- Infection control is concerned with two main areas. Firstly, transmission from person to person, and secondly, transmission via a contaminated object.
- You must ensure that a safe environment is provided to deliver care to your patients.
- You must follow appropriate infection controls, including hand hygiene.
- You should keep up-to-date with immunisations.
- You must use and dispose of sharps safely.
- You should be aware of situations of increased concern, including patients with transmissible infections.
- You should use routine infection control precautions, including decontaminating equipment that comes into contact with patients.
- You should know the measures to take in case of accident.
- You must dispose of waste safely.
- physical contact, which can spread:
- ophthalmic infections, such as bacterial and adenoviral conjunctivitis
- skin infections, for example staphylococcus, herpes simplex or fungi
- enteric infections, for example viral gastroenteritis
- airborne particles, including respiratory infections, for example tuberculosis:
- you are at a special risk of the transmission of airborne infection because of the proximity to the patient’s nose and mouth
- potentially infectious respiratory aerosols are generated when an individual sneezes, coughs or talks. Particles over 5 microns in diameter do not normally travel more than 1m but smaller particles can travel longer distances and remain airborne for longer
- contact with bodily fluids:
- you are at extremely low risk of transmitting blood borne viruses, such as human immunodeficiency virus (HIV) and hepatitis B and C, in optometric practice
- tears can contain infectious agents (including these viruses, and others that are much more contagious, such as adenovirus) which may be transmitted to yourself or to other patients if your hands are not properly cleaned after the clinical examination
- all spillages of blood and body fluids should be cleaned up immediately using a product that contains a detergent and disinfectant. Do not use mops for this. Use disposable paper towels and dispose of them as clinical waste.173
- use of sharps: the main risk of transmission is associated with invasive procedures in which injury, for example needlestick, could result in blood from the infected individual entering open tissues of another person. If you suffer an injury from a sharp which may be contaminated, you should:
- gently encourage the wound to bleed, if possible whilst holding it under running water
- wash the wound using running water and plenty of soap
- dry the wound and cover it with a waterproof plaster or dressing
- seek urgent medical advice
- report the injury to your employer.174 175
References
173 Health Protection Agency/Public Health Agency NI (2017) Guidance on infection control in schools and other childcare settings [Accessed 5 Dec 2019]174 Health and Safety Executive. Sharps injuries [Access 20 Nov 2020]
175 NHS (2018). What should I do if I injure myself with a used needle? [Accessed 20 Nov 2020]
176 General Optical Council (2016) Standards of Practice for Optometrists and Dispensing Opticians para 12.1 [Accessed 20 Nov 2020]
- before every episode of direct patient contact or care
- after every episode of direct patient contact or care
- after any exposure to body fluids (including tears)
- after any other activity or contact with a patient’s surroundings that could potentially result in hands becoming contaminated
- after removal of gloves.
- before (and after) contact lens insertion or removal
- after going to the toilet
- when hands are visibly dirty
- before (and after) contact with ocular surfaces and adnexae
- before (and after, if necessary) administering medication, for example eye drops
- after any possible microbial contamination, e.g. contact with body fluids, wounds, or clinical waste.
- wet hands under running water (use warm water where available)
- dispense liquid soap or antiseptic into cupped hand (bar soap should not be used)
- rub hands vigorously and thoroughly for at least 15 seconds without adding more water
- ensure all surfaces of the hands are covered
- rinse hands thoroughly under running water (use warm water where available)
- dry hands with a disposable paper towel. You should not use non-disposable towels.
- liquid soap
- antiseptic
- antibacterial (alcohol-based) handrubs.178
- use liquid soap in disposable containers or containers that are washed and dried before refilling
- never top up the containers.
- before and after direct contact with patients in clinical settings, where there is an outbreak of antimicrobial resistant organisms (e.g. residential or nursing homes)
- where there is heavy microbial contamination
- before performing invasive procedures or minor operations.
- cover cuts and abrasions to skin with waterproof dressings (preferably coloured)
- dry your skin properly with paper hand towels after washing
- use hand cream as appropriate; you should not share jars of hand cream with others.
