,MODULE 28: BASIC TRIAGE

CODE: BST 403

Hours: 30
Credit: 3
Pre-requisites
Anatomy and Physiology, First Aid, Communication Skills
Module Competency
This module is designed to enable the learner apply basic principles in triage to manage the sick
in the community

Learning Outcomes
By the end of this module, the learner should;
1. Explain the concepts of basic triage
2. Identify vital signs in patient’s triage
3 Apply basic principles of infection prevention
Module units

Hours

Unit Name Theory practical

1. Concepts of basic triage 10 00
2. Vital signs used in triage 04 06
3. Components of infection prevention 04 06

Module Content
Concepts of basic triage; definition, types of triage, criteria for triage, colour codes for
triaging,
Vital signs; Weight, BMI, temperature, respiration rate, pulse rate, blood pressure,
menstrual cycle, Glasgow coma scale, pulse oximetry, blood glucose level.

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 Components of Infection Prevention; organization for Infection prevention,
surveillance of Hospital acquired infection, isolation, prevention, cleaning, disinfection,
sterilization, waste segregation, policy guidelines on infection prevention.
Unit Objectives

By the end of this unit learners should be able to explain the Concept and the different types of
Triage

Unit Learning Requirements

To proficiently complete this unit, you ought to make sure you spend quality time and purpose
to;

1. Carry out all tasks within the sections and subsections

2. Participate in discussion forums as and when they are scheduled.

3. Participate in chat sessions as and when they are scheduled

Topic One: Objectives

By end of this topic, you should be able to:-

1. Define Triage

2. Explain the concept of triage

3. Explain the different types of Triage

Unit One: Concepts of basic triage

Introduction to Basic Triage;

Triage (/ˈtriːɑːʒ, triˈɑːʒ/) is the process of determining the priority of patients' treatments by the
severity of their condition or likelihood of recovery with and without treatment.
This rations patient treatment efficiently when resources are insufficient for all to be treated
immediately; influencing the order and priority of emergency treatment, emergency transport, or
transport destination for the patient.
This article covers the various types of triage systems as it occurs in medical emergencies,
including the pre-hospital setting, disasters, and emergency department treatment, along with
their limitations and ethical considerations
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Management is the art of getting things done through people in order to achieve stated
organizational objectives.

Triage: The process of sorting people based on their need for immediate medical treatment as
compared to their chance of benefiting from such care. Triage is done in emergency rooms,
disasters, and wars, when limited medical resources must be allocated to maximize the number
of survivors

Definition of triage.

a) The sorting of and allocation of treatment to patients and especially battle and disaster
victims according to a system of priorities designed to maximize the number of survivors.
b) The sorting of patients (as in an emergency room) according to the urgency of their need for
care.

Triage categories

Immediate category. These casualties require immediate life-saving treatment. Urgent category.
These casualties require significant intervention as soon as possible. Delayed category. These
patients will require medical intervention, but not with any urgency. Expectant category.

What are the principles of triage?

The Simple Triage And Rapid Treatment (START) system was developed to allow first
responders to triage multiple victims in 30 seconds or less, based on three primary observations:
Respiration, Perfusion, and Mental Status (RPM)
Triage category 1
People who need to have treatment immediately or within two minutes are categorized as having
an immediately life-threatening condition. People in this category are critically ill and require
immediate attention. Most would have arrived in emergency department by ambulance
What are the four triage categories?
First responders using START evaluate victims and assign them to one of the following four
categories:
 Deceased/expectant (black)
 Immediate (red)
 Delayed (yellow)

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  What is the first step in triage?

Disaster Triage Color Tags

There are four colors and a wounded individual will be tagged one color based on their health
status. The four colors include:

 Red
 Yellow
 Green
 Black

To help you keep the meaning of the tag colors red, yellow, and green separated, think of a
traffic light and what you do at the traffic light when it turns certain colors. The reason I include
this is because many students get confused about these three colors on exams. The black tag
color is easy to remember because black is most commonly associated with death, which is the
meaning of this tag color. The first step in triage is to clear out the minor injuries and those with
low likelihood of death in the immediate future

Red Tag: Immediate

What do you do at a traffic light when it turns red? You stop! Therefore, when a patient is tagged
red, STOP and get them treatment because they have first priority in receiving care.

 Seen 1st
 Injuries are life-threatening but they could possibly survive if they are immediately
treated.

 Severe alteration in breathing, circulation, and neuro/mental status

 Conditions that would cause a wounded individual to be tagged red (think of conditions
or systems of the body that if severely damaged could majorly alter the breathing,
circulation, and neuro system)

 Spinal cord injuries: remember various areas of the spinal cord control breathing, brain
and heart function…shock can occur like neurogenic, cardiogenic etc.

 Severe bleeding (internal or external): if the patient is treated immediately so the bleeding
could be stopped and transfused with blood products they may live

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Yellow Tag: Delayed

What do you do at a traffic light when it turns yellow? You slow down or delay because you’re
about to stop. Therefore, when a patient is tagged yellow their treatment is delayed but for only
about an hour or so because they could turn critical based on their presenting injuries.

 Seen 2nd (second priority)

 Significant injuries BUT at this point their breathing, circulation, and mental status is
within normal range but this could change.

 Conditions:

Bone fractures: major fractures that require medical treatment

Integumentary damages: open wounds, deep lacerations etc.

Green Tag: Minor

What do you do at a traffic light when it turns green? You go! Many times these wounded
individuals are termed the “walking wounded”. Therefore, these patients can get up and GO
(move around). Their injuries are minimal.

 Treatment can be delayed for several hours and some can treat themselves.
 Breathing, circulation, mental status not expected to change

Black Tag: Expectant

 Wounded is dying or expired.

 Injuries are deadly to the point the individual will not survive.

 Absence of breathing, circulation, mental status.

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  Major burns that affects a high percentage of the body: burns can affect the circulation
and the respiratory system (depending on the burn type and where it’s located)
 Some types of major respiratory trauma: pneumothorax etc.

Walking wounded/minor (green)

 What are the colors for triage?

This advanced triage system involves a color-coding scheme using red, yellow, green,
white, and black tags: Red tags - (immediate) are used to label those who cannot survive
without immediate treatment but who have a chance of survival

Triage category 2

People who need to have treatment within 10 minutes are categorised as having an
imminently life-threatening condition. People in this category are suffering from a
critical illness or in very severe pain.

 What is a priority 3 patient?

Priority 3 (Green) "Walking-wounded" Victims who are not seriously injured, are
quickly triaged and tagged as "walking wounded", and a priority 3 or "green"
classification (meaning delayed treatment/transportation)

Why is triage important?

The importance of field triage. ... Triage is the term applied to the process of
classifying patients at the scene according to the severity of their injuries to determine
how quickly they need care. Careful triage is needed to ensure that resources available in
a community are properly matched to each victim's needs

What is a Level 3 patient?

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 Level 3 (PATIENTS requiring advanced respiratory support alone or monitoring and
support for two or more organ systems. This level includes all
complex PATIENTS requiring support for multi-organ failure.)

How do you triage a patient?

Tags
1. Identify the patient.
2. Bear record of assessment findings.

