spillage must be cleaned up immediately and effectively. Hypochlorite releasing agents can be a hazard especially if used in large volumes in

confined spaces, or mixed with other chemicals or urine. A risk assessment and Control of Substance Hazardous to Health (COSHH) assessment must be carried out if using these chemicals.

Wear disposable gloves and aprons. Glove choice must be Nitral or Latex gloves please refer to Guideline on Non-Sterile

Examination Glove (Corp/Guid/052). Vinyl gloves are not suitable for use when dealing with blood and or body fluids.

Wounds and lesions on exposed skin should be covered with a waterproof dressing. Ensure adequate ventilation is required when using Hypochlorite to clean areas.

(Ensure windows and doors are open) By following instructions Hypochlorite solution must be prepared and used within

24 hours any remaining fluid must be discarded into the drainage system.

Spills on the body Splashes of blood or body fluid on to the skin must be washed off immediately with

soap and water. Please Note A warning sign must be displayed and clearly visible at all times around the affected area.





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Strong Hypochlorite Solution 1% (10,000) for use when dealing with blood and other blood stained body fluids. - Dissolve 4 (four) Haz-tabs in Cold Tap Water in a One Litre Dilutor - Screw the cap firmly onto the dilutor - Agitate the dilutor gently to dissolve the Haz-Tabs. - Discard any excess solution immediately after use. Small Spills Must be wiped up with a paper towel soaked in Hypochlorite (10,000 ppm available

chlorine) Wash area with general-purpose detergent and warm water. Gloves, aprons and paper towels must be disposed in Clinical Waste. Wash hands as per Hand Hygiene Policy. Large Spills Cover the spill with disposable paper towels. Pour Hypochlorite (10,000 ppm available chlorine) over the towels. Leave for 2 minutes. Remove towels and discard into yellow waste bag. Wash area with general-purpose detergent and warm water. Gloves, aprons and paper towels must be disposed of in Clinical Waste. Wash hands as per Hand Hygiene Policy.

Extensive Large Spills It may be impractical to treat large spills of blood or body fluid with Hypochlorite. In

this instance the spill must be soaked up with disposable paper towels and discarded into Clinical Waste bags.

The area must then be cleaned with Hypochlorite 10,000ppm followed by general-purpose detergent and warm water.

Gloves and Aprons must be disposed into Clinical Waste. Wash hands as per Hand Hygiene Policy.

Please Note: Do not use Hypochlorite on large spillages of Urine

4 ATTACHMENTS. Appendix 1 References

5 ELECTRONIC AND MANUAL RECORDING OF INFORMATION. Held By: Clinical Governance Held in format: Electronic and/or hard copy Database for Policies, Procedures, Protocols and Guidelines

Archive/Policy Co-ordinators office





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6 LOCATIONS THIS DOCUMENT ISSUED TO.

Copy No Location Date Issued 1 Intranet 05/03/2007 Wards and Departments 05/03/2007

7 OTHER RELEVANT /ASSOCIATED DOCUMENTS.

Procedure No.

Title

Corp/Pol/ 149 Management of the Control of Substance Hazardous to Health (COSHH) Regulations

Corp/Proc/ 006 Carrying out a Risk Assessment and developing a Risk Register

Corp/Proc/ 421 Implementation of the Personal Protective Equipment (PPE) Regulations 1992

Corp/Pol/ 056 Hand Hygiene Policy

Corp/Proc/ 418 Hand Hygiene Procedure

Corp/Pol/186 Blood and Body Fluid Spillage Policy

8 AUTHOR/DIRECTORATE MANAGER APPROVAL.

Issued By Mrs J Lickiss Checked By M Aubrey

Job Title Clinical Nurse Specialist In

Job Title Head of Clinical Governance

Signature Signature

Date January 2007 Date March 2007





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Appendix 1 References: Good Practice Guidelines for Renal Dialysis/transplantation Units Prevention and control of Blood-Borne Virus infection Public Health Laboratory Service on behalf of Department of Health. 2002. Page 33 8.25 8.26 Wilson J (2006) 3rd Edition. Infection Control in Clinical Practice. Bailliere Tindall Elsevier. Royal College of Nursing (2005) Good practice in Infection Prevention and Control. Cavendish Square. London.

Unique Identifier:VersionNumber:Scope:Classification:Name of Committee/Directorate/Working Group:Validation Date:Please Note A warning sign must be displayed and clearly visSmall SpillsLarge SpillsExtensive Large Spills

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spillage procedure

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