- tetanus
- polio
- tuberculosis
- hepatitis B.
- covering your nose and mouth and using a tissue whilst coughing or sneezing
- disposing of used tissues in the nearest appropriate receptacle as soon as possible181
- performing hand hygiene after coughing or sneezing
- not working in clinical practice if you have an acute upper respiratory tract infection, such as the common cold
- avoiding touching your mouth, eyes and nose unless you have performed hand hygiene.
- Attach a breath guard or shield where appropriate, such as the slit lamp or keratometer.
- You must comply with appropriate health and safety measures for adequate ventilation throughout the practice.
You should risk assess whether to wear personal protective equipment (PPE).
a. where you anticipate exposure to protect against direct contact with blood, body fluids or non-intact skin.
b. while handling and cleaning decontaminated equipment.
All PPE should be:
c. located close to the point of use
d. single-use only items, unless specified by the manufacturer or public health body. Reusable PPE items, must be decontaminated according to the manufacturer recommendations.
e. stored appropriately
f. disposed of after use into the correct waste stream.
- Performing procedures when in close proximity to the patient
- You consider there is a risk of respiratory infection
- There is a public health requirement to wear one, such as during a pandemic, unless the mask type specified by the relevant national or local public health guidance recommends an alternative specification and level of protection.
- invasive procedures
- contact with:
- non-intact skin
- mucous membranes
- exposure to:
- blood
- bodily fluids, including tears
- secretions
- excretions
- sharp or contaminated instruments
- other contaminated material, for example dressings.
- whether the patient has an overt infection, such as ulcerative blepharitis or acute viral or bacterial conjunctivitis
- the degree of contact with bodily fluids or infected tissue
- the consequences of infection.
- carry out a normal eye examination
- perform minor procedures where there is no likelihood of cross-inoculation with bodily fluids
- fit contact lenses.
- using equipment with safety devices
- using safe handling and disposal procedures.
References
177 National Institute for Health and Care Excellence (2017) Healthcare-associated infections: prevention and control in primary and community care. Clinical Guideline 139 [Accessed 20 Nov 2020]178 British Standards Institute (2013) Chemical disinfectants and antiseptics. Hygienic handrub. Test method and requirements (phase 2/step 2). BS EN 1500:2013. [Accessed 19 April 2022]
179 Chlorhexidine is known to induce hypersensitivity, including generalised allergic reactions and anaphylactic shock. The prevalence of chlorhexidine hypersensitivity is unknown but is likely to be very rare. For further information see MHRA (2012) Chlorhexidine: reminder of potential for hypersensitivity [Accessed 20 Nov 2020].
180 NHS Choices. Catch it, Bin it, Kill it [Accessed 20 Nov 2020]
181 Health and Safety Executive: Pandemic Flu – Workplace guidance [Accessed 1 Dec 2020]
182 Pratt RJ, Pellowe CM, Wilson JA et al (2007) Epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 65(S1) S1-S61, but see page S22
183 NHS Plus, Royal College of Physicians, Faculty of Occupational Medicine (2008) Latex allergy: occupational aspects of management. A national guideline [Accessed 20 Nov 2020]
184 Health and Safety Executive. Latex allergies [Accessed 20 Nov 2020]
186 The Health and Safety (Sharp Instruments in Healthcare) Regulations SI 645 of 2013.
Health and Safety Executive (2013) Health and Safety (Sharp Instruments in Healthcare) Regulations 2013: Guidance for employers and employees [Accessed 20 Nov 2020]
187 National Institute for Health and Care Excellence (2017) Healthcare-associated infections: prevention and control in primary and community care. Clinical Guideline 139 [Accessed 1 Dec 2020]
- patients discharged from hospital with MRSA
- nursing home residents who have acquired MRSA
- MRSA transmitted to non-hospitalised patients, or other individuals, from MRSA patients
- MRSA arising naturally in the community.