3. Identify the priority of the patient's need for medical treatment and transport from the
emergency scene.

4. Track the patients' progress through the triage process.

5. Identify additional hazards such as contamination Triage is initially performed to assess

and apply priority in 30 to 60 seconds per casualty.

Triage must be:

a) dynamic – effective, changing based on initial and following assessments and

response to treatment
b) safe – and evidence based
c) fast
d) reproducible – allow different personnel to arrive at the same decisions
e) This allows rescuers to allocate correct resources using minimal time and
segregates casualties into groups, which allows rescuers to organise
themselves and resources.

There are a variety of triage systems in operation across the world. One of the most common
tools is the START triage system.

The START system (Simple Triage And Rapid Treatment) classifies a casualty’s treatment
category from an assessment of their respiratory (respiratory rate), circulatory (capillary refill)
and neurological (ability to obey simple commands/ functions).

Casualties are then attributed to one of the following four categories:

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1. Immediate (red tag): casualties with life threatening but treatable injuries requiring
immediate medical attention are assigned a red tag. These casualties are the first to be
transported to hospital when medical help arrives, without delaying transportation for
stabilization
2. Urgent (orange or yellow tag): casualties with serious injuries, but able to wait a short time
for treatment are assigned an orange tag
3. Delayed (green tag): casualties who can wait hours to days for treatment are assigned a green
tag. These casualties can be separated from the more seriously injured by asking for
casualties able to walk (i.e. ‘minor’ casualties) to congregate in a specified area
4. Dead (white or black tag): casualties who are dead or not expected to live because of the
severity of their injuries and the limited resources available. These casualties are assigned
either a white or black tag

Simple triage is usually used in a scene of an accident or "mass-casualty incident" (MCI), in

order to sort patients into those who need critical attention and immediate transport to the
hospital and those with less serious injuries. This step can be started before transportation
becomes available.

Upon completion of the initial assessment by physicians, nurses or paramedical personnel, each
patient may be labelled which may identify the patient, display assessment findings, and identify
the priority of the patient's need for medical treatment and transport from the emergency scene.
At its most primitive, patients may be simply marked with colored flagging tape or with marker
pens. Pre-printed cards for this purpose are known as a triage tags
Tags
Main article: Triage tag
Many triage systems use triage tags with specific formats
Emergency Triage (E/T) Lights – particularly useful at night or under adverse conditions
A triage tag is a prefabricated label placed on each patient that serves to accomplish several
objectives:
I. Identify the patient.
II. Bear record of assessment findings.
III. Identify the priority of the patient's need for medical treatment and transport from the
emergency scene.

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IV. Track the patients' progress through the triage process.
V. Identify additional hazards such as contamination.

Triage tags may take a variety of forms. Some coun tries use a nationally standardized triage
tag, while in other countries commercially available triage tags are used, and these will vary by
jurisdictional choice.

The most commonly used commercial systems include the METTAG, the SMARTTAG, E/T
LIGHT tm and the CRUCIFORM systems. More advanced tagging systems incorporate special
markers to indicate whether or not patients have been contaminated by hazardous materials, and
Z also tear off strips for tracking the movement of patients through the process. Some of these
tracking systems are beginning to incorporate the use of handheld computers, and in some cases,
bar code scanners. //// /

Advanced triage
For classifications, see the specific section for that topic
In advanced triage, specially trained doctors, nurses and paramedics may decide that some
seriously injured people should not receive advanced care because they are unlikely to survive. It
is used to divert scarce resources away from patients with little chance of survival in order to
increase the chances for others with higher likelihoods.
The use of advanced triage may become necessary when medical professionals decide that the
medical resources available are not sufficient to treat all the people who need help. The treatment
being prioritized can include the time spent on medical care, or drugs or other limited resources.
This has happened in disasters such as terrorist attacks, mass shootings, volcanic eruptions,
earthquakes, tornadoes, thunderstorms, and rail accidents. In these cases some percentage of
patients will die regardless of medical care because of the severity of their injuries. Others would
live if given immediate medical care, but would die without it.

In these extreme situations, any medical care given to people who will die anyway can be
considered to be care withdrawn from others who might have survived (or perhaps suffered less
severe disability from their injuries) had they been treated instead. It becomes the task of the
disaster medical authorities to set aside some victims as hopeless,

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 to avoid trying to save one life at the expense of several [Link] immediate treatment is
successful, the patient may improve (although this may be temporary) and this improvement may
allow the patient to be categorized to a lower priority in the short term. Triage should be a
continuous process and categories should be checked regularly to ensure that the priority remains
correct given the patient's condition. A trauma score is invariably taken when the victim first
comes into hospital and subsequent trauma scores are taken to account for any changes in the
victim's physiological parameters. If a record is maintained, the receiving hospital doctor can see
a trauma score time series from the start of the incident, which may allow definitive treatment
earlier.

Reverse triage

Usually, triage refers to prioritizing admission. A similar process can be applied to discharging
patients early when the medical system is stressed. This process has been called "reverse triage".
When a major wave of patients arrive to a hospital, such as immediately after a natural disaster,
many hospital beds will be already occupied by regular non-critical patients. To accommodate a
greater number of the new critical patients, the existing patients may be triaged, and those who
will not need immediate care can be discharged until the surge has dissipated, for example
through the establishment of temporary medical facilities in the region.

Under triage and over triage

Under triage is underestimating the severity of an illness or injury. An example of this would be
categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3 (Minimal).
Historically, acceptable under triage rates have been deemed 5% or less.

Over triage is the overestimating of the severity of an illness or injury. An example of this
would be categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or Priority 1
(Immediate). Acceptable over triage rates have been typically up to 50% in an effort to avoid
under triage. Some studies suggest that over triage is less likely to occur when triaging is
performed by hospital medical teams, rather than paramedics or EMTs.

Telephone triage

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In telephone triage, decision makers over the phone must effectively assess the patient's
symptoms and provide directives based on the urgency. This should be done in a timely fashion
while meeting standard guidelines in order to prevent symptoms from worsening.

What is triage and why is it needed

Ideally, the first people to need medical care receive it. In less than ideal conditions, somebody
has to decide who receives care first. Some health facilities face these decisions on a daily basis,
even without any disaster or health emergency. However, natural disasters (e.g., earthquakes) or
other events (e.g., train crash or bombing) can result in a large number of injured or sick people
at one time. When this happens, decisions must be made about how to best allocate care when
resources are insufficient for all those who need care. This process is called triage. The purpose
of triage is to save as many lives as possible.

During a severe pandemic, you can expect that the period of time when the need for care will be
greater than the resources available will last for weeks or months. Using scarce medical
resources to provide care for patients who may be very sick, but who will probably die even with
intensive care, may result in other less sick patients not receiving care, getting sicker, and
dying .

When done properly, triage results in the best outcome for the greatest number of people.
Without a triage plan in place, resources are likely to be wasted and more people are likely to
die.

Therefore, it is important that your municipality develop a pandemic triage plan. It is very
important for you to determine in advance who will have the authority to implement the triage
plan.