- increase the effectiveness of your hand hygiene by:
- keeping nails short, clean and free of nail varnish, and by avoiding artificial nails
- avoiding wearing jewellery, especially rings with ridges or stones
- avoiding wearing wristwatches
- keep in mind NHS policy on clinician attire by:
- wearing short sleeves or rolling up long sleeves
- not wearing a tie.
- contact lenses, contact lens cases and other paraphernalia
- ophthalmic devices such as:
- tonometer heads
- pachymeters
- diagnostic lenses that come into contact with the ocular surface, such as: gonioscopes, fundus lenses, three-mirror lenses and lenses used in conjunction with laser therapy
- the environment: bacteria may contaminate flat surfaces if they become airborne. Bacteria that are shed into the environment may survive for long periods in dust. Flat surfaces act as reservoirs for S. aureus, including MRSA, and contamination will transfer easily to hands that touch them. Contamination on hands and/or gloves may then be transferred by contact with equipment, switches, phones, computer keyboards, door handles, light switches etc.
- maintain good hand hygiene,188 see paragraphs B21-B34
- decontaminate equipment after use, see paragraphs B57-B81
- disinfect used linen
- decontaminate the environment by:
- keeping it clean and free from clutter and dust
- disinfecting spills of body fluid.
References
188 National Institute for Health and Care Excellence (2017) Healthcare-associated infections: prevention and control in primary and community care. Clinical Guideline 139 [Accessed 1 Dec 2020]- trial frames
- chin and forehead rests
- refractor heads
- handheld occluders
- rulers
- tonometer heads
- medical devices such as contact lenses and sample frames
- gonioscopes and other diagnostic lenses.
- cleaning to remove organic or inorganic debris. This may be done with detergents or ultrasonic cleaning
- disinfecting to reduce viable microorganisms with heat or chemicals
- sterilising to kill or remove all microorganisms, including spores. This is not normally required in optometric practice.
- clean equipment which does not come into close contact with mucous membranes or sterile body areas, e.g. trial frames and refractor heads
- clean surfaces in the consulting room, unless contaminated with body fluids, see d below
- disinfect equipment which comes into close contact with intact mucous membranes
- disinfect surfaces in the consulting room if contaminated with body fluids, using a chlorine-releasing disinfectant such as sodium hypochlorite 1% (10,000 ppm of available chlorine)
- sterilise equipment introduced into a sterile body area or in contact with a break in the skin or mucous membrane.
Agent | Preparation | Examples of use |
---|---|---|
Liquid soap | as supplied | handwash |
Chlorhexidine gluconate 4% skin cleanser | 500 ml bottles with pump dispenser eg Hibiscrub | antiseptic handwash |
Chlorhexidine 5% in 70% isopropyl alcohol 189 | 500 ml bottles with pump dispenser eg Hibisol |
antiseptic hand disinfectant for use before aseptic procedures or after handling contaminated materials |
Alcohol-based hand sanitizer | as supplied, usually in bottles with pump dispenser eg Purell (contains 63% ethyl alcohol) | routine handrub |
Detergent | general purpose detergent or detergent impregnated wipes eg Cutan multisurface wipes | leaning of hard surfaces |
Isopropyl alcohol 70% | Isopropyl alcohol of a concentration of 70% has been shown to be effective against SARS-CoV-2, MRSA, and staphylococcus infection. Alternative wipes may be used provided they carry the CE or UKCA mark and used according to the manufacturer's instructions | disinfection of hard surfaces, chin rests etc. (not suitable for use with medical devices that come into contact with the surface of the eye) |
Hypochlorite solution 0.1% (1,000 ppm available chlorine) |
available from pharmacies eg Milton or own brand sterilising solution (dilute to concentration required) under normal usage, these agents are disinfectants, and not sterilants |
general disinfection (ensure that items are thoroughly rinsed in sterile saline or distilled water after using hypochlorite) |
Hypochlorite solution 1% (10,000 ppm available chlorine) |
disinfection of body fluid spills and decontamination of trial contact lenses, diagnostic contact lenses, tonometer heads and other devices that come into contact with the surface of the eye (ensure that items are thoroughly rinsed in sterile saline or distilled water after using hypochlorite) |
- You should use single patient use lenses and devices that contact the surface of the eye where practicable.
- You should not re-use a lens or device that is intended by the manufacturer for single use.
- When single use lenses and devices are not practicable, you should:
- balance the benefits that patients receive from contact lenses and ophthalmic devices against the transmission of disease
- apply appropriate disinfection procedures. These should include the use of sodium hypochlorite solution where possible, see paragraph B63.
- trial contact lens: a lens that is used to assess fitting following which it is either disposed of by the clinician or dispensed to the patient. The majority of contact lens patients are currently fitted with single patient use lenses of various types
- special complex lens: a lens used by the clinician to assess performance of the design on the eye. This may be necessary where there is disease or abnormality of the lid, cornea or ocular surface. These lenses may be re-used.
- hydrogel lenses
- silicone hydrogel lenses
- hybrid lenses
- rigid lenses, including:
- corneal
- sclera
- scleral shells
- ocular prostheses.
- tonometer
- contact pachymeter
- gonioscope
- other lens to aid diagnosis of disease.
- appropriate for inactivating infectious agents such as bacteria and viruses
- less harmful to the eye than stronger concentrations, should it accidentally come into contact with it.
- water for irrigation BP, or sterile normal saline
- cleaning solution, such as liquid soap or detergent
- sodium hypochlorite solution 1% (10,000 ppm of available chlorine).
Step | ACDP TSE WG, 2011 recommendation164 | Notes |
---|---|---|
Timing | immediately after use | immediately disinfect the item, and if this is not possible, keep it in a container of water for irrigation BP or sterile normal saline, until it can be disinfected. |
Do not dry | do not allow to dry | |
Rinse | in water for irrigation BP/sterile normal saline for at least 30 sec | |
Clean | rubbing with liquid soap or detergent | thoroughly clean the item (including by rubbing) to remove cellular debris and adherent protein |
Disinfect | using sodium hypochlorite 1% (10,000 ppm of available chlorine) for 10 min |
disinfect it by using sodium hypochlorite |
Rinse | in water for irrigation BP/sterile normal saline for at least 10 min with 3 changes of water/saline | thoroughly rinse off the sodium hypochlorite, which is toxic to the eye, before re-use |
Dry | shake off excess, dry with tissue, re-use immediately or store dry | return the item to its dedicated case, if it has one |
Further steps | if necessary, since hypochlorite is not effective against all spores or cysts | follow with conventional disinfection |
References
190 Managing CJD/vCJD risk in ophthalmology Annex L In: Department of Health. Advisory Committee on Dangerous Pathogens Transmissible Spongiform Encephalopathy (ACDP TSE) Risk Management Subgroup (2011) Guidance on prevention of CJD and vCJD [Accessed 20 Nov 2020]191 Buckley R (2010) Decontamination. Optometry in Practice 11(1), 25-29 [Accessed 1 Dec 2020]
192 For cellular debris: Lim R, Dhillon B, Kurian KM et al (2003) Retention of corneal epithelial cells following Goldmann tonometry: implications for CJD risk. British Journal of Ophthalmology 87(5), 583-586
193 For proteinaceous debris: Amin SZ, Smith L, Luthert PJ et al (2003) Minimising the risk of prion transmission by contact tonometry. British Journal of Ophthalmology 87(11), 1360-1362
- irrigate the affected eye immediately with copious quantities of sterile normal saline solution or water
- check the ocular surface for epithelial damage using fluorescein
- examine the anterior segment for inflammation
- check intraocular pressure
- if there are no clinically significant signs, advise the patient to return to the practice if they experience any problems with their eyes. Otherwise you should re-examine them at the normal interval
- if there are clinically significant signs, you should re-examine the patient the following day or refer them to the Hospital Eye Service, as appropriate
- record any adverse incident centrally, in your practice’s system or in the practice Accident Book
- if you feel it is appropriate, report the incident to the National Reporting and Learning System This is anonymous and helps us to learn lessons from adverse incidents.194
References
194 National Reporting and Learning System (NRLS) [Accessed 20 Nov 2020]References
195 The Control of Substances Hazardous to Health Regulations 2002 SI 2677 [Accessed 20 Nov 2020]- be aware that multi-dose containers can be a source of infection
- be aware that varying levels of contamination exist in plastic bottles containing contact lens solutions
- note on the bottle when it was opened and when it should be discarded according to manufacturer’s guidelines.