The need for triage is likely to change rapidly and frequently during the pandemic wave, as the
epidemic escalates to its peak and then begins to subside. The person or group responsible for the
triage planning will need to consider the need for healthcare resources and the availability of
those resources on a daily basis, then communicate to the healthcare providers the appropriate
triage plan. In situations where sick patients cannot be cared for and the public panics or
violently protests the decision making, you may need security forces to protect healthcare
facilities and providers

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UNIT 2: VITAL SIGN USED IN TRIAGE
1: objectives
By the End of this Topic the leaner should be able to
Explain how the following vital signs are recorded
Temperature
Blood pressure
Respiration rate
Pulse

Introduction
Vital signs are measurements of the body's most basic functions. The four main vital signs
routinely monitored by medical professionals and health care providers include the following:
 Body temperature
 Pulse rate
 Respiration rate (rate of breathing)

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  Blood pressure (Blood pressure is not considered a vital sign, but is often measured along
with the vital signs.)

Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured
in a medical setting, at home, at the site of a medical emergency, or elsewhere.
Unit Objectives
By the end of this unit, you will have achieved the following objectives;
1. Explain the importance of Taking Temperate
2. Describe how to record blood pressure

3. Explain check for vital signs

4. how check pulse rate

Unit Learning Requirements

1. To proficiently complete this unit, you ought to make sure you spend quality time and
purpose to;
2. Carry out all tasks within the sections and subsections
3. Participate in discussion forums as and when they are scheduled.
4. Participate in chat sessions as and when they are scheduled.

Topic 1: VITAL SIGNS

VITALS
 Vital signs are a group of the four to six most important medical signs that indicate the
status of the body’s vital functions. These measurements are taken to help assess the
general physical health of a person, give clues to possible diseases, and show progress
toward recovery
 The four main vital signs routinely monitored by medical professionals and health care
providers include the following:
o Body temperature.
o Pulse rate.
o Respiration rate (rate of breathing)
o Blood pressure (Blood pressure is not considered a vital sign, but is often
measured along with the vital signs.

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 There are four primary vital signs which are standard in most medical settings:

a) Body temperature
b) Heart rate or Pulse
c) Respiratory rate
d) Blood pressure
The equipment needed is a thermometer, a sphygmomanometer, and a watch. Although a pulse
can be taken by hand, a stethoscope may be required for a patient with a very weak pulse.

a) Temperature
Temperature recording gives an indication of core body temperature which is normally tightly
controlled (thermoregulation) as it affects the rate of chemical reactions. Body temperature is
maintained through a balance of the heat produced by the body and the heat lost from the body.
Oral glass thermometer
Temperature can be recorded in order to establish a baseline for the individual's normal body
temperature for the site and measuring conditions.
Temperature can be measured from the mouth, rectum, axilla (armpit), ear, or skin. Oral, rectal,
and axillary temperature can be measured with either a glass or electronic thermometer. Note
that rectal temperature measures approximately 0.5°C higher than oral temperature, and axillary
temperature approximately 0.5°C less than oral temperature Aural and skin temperature
measurements require special devices designed to measure temperature from these locations.

While 37°C (98.6°F) is considered "normal" body temperature, there is some variance between
individuals. Most have a normal body temperature set point that falls within the range of 36.0°C
to 37.5°C (96.5–99.5°F).

The main reason for checking body temperature is to solicit any signs of systemic infection or
inflammation in the presence of a fever. Fever is considered temperature of 37.8°C or above
Other causes of elevated temperature include hyperthermia, which results from unregulated heat
generation or abnormalities in the body's heat exchange mechanisms

Temperature depression (hypothermia) also needs to be evaluated. Hypothermia is classified as

temperature below 35°C (95°F)

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It is also recommended to review the trend of the patient's temperature over time. A fever of 38
°C does not necessarily indicate an ominous sign if the patient's previous temperature has been
higher.

b) Pulse
Pulse An individual taking their own radial pulse.
The pulse is the rate at which the heart beats while pumping blood through the arteries, recorded
as beats per minute (bpm). It may also be called "heart rate". In addition to providing the heart
rate, the pulse should also be evaluated for strength and obvious rhythm abnormalities. The pulse
is commonly taken at the wrist (radial artery). Alternative sites include the elbow (brachial
artery), the neck (carotid artery), behind the knee (popliteal artery), or in the foot (dorsalis pedis
or posterior tibial arteries). The pulse is taken with the index finger and middle finger by pushing
with firm yet gentle pressure at the locations described above, and counting the beats felt per 60
seconds (or per 30 seconds and multiplying by two).

The pulse rate can also be measured by listening directly to the heartbeat using a stethoscope.
The pulse may vary due to exercise, fitness level, disease, emotions, and medications.

The pulse also varies with age. A newborn can have a heart rate of 100-160 bpm, an infant (0-5
months old) a heart rate of 90–150 bpm, and a toddler (6-12 months old) a heart rate of 80–140
bpm.

A child aged 1-3 years old can have a heart rate of 80-130 bpm, a child aged 3-5 years old a heart
rate of 80-120 bpm, an older child (age of 6-10) a heart rate of 70-110 bpm, and an adolescent
(age 11-14) a heart rate of 60–105 bpm. An adult (age 15+) can have a heart rate of 60–100 bpm.

c) Respiratory rate

Average respiratory rates vary between ages, but the normal reference range for people age 18 to
65 is 16–20 breaths per minute. The value of respiratory rate as an indicator of potential
respiratory dysfunction has been investigated but findings suggest it is of limited value.
Respiratory rate is a clear indicator of acidotic states, as the main function of respiration is
removal of CO2 leaving bicarbonate base in circulation.

d) Blood pressure

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Manual sphygmomanometer and stethoscope used to take blood pressure in clinic.

Blood pressure is recorded as two readings: a higher systolic pressure, which occurs during the
maximal contraction of the heart, and the lower diastolic or resting pressure. In adults, a normal
blood pressure is 120/80, with 120 being the systolic and 80 being the diastolic reading. Usually,
the blood pressure is read from the left arm unless there is some damage to the arm. The
difference between the systolic and diastolic pressure is called the pulse pressure. The
measurement of these pressures is now usually done with an aneroid or electronic
sphygmomanometer.

The classic measurement device is a mercury sphygmomanometer, using a column of mercury

measured off in millimeters. In the United States and UK, the common form is millimeters of
mercury, while elsewhere SI units of pressure are used. There is no natural 'normal' value for
blood pressure, but rather a range of values that on increasing are associated with increased risks.

The guideline acceptable reading also takes into account other co-factors for disease. Therefore,
elevated blood pressure (hypertension) is variously defined when the systolic number is
persistently over 140–160 mmHg. Low blood pressure is hypotension. Blood pressures are also
taken at other portions of the extremities. These pressures are called segmental blood pressures
and are used to evaluate blockage or arterial occlusion in a limb.

Other signs
In addition to the above four, many providers are required or encouraged by government
technology-in-medicine laws to record the patient's height, weight, and body mass index. In
contrast to the traditional vital signs, these measurements are not useful for assessing acute
changes in state because of the rate at which they change; however, they are useful for assessing
the impact of prolonged illness or chronic health problems.

The definition of vital signs may also vary with the setting of the assessment. Emergency
medical technicians (EMTs), in particular, are taught to measure the vital signs of respiration,
pulse, skin, pupils, and blood pressure as "the 5 vital signs" in a non-hospital setting.

The Glasgow Coma Scale (GCS) is a neurological scale used to describe the severity of
impaired consciousness in all types of acute medical and trauma patients.

It can be used both as an initial assessment tool and a prognostic outcome measure.

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The scale was first published in 1974 at the University of Glasgow by neurosurgery professors -
Graham Teasdale and Bryan Jenett.

The scale assesses patients according to three aspects of responsiveness:

 👀 Eye opening
 👄 Verbal response

 👍🏻 Motor response

 Eye opening
(Mneumonic - *ESPN*)
E - Eye opening spontaneously (4)
S - to Speech (3)
P - to Pain (2)
N - No response (1)
 ✔ Verbal response
(Mneumonic - *Our Country WIN*)
Our - Oriented (5)
Country - Confused conversation (4)
W - inappropriate Words (3)
I - Incomprehensible sounds (2)
N - No response (1)
 ✔ Motor response
(Mneumonic - *Can't Live Without FANs*)
Cant't - obeys Commands (6)
Live - Localises to central pain (5)
Without - Withdrawal response (4)
F - Flexion abnormal (3)
A - Abnormal extension (2)
N - No response (1)
 Interpretation and Scoring:
Maximum score - 15
Minimum score - 03
 A score of
13-15 indicates Mild injury
09-12 indicates Moderate injury
03-08 indicates Severe injury (requires immediate intervention)
 The GCS can be used in children older than 5 years with no modification.
A Paediatric Glasgow Coma Scale is used for younger children (<5 years) and infants

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A pulse oximeter measures your blood oxygen levels and pulse. A low level of oxygen saturation
may occur if you have certain health conditions. Your skin tone may also affect your reading.

Pulse oximetry is a noninvasive test that measures the oxygen saturation level of your blood.
It can rapidly detect even small changes in oxygen levels. These levels show how efficiently
blood is carrying oxygen to the extremities furthest from your heart, including your arms and
legs.
The pulse oximeter is a small, clip-like device. It attaches to a body part, most commonly to a
finger.

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Medical professionals often use them in critical care settings like emergency rooms or hospitals.
Some doctors, such as pulmonologists, may use them in office settings. You can even use one at
home.
Pulse Oximetry

The purpose of pulse oximetry is to see if your blood is well oxygenated.

Medical professionals may use pulse oximeters to monitor the health of people with conditions
that affect blood oxygen levels, especially while they’re in the hospital.
These can include:

 chronic obstructive pulmonary disease (COPD)

 asthma

 pneumonia

 lung cancer

 anemia

 heart attack or heart failure

 congenital heart disease

Doctors use pulse oximetry for a number of different reasons, including:

 to assess how well a new lung medication is working

 to evaluate whether someone needs help breathing

 to evaluate how helpful a ventilator is

 to monitor oxygen levels during or after surgical procedures that require sedation

 to determine whether someone needs supplemental oxygen therapy

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 to determine how effective supplemental oxygen therapy is, especially when treatment is new

 to assess someone’s ability to tolerate increased physical activity

 to evaluate whether someone momentarily stops breathing while sleeping — like in cases of
sleep apnea — during a sleep study

How to take a reading

Pulse oximetry may be useful in both inpatient and outpatient settings. In some cases, your
doctor may recommend that you have a pulse oximeter for home use.

To take a reading with a pulse oximeter, you will:

Remove any jewelry or fingernail polish on your finger if measuring from this location.

Make sure your hand is warm, relaxed, and below heart level if attaching the device here.

Place the device on your finger, earlobe, or toe.

Keep the device on for as long as needed to monitor your pulse and oxygen saturation.

Remove the device once the test is over.

In pulse oximetry, small beams of light pass through the blood in your finger, measuring the
amount of oxygen. According to the British Lung Foundation, pulse oximeters do this by
measuring changes in light absorption in oxygenated or deoxygenated blood. This is a painless
process.

The pulse oximeter will be able to tell you your oxygen saturation levels along with your heart
rate.
Pulse oximetry readings
Pulse oximetry tests are an estimation of blood oxygen levels, but they’re typically precise. This
is especially true when using high quality equipment found in most medical offices or hospital
settings. With this equipment, medical professionals can carry out the tests accurately.
The Food and Drug Administration (FDA) Trusted Source requires that prescription oximeters
must provide results within an accuracy range of 4 to 6 percent.
Having an oxygen saturation temporarily below this level may not cause damage. But repeated
or consistent instances of lowered oxygen saturation levels may be damaging.

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An oxygen saturation level of 95 percent is considered typical for most healthy people. A level
of 92 percent or lower can indicate potential hypoxemia, which is a seriously low level of
oxygen in the blood.
Various factors can affect readings, including a person’s skin tone.
A 2020 report compared the accuracy of pulse oximetry tests and blood gas measurements in
detecting hypoxemia in Black and white patients.
Researchers found that among Black patients, there were three times as many cases of pulse
oximetry tests failing to detect occult hypoxemia when blood gas measurements did so.

What is a blood glucose (sugar) test?

A blood glucose test is a blood test that mainly screens for diabetes by measuring the level of
glucose (sugar) in your blood.

There are two main types of blood glucose tests:

 Capillary blood glucose test: A healthcare professional collects a drop of blood — usually
from a fingertip prick. These tests involve a test strip and glucose meter (glucometer), which
show your blood sugar level within seconds.
 Venous (plasma) blood glucose test: A phlebotomist collects a sample of blood from a vein
(venipuncture). These glucose tests are usually part of a blood panel, such as a basic
metabolic panel. The provider will send the samples to a lab. There, a medical laboratory
scientist will prepare your samples and perform the test on machines known as analyzers.

Venous blood glucose tests are generally more accurate than capillary blood glucose tests.

Healthcare providers often order fasting blood glucose tests to screen for diabetes. Since eating
food affects blood sugar, fasting blood glucose tests show a more accurate picture of your
baseline blood sugar.

There’s also at-home blood sugar testing (using a glucometer) for people who have diabetes.
People with Type 1 diabetes especially need to monitor their blood sugar multiple times a day to
effectively manage the condition. Continuous glucose monitoring devices (CGMs) are another
option for this.

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What is blood glucose (sugar)?

Glucose (sugar) mainly comes from carbohydrates in the food and drinks you consume. It’s your
body’s main source of energy. Your blood carries glucose to all of your body’s cells to use for
energy.

Several bodily processes help keep your blood glucose in a healthy range. Insulin, a hormone
your pancreas makes, is the most significant contributor to maintaining healthy blood sugar.

If you have elevated blood glucose levels (hyperglycemia), it usually indicates diabetes. Diabetes
develops when your pancreas doesn’t make any insulin or enough insulin or your body isn’t
responding to the effects of insulin properly.

When would I need a blood glucose test?

There are three main reasons why you may need a blood glucose (sugar) test:

 Your healthcare provider may have ordered routine bloodwork called a basic metabolic
panel (BMP) or a comprehensive metabolic panel (CMP), which both include a glucose
blood test.
 You may be having symptoms of high blood sugar or low blood sugar, which could indicate
diabetes or another condition.
 If you take a long-term medication that affects your blood sugar levels, such as
corticosteroids, you may need routine glucose blood tests to monitor your levels.

The most common use of a blood glucose test is to screen for Type 2 diabetes (T2D), which is a
common condition. Certain people are at risk for developing Type 2 diabetes. If you have risk
factors, your provider will likely recommend regular screening no matter your age. The
American Diabetes Association recommends regular screening for anyone age 35 or older.

Your provider will also order a blood glucose test if you have symptoms of high blood sugar
(hyperglycemia) or low blood sugar (hypoglycemia).

Symptoms of diabetes and high blood sugar include:

 Feeling very thirsty (polydipsia).

 Frequent urination (polyuria).
 Fatigue.

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  Feeling very hungry (polyphagia).
 Unexplained weight loss.
 Blurred vision.
 Slow healing of cuts or sores.

If you or your child have these symptoms in addition to vomiting, deep labored breathing and/or
confusion, go to the nearest emergency room as soon as possible. You may have diabetes-related
ketoacidosis, which is a life-threatening condition.

Symptoms of low blood sugar include:

 Shaking or trembling.
 Sweating and chills.
 Dizziness or lightheadedness.
 Faster heart rate.
 Intense hunger.
 Anxiousness or irritability.

You need to consume carbohydrates (sugar) to treat hypoglycemia, such as a banana or apple
juice. Severe hypoglycemia can be life-threatening.

What do the results of a blood glucose test mean?

Blood test reports, including blood glucose test reports, usually provide the following
information:

 The name of the blood test or what was measured in your blood.
 The number or measurement of your blood test result.
 The normal measurement range for that test.
 Information that indicates if your result is normal or abnormal or high or low.

What is a normal glucose level in a blood test?

A healthy (normal) fasting blood glucose level for someone without diabetes is 70 to 99 mg/dL
(3.9 to 5.5 mmol/L). Values between 50 and 70 mg/dL (2.8 to 3.9 mmol/L) for people without
diabetes can be “normal” too.

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What does a high blood glucose level mean?

If you’re fasting blood glucose level is 100 to 125 mg/dL (5.6 to 6.9 mmol/L), it usually means
you have prediabetes. People with prediabetes have up to a 50% chance of developing Type 2
diabetes over the next five to 10 years. But you can take steps to prevent Type 2 diabetes from
developing.

If your fasting blood glucose level is 126 mg/dl (7.0 mmol/L) or higher on more than one testing
occasion, it usually means you have diabetes.

In either of these cases, your provider will likely order a glycated hemoglobin test (A1c) before
diagnosing you with prediabetes or diabetes. An A1c shows your average blood sugar over a few
months.

There are a few different types of diabetes. The most common forms are:

 Type 2 diabetes (T2D): T2D happens when your pancreas doesn’t make enough insulin or
your body doesn’t use insulin well (insulin resistance), resulting in high blood glucose levels.
This is the most common type of diabetes.
 Type 1 diabetes (T1D): T1D is an autoimmune disease in which your immune system
attacks the insulin-producing cells in your pancreas for unknown reasons. Your pancreas can
no longer produce insulin. At diagnosis, people with Type 1 diabetes usually have very high
blood glucose (200 mg/dL, or 11.1 mmol/L, or higher).
 Gestational diabetes: This condition can develop in pregnant people — usually appearing
during the middle of pregnancy, between 24 and 28 weeks. The high blood sugar (diabetes)
goes away once the pregnancy is over. Pregnant people have screenings for gestational
diabetes with a glucose challenge test and/or glucose tolerance test.

Other causes of high glucose levels

Other causes of high glucose levels include:
 Issues with your adrenal glands, such as Cushing syndrome.
 Issues with your pancreas, such as pancreatitis.
 Hyperthyroidism.

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 Experiencing significant stress, such as from surgery or trauma.
 Certain medications, especially corticosteroids.

What does a low blood glucose level mean?

A blood sugar result of 70 mg/dL or lower is usually considered low.
Low blood sugar (hypoglycemia) episodes are common in people with Type 1 diabetes and
people with Type 2 diabetes who take certain medications. They’re much less common in people
who don’t have diabetes.
If you don’t have diabetes, low blood glucose levels may be a sign of:
 Liver disease.
 Kidney disease.
 Hypothyroidism.
 Addison disease (adrenal insufficiency).
 Alcohol use disorder (AUD).
 Insulinoma (a rare tumor).
These conditions typically cause frequent low blood sugar episodes. A single low blood sugar
test result usually isn’t a cause for concern in people who don’t have diabetes.

As medical technology has advanced, so have modern approaches to triage, which are
increasingly based on scientific models. The categorizations of the victims are frequently the
result of triage scores based on specific physiological assessment findings. Some models, such as
the START model may be algorithm-based. As triage concepts become more sophisticated,
triage guidance is also evolving into both software and hardware decision support products for
use by caregivers in both hospitals and the fi Simple triage

UNIT 3: Components of Infection Prevention

Why IPC is so important for patient outcomes

Core components

Facility level

National level

Evidence

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-based recommendations

Good practice

Implementation of the IPC Core Components

The WHO CC are a road map to indicate how IPC can effectively prevent harm due to HAI and
AMR Implementation, including effective leadership, is key to translate guidelines into practices
– not always easy and takes time – multimodal/multidisciplinary strategies – monitoring
approaches – patient-centred – integrated within clinical procedures – innovative and locally
adapted – tailored to specific cultures and resource level

Main challenges to implement IPC in low- and middle-income countries

HAIs and IPC not on the top of the national health agenda

Gap between policy and actual implementation

Lack of reliable data on HAIs (poor laboratory support and surveillance systems)

Limited access to qualified and trained IPC professionals

Limited human resources (understaffing)

Inadequate budgets

WASH and infrastructure gaps

Supplies procurement challenges

Need for adaptation or tailoring to the cultural setting and local context, and according to
available resources.

IPC implementation:

Implications for low- and middle-income countries

However: Resources invested are worth the net gain, irrespective of the context and despite the
costs incurred

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Not all solutions require additional resources. Some solutions can likely be low cost and local
production (e.g. alcohol-based hand rubs) should be encouraged. Partnerships or partners’
collaborations could assist in the achievement of the core components delivery and funding

Making improvement with limited resources.

There are three approaches to improve IPC in settings with limited resources:

i. Focus on improving
ii. Low-cost practices
iii. Stop wasteful and unnecessary practices.

These three approaches have the potential to save money, time and improve the quality and
safety of health care.

Healthcare-associated infections (HAI) are a major public health problem with a significant
impact on morbidity, mortality and quality of life. They represent also an important economic
burden to health systems worldwide. However, a large proportion of HAI are preventable
through effective infection prevention and control (IPC) measures.

Improvements in IPC at the national and facility level are critical for the successful containment
of antimicrobial resistance and the prevention of HAI, including outbreaks of highly
transmissible diseases through high quality care within the context of universal health coverage.

Given the limited availability of IPC evidence-based guidance and standards, the World Health
Organization (WHO) decided to prioritize the development of global recommendations on the
core components of effective IPC programs both at the national and acute healthcare facility
level, based on systematic literature reviews and expert consensus. The aim of the guideline
development process was to identify the evidence and evaluate its quality, consider patient
values and preferences, resource implications, and the feasibility and acceptability of the
recommendations.

Standard infection control precautions (SICPs) are to be used by all staff, in all care settings, at
all times, for all patients whether infection is known to be present or not, to ensure the safety of
those being cared for, staff and visitors in the care environment.

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SICPs are the basic infection prevention and control measures necessary to reduce the risk of
transmitting infectious agents from both recognised and unrecognised sources of infection.

Sources of (potential) infection include blood and other body fluids, secretions or excretions
(excluding sweat), non-intact skin or mucous membranes and any equipment or items in the care
environment that could have become contaminated.

The application of SICPs during care delivery is determined by assessing risk to and from
individuals. This includes the task, level of interaction and/or the anticipated level of exposure to
blood and/or other body fluids.

To protect effectively against infection risks, SICPs must be used consistently by all staff. SICPs
implementation monitoring must also be ongoing to ensure compliance with safe practices and to
demonstrate ongoing commitment to patient, staff and visitor safety as required by the Health
and Safety Executive and the care regulators, the Care Quality Commission.

There are 10 elements of SICPs:

1. patient placement/assessment of infection risk
2. hand hygiene
3. respiratory and cough hygiene
4. personal protective equipment
5. safe management of the care environment
6. safe management of care equipment
7. safe management of healthcare linen
8. safe management of blood and body fluids
9. safe disposal of waste (including sharps)
10. occupational safety/managing prevention of exposure (including sharps)

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1.1 Patient placement/assessment for infection risk

Patients must be promptly assessed for infection risk on arrival at the care area, eg
inpatient/outpatient/care home, (if possible, prior to accepting a patient from another care area)
and should be continuously reviewed throughout their stay.

This assessment should influence placement decisions in accordance with clinical/care need(s).

Patients who may present a cross-infection risk include those:

 with diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms

 known to have been previously positive with a multi-drug resistant organism (MDRO), eg
MRSA, CPE

 Who have been an inpatient in any hospital in the UK or abroad or are a known
epidemiological link to a carrier of CPE.

1.2 Hand hygiene

Hand hygiene is considered one of the most important ways to reduce the transmission of
infectious agents that cause healthcare associated infections (HCAIs).

Clinical hand-wash basins must:

 Be used for that purpose only and not used for the disposal of other liquids

 Have mixer taps, no overflow or plug and be in a good state of repair

 Have wall mounted liquid soap and paper towel dispensers.

Hand hygiene facilities should include instructional posters.

Before performing hand hygiene:

 Expose forearms (bare below the elbow). If disposable over-sleeves are worn for religious
reasons, these must be removed and disposed of before performing hand hygiene, then
replaced with a new pair*

 Remove all hand and wrist jewellery. The wearing of a single, plain metal finger ring, eg a
wedding band, is permitted but should be removed (or moved up) during hand hygiene. A

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 religious bangle can be worn but should be moved up the forearm during hand hygiene and
secured during patient care activities

 ensure fingernails are clean and short, and do not wear artificial nails or nail products

 Cover all cuts or abrasions with a waterproof dressing.

To perform hand hygiene:

Wash hands with non-antimicrobial liquid soap and water if:

 hands are visibly soiled or dirty

 caring for patients with vomiting or diarrhoeal illnesses

 Caring for a patient with a suspected or known gastrointestinal infection, eg norovirus or a

spore-forming organism such as clostridioides difficile.

In all other circumstances, use alcohol-based handrubs (ABHRs) for routine hand hygiene during
care.

ABHRs must be available for staff as near to the point of care as possible. Where this is not
practical, personal ABHR dispensers should be used, eg within the community, domiciliary care,
mental health units etc.

Where running water is unavailable, or hand hygiene facilities are lacking, staff may use hand
wipes followed by ABHR and should wash their hands at the first opportunity.

Perform hand hygiene:

 Before touching a patient.

 Before clean or aseptic procedures.

 after body fluid exposure risk

 after touching a patient; and

 After touching a patient’s immediate surroundings.

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Always perform hand hygiene before putting on and after removing gloves.

Skin care

 dry hands thoroughly after hand washing, using disposable paper towels

 use an emollient hand cream regularly eg during breaks and when off duty

 do not use or provide communal tubs of hand cream in the care setting

 staff with skin problems should seek advice from occupational health or their GP and
depending on their skin condition and the severity may require additional interventions or
reporting.

Surgical hand antisepsis

Surgical scrubbing/rubbing (this applies to those undertaking surgical and some invasive
procedures):

 perform surgical scrubbing/rubbing before donning sterile theatre garments or at other

times, eg before inserting central vascular access devices

 remove all hand and wrist jewellery (including wedding band)

 nail brushes should not be used for surgical hand antisepsis

 nail picks (single-use) can be used if nails are visibly dirty

 soft, non-abrasive, sterile (single-use) sponges may be used to apply antimicrobial liquid
soap to the skin if licensed for this purpose

 use an antimicrobial liquid soap licensed for surgical scrubbing or an ABHR licensed for
surgical rubbing (as specified on the product label)

 ABHR can be used between surgical procedures if licensed for this use or between glove
changes if hands are not visibly soiled.

For surgical scrubbing (not rubbing), follow the step-by-step guide in appendix 3 of this
document.

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For surgical rubbing (not scrubbing), follow the step-by-step guide in appendix 4 of this
document.

For hand hygiene posters/leaflet, refer to the resources section of NIPCM.

1.3 Respiratory and cough hygiene

Respiratory and cough hygiene is designed to minimise the risk of cross transmission of known
or suspected respiratory illness (pathogens):

 cover the nose and mouth with a disposable tissue when sneezing, coughing, wiping and
blowing the nose; if unavailable use the crook of the arm

 dispose of all used tissues promptly into a waste bin

 wash hands with non-antimicrobial liquid soap and warm water after coughing, sneezing,
using tissues, or after contact with respiratory secretions or objects contaminated by these
secretions

 where there is no running water available or hand hygiene facilities are lacking, staff may
use hand wipes followed by ABHR and should wash their hands at the first available
opportunity

 keep contaminated hands away from the eyes nose and mouth.

Staff should promote respiratory and cough hygiene helping those (e.g., elderly, children) who
need assistance with this, e.g. providing patients with tissues, plastic bags for used tissues and
hand hygiene facilities as necessary.

1.4 Personal protective equipment (PPE)

Before undertaking any procedure, staff should assess any likely exposure to blood and/or other
body fluids, non-intact skin or mucous membranes and wear personal protective equipment
(PPE) that protects adequately against the risks associated with the procedure. The principles of
PPE use set out below are important to ensure that PPE is used correctly to ensure patient and
staff safety. Avoiding overuse or inappropriate use of PPE is a key principle that ensures this is
risk-based and minimizes its environmental impact. Where appropriate, consideration should be

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given to the environmental impact of sustainable or reusable PPE options versus single-use PPE
while adhering to the principles below.

All PPE must be:

 Located close to the point of use. PPE for healthcare professionals providing care in the
community and domiciliary care providers must be transported in a clean receptacle

 stored to prevent contamination in a clean, dry area until required (expiry dates must be
adhered to)

 single-use only unless specified by the manufacturer

 changed immediately after each patient and/or after completing a procedure or task

 disposed of after use into the correct waste stream, eg domestic waste, offensive (non-
infectious) or clinical waste

 discarded if damaged or contaminated.

NB Reusable PPE such as goggles/face shields/visors, must be decontaminated after each use
according to manufacturer’s instruction.

Gloves must be:

 worn when exposure to blood and/or other body fluids, non-intact skin or mucous
membranes is anticipated or likely

 changed immediately after each patient and/or after completing a procedure/task even on the
same patient

 changed if a perforation or puncture is suspected

 appropriate for use, fit for purpose and well-fitting

 never decontaminated with ABHR or soap between use

 low risk of causing sensitisation to the wearer

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 Appropriate for the tasks being undertaken, taking into account the substances being handled,
type and duration of contact, size and comfort of the gloves, and the task and requirement for
glove robustness and sensitivity.

Sterile gloves must be worn:

 when sterility is required in an operating theatre, and

 for some aseptic techniques eg insertion of central venous catheters, insertion of peripherally
inserted central catheters, insertion of pulmonary artery catheters and spinal, epidural and
caudal procedures

NB Double gloving is NOT recommended for routine clinical care. However, it may be required
for some exposure prone procedures, eg orthopaedic and gynaecological operations, when
attending major trauma incidents or as part of additional precautions for high consequence
infectious disease management.

Gloves are NOT required to carry out near patient administrative tasks, eg, when using the
telephone, using a computer or tablet, writing in the patient chart; giving oral medications;
distributing or collecting patient dietary trays.

Further information can be found in the gloves literature review.

Aprons must be:

 Worn to protect uniform or clothes when contamination is anticipated or likely, eg when in

direct care contact with a patient.

 Changed between patients and/or after completing a procedure or task.

Full body gowns or fluid-resistant coveralls must be:

 worn when there is a risk of extensive splashing of blood and/or body fluids, eg operating
theatre, ITU

 worn when a disposable apron provides inadequate cover for the procedure or task being
performed

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 changed between patients and removed immediately after completing a procedure or task

 sterile when sterility is required in an operating theatre and for some aseptic techniques eg
for insertion of central venous catheters, insertion of peripherally inserted central catheters,
insertion of pulmonary artery catheters and spinal, epidural and caudal procedures.

Eye or face protection (including full-face visors) must:

 be worn if blood and/or body fluid contamination to the eyes or face is anticipated or
likely, eg by members of the surgical theatre team and always during aerosol generating
procedures; regular corrective spectacles are not considered eye protection

 not be impeded by accessories such as piercings or false eyelashes

 not be touched when being worn.

Further information can be found in the eye/face protection literature review.

Fluid resistant surgical face masks (FRSM):

Surgical face masks are required:

 as a means of source control, eg to protect the patient from the wearer during sterile
procedures such as surgery, and

 to protect the wearer when there is a risk splashing or spraying of blood, body fluids,
secretions or excretions onto the respiratory mucosa.

 as an element of PPE for droplet precautions (see section 2.4 and appendices 5b and 6).

FRSM must be:

 worn (with eye protection) if a full-face visor is not available and spraying or splashing
of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and
mouth) is anticipated or likely (Type IIR)

 worn to protect patients from the operator as a source of infection, eg when performing
surgical procedures or epidurals or inserting a central vascular catheter (CVC) (Type II
(not classed as an FRSM) or Type IIR)

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  well-fitting and fit for purpose, fully covering the mouth and nose (manufacturers’
instructions must be followed to ensure effective fit and protection)

 removed or changed:

‒ at the end of a procedure/task

‒ if the mask’s integrity is breached, e.g. from moisture build-up after extended use or
from gross contamination with blood or body fluids

‒ In accordance with manufacturers’ specific instructions.

Footwear must be:

 visibly clean, non-slip and well-maintained, and support and cover the entire foot to
avoid contamination with blood or other body fluids or potential injury from sharps

 removed before leaving a care area where dedicated footwear is used, eg theatre; these
areas must have a decontamination schedule with responsibility assigned.

Further information can be found in the footwear literature review.

Headwear

Headwear is not routinely required in clinical areas unless part of theatre attire or to prevent
contamination of the environment such as in clean rooms.

Headwear must be:

 worn in theatre settings and clean rooms, eg central decontamination unit

 well-fitting and completely cover the hair

 changed or disposed of between clinical procedures/lists or tasks and if contaminated

with blood and/or body fluids

 removed before leaving the theatre or clean room

 individuals with facial hair must also cover this in areas where headwear is required, eg
wear a snood.

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NB Headwear worn for religious reasons such as turbans, kippot veils, headscarves must not
compromise patient care and safety. These must be washed and/or changed daily or immediately
if contaminated and comply with additional attire requirements, for example, in theatres.

1.5 Safe management of care equipment

Care equipment is easily contaminated with blood, other body fluids, secretions, excretions and
infectious agents. Consequently, it is easy to transfer infectious agents from communal care
equipment during care delivery.

Care equipment is classified as either:

 Single use: equipment which is used once on a single patient then discarded. This
equipment must never be re-used. The packaging will carry the symbol of the number
two in a circle with a diagonal cross

 Single patient use: equipment which can be reused on the same patient and may require
decontamination in-between use such as nebuliser masks

 Reusable invasive equipment: used once then decontaminated, eg surgical instruments

 Reusable non-invasive equipment: (often referred to as communal equipment) – reused

on more than one patient following decontamination between each use, eg commode,
patient transfer trolley.

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NB Needles and syringes are single use devices, they should never be used more than once or
reused to draw up additional medication. Never administer medications from a single-dose vial
or intravenous (IV) bag to multiple patients.

Before using any sterile equipment check that:

 the packaging is intact

 there are no obvious signs of packaging contamination

 the expiry date remains valid

 Any sterility indicators are consistent with the process being completed successfully.

Decontamination of reusable non-invasive care equipment must be undertaken:

 between each use/between patients

 after blood and/or body fluid contamination

 at regular predefined intervals as part of an equipment cleaning protocol

 Before inspection, servicing or repair.

If providing domiciliary care, equipment should be transported safely and decontaminated as

above before leaving the patient’s home.

Always adhere to Control of Substances Hazardous to Health (COSHH) risk assessments and
manufacturers’ guidance for use and decontamination of all care equipment.

 All reusable non-invasive care equipment must be decontaminated between

patients/clients using either approved detergent wipes or
detergent solution, in line with manufacturers’ instructions, before being stored clean and
dry.

 decontamination protocols must include responsibility for; frequency of; and method of
environmental decontamination

 an equipment decontamination status certificate will be required if any item of equipment

is being sent to a third party, e.g. for inspection, servicing or repair

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  guidance should be sought from the infection, prevention and control team prior to
procuring, trialling or lending any reusable non-invasive equipment

 Medical devices and other care equipment must have evidence of planned preventative
maintenance programmes.

1.6 Safe management of the care environment

The care environment must be:

 visibly clean, free from non-essential items and equipment to facilitate effective cleaning

 Well maintained, in a good state of repair and with adequate ventilation for the clinical
specialty.

Always adhere to COSHH risk assessments for product use and processes for decontamination of
the care environment.

Routine cleaning

 the environment should be routinely cleaned in accordance with the National Cleaning
Standards

 use of detergent wipes is acceptable for cleaning surfaces/frequently touched sites within
the care area

 A fresh solution of general-purpose neutral detergent in warm water is recommended for

routine cleaning. This should be changed when dirty or when changing tasks

 routine disinfection of the environment is not recommended however, 1,000ppm

available chlorine should be used routinely on sanitary fittings

 staff groups should be aware of their environmental cleaning schedules for their area and
clear on their specific responsibilities

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  cleaning protocols should include responsibility for, frequency of, and method of
environmental decontamination.

1.7 Safe management of linen

Clean linen

 should be stored in a clean, designated area, preferably an enclosed cupboard

 if clean linen is not stored in a cupboard, then the trolley used for storage must be
designated for this purpose and completely covered with an impervious covering/or door
that is able to withstand decontamination

 do not:

(i) Rinse, shake or sort linen on removal from beds/trolleys

(ii) Place used linen on the floor or any other surfaces eg a locker/table top
(iii) Re-handle used linen once bagged
(iv)Overfill laundry receptacles (not more than 2/3 full); or
(v) Place inappropriate items in the laundry receptacle e.g. used equipment/needles.

Healthcare laundry must be managed and segregated in accordance with HTM 01-04 which
categorises laundry as follows:

Used linen (previously known as soiled/fouled linen):

 ensure a laundry receptacle is available as close as possible to the point of use for immediate
linen deposit

 Should be placed in an impermeable bag immediately on removal from the bed or before
leaving a clinical department.

Infectious linen (this mainly applies to healthcare linen)

Infectious linen includes linen that has been used by a patient who is known or suspected to be
infectious and/or linen that is contaminated with blood and/or other body fluids, e.g. faeces:

 linen in this category must not be sorted but should be sealed in a water soluble bag (entirely
water soluble ‘alginate’ bag or impermeable bag with soluble seams), which is then placed in

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 an impermeable bag immediately on removal from the bed and secured before leaving a
clinical area

 infectious linen bags/receptacles must be tagged (eg, hospital ward/care area) and dated

 Store all used/infectious linen in a designated, safe, lockable area while awaiting collection.
Collection schedules must be acceptable to the care area and there should be no build-up of
linen receptacles

 all linen that is deemed unfit for re-use, eg, torn or heavily contaminated, should be
categorised at the point of use and returned to the laundry for assessment and disposal.

Linen used during patient transfer, eg, blankets, should be categorised at the point of destination.

1.8 Safe management of blood and body fluid spillages

Spillages of blood and other body fluids may transmit blood borne viruses.

Spillages must be treated immediately by staff trained to undertake this safely.

Responsibilities for the management of blood/body fluid spills must be clear within each
area/care setting.

If an organisation locally approves a product for use in the management of blood and body fluid
spills, the organisation is responsible for ensuring safe systems of work, including the
completion of a risk assessment approved through local governance procedures. Organisations
must confirm the efficacy and suitability of the product (i.e., that it conforms to the relevant
standards and is appropriate for the intended use) with the product manufacturer.

1.9 Safe disposal of waste (including sharps)

Health Technical Memorandum (HTM 07-01) contains the regulatory waste management
guidance for all health and care settings (NHS and non-NHS) in England and Wales including
waste classification, segregation, storage, packaging, transport, treatment and disposal.

Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory
requirements for employers and contractors in the healthcare sector in relation to the safe
disposal of sharps.

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 Definitions

Healthcare (including clinical) waste:

Clinical waste means waste from a healthcare activity (including veterinary healthcare) that:

 Contains viable micro-organisms or their toxins which are known or reliably believed to
cause disease in humans or other living organisms. For example, if a patient is known or
suspected to be infected, or colonised, by an infectious agent. Clinical judgement should be
applied in the assessment of waste and should consider the infection status of a patient and
the item of waste produced.

 contains or is contaminated with a medicine that contains a biologically active

pharmaceutical agent, or

 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 Regulation
(EC) No 1272/2008 of the European Parliament and of the Council on classification,
labelling and packaging of substances and mixtures, as amended from time to time.

Offensive waste is waste that:

 is not clinical waste,

 is not infectious, but may contains body fluids, secretions or excretions,

 Is non-hazardous, and

 Falls within waste codes 18 01 04 if from healthcare, or 20 01 99 if from municipal sources.

Table 1: Categories of waste and segregation at source

Category Segregation Treatment/disposal

Yellow bag with black stripeEnergy from waste, landfill or other

Offensive (non-infectious) (tiger) bag permitted processes

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Clinical waste (infectiousUn approved orange bag, un
only) approved box or sharps container For alternative treatment

Healthcare waste
contaminated with non-
hazardous pharmaceuticalsUn approved yellow bag, unFor incineration or other permitted
or chemicals) approved box or sharps container process

Waste contaminated with

cytotoxic or cytostaticUn approved purple bag, un
medication approved box or sharps container For incineration

Non-hazardous For incineration or other permitted

pharmaceuticals (no sharps) Blue box/container process

Anatomical waste/full blood

bag and blood preserves Un approved red lidded container For incineration only

Energy from waste, recovery or

Domestic Black/clear bags landfill

Recycling Clear, green or other color bag Recycling

Safe waste disposal at care area level:

Always dispose of waste:

 immediately and as close to the point of use as possible; and

 into the correct segregated color coded rigid container or sharps box if a sharp

 Liquid waste, eg, suction canisters, must be rendered safe by adding a polymer gel or
compound to the container prior to placing in an orange lidded leak proof bin or yellow
lidded leak proof bin if contaminated by pharmaceuticals.

 waste bags must be no more than 2/3 full and no more than the UN approved weight and
must be securely tied using a plastic tie or secure knot using a ‘swan neck’ to close. Waste

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 must be traceable back to ward/care area or department, this may be achieved by writing on
bags (prior to use), attaching sticky labels or uniquely numbered tags with the post code on
them.

 Store all waste in a designated, safe, lockable area while awaiting collection.
Collection schedules must be acceptable to the care area and there should be no build-up of
waste receptacles.

 Local guidance on management of waste at care level, eg, domiciliary settings should be
followed.

Sharps containers (for safety devices, refer to section 1.10)

Sharps containers must:

 have a handle (small community boxes do not require a handle) and temporary closure
mechanism, employed when box is not in use

 be disposed of when the manufacturers’ fill line is reached

 Be labelled with point of origin and date of assembly and disposal. Where re-usable
sharps containers are used, organisations must have a protocol in place to assure
themselves of safe use and reprocessing.

Further information can be found in the Health Technical Memorandum (HTM 07-01).

1.10 Occupational safety: prevention of exposure (including sharps injuries)

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 outline the regulatory
requirements for employers and contractors in the healthcare sector in relation to: arrangements
for the safe use and disposal of sharps; provision of information and training to employees;
investigations and actions required in response to work related sharps injuries.

There is a potential risk of transmission of a BBV (blood borne virus) from a significant
occupational exposure and staff must understand the actions they should take when a significant
occupational exposure incident takes place. There is a legal requirement