- keep the dropper tip free from contamination
- replace the lid on the container immediately after use, as all solutions are susceptible to contamination while the lid is off
- dispose of solutions immediately if you suspect contamination.
- patients with a family history of CJD or other prion disease
- recipients of pituitary derived hormones such as human growth hormone or gonadotrophins
- patients who have had surgery on the brain or spinal cord
- patients who have received more than 50 units of blood or have received blood or blood components on more than 20 occasions, since 1980.
- cover cuts and abrasions to skin with waterproof dressings (preferably coloured)
- carry out hand hygiene before and after each patient contact and before and after leaving their home or care home, see paragraphs B21-B34 above, and
- follow the guidance in paragraphs B53 a and B53 b.
- contains viable microorganisms or their toxins which are known or reliably believed to cause disease in humans or other living organisms
- contains, or is contaminated with, a medicine that contains a biologically active pharmaceutical agent
- is a sharp, or a body fluid or other biological material (including human and animal tissue) containing, or contaminated with, a dangerous substance within the meaning of Council Directive 67/548/EEC on the approximation of laws, regulations and administrative provisions relating to the classification, packaging and labelling of dangerous substances.
- is not clinical waste
- contains body fluids, secretions or excretions
-
falls within code 18-01-04, 18-02-03 or 20-01-99 in Schedule 1 to the List of Wastes (England) Regulations 2005, in relation to England,202 or the List of Wastes (Wales) Regulations 2005, in relation to Wales.203
Is covered within the Scottish Environmental Protection Agency’s Guidance on the classification and assessment of waste.204
Is covered within the waste management section of the Northern Ireland Regional Infection Prevention and Control Manual.205
References
196 Environmental Protection Act, 1990 [Accessed 20 Nov 2020]197 The College of Optometrists (2014) Guidance on the disposal of waste (College members only) [Accessed 20 Nov 2020]
198 Scottish Environment Protection Agency (SEPA). Clinical waste [Accessed 19 Nov 2020]
199 Northern Ireland Department of Agriculture, Environment and Rural Affairs. Waste [Accessed 20 Nov 2020]
200 Controlled Waste Regulations 2012 SI 588 [Accessed 20 Nov 2020]
201 Classify different types of waste [Accessed 20 Nov 2020]
202 The List of Wastes (England) Regulations 2005 SI 895 [Accessed 20 Nov 2020]
203 The List of Wastes (Wales) Regulations 2005 SI 1820 [Accessed 20 Nov 2020]
204 Scottish Environment Protection Agency (2015). Waste Classification [Accessed 23 Nov 2020]
205 The Northern Ireland Regional Infection Prevention and Control Manual. Waste Management [Accessed 23 Nov 2020]
Department of Health and Social Care (2013): Prevention and control of infection in care homes [Accessed 20 Nov 2020]
Environmental management: Waste [Accessed 20 Nov 2020]
NetRegs. Environmental guidance for your business in Northern Ireland and Scotland [Accessed 20 Nov 2020]
National Institute of Health and Care Excellence (2017): Healthcare-associated infections: prevention and control in primary and community care CG139 [Accessed 20 Nov 2020] and interactive flowchart [Accessed 20 Nov 2020]
Royal College of Ophthalmologists (2016) Ophthalmic instrument decontamination [Accessed 20 Nov 2020]
SEPA, NIEA, CNC and EA (2015) Guidance on the classification and assessment of waste [Accessed 20 Nov 2020]
University of Leicester (2009) Washing your hands with alcohol rub. Video [Accessed 20 Nov 2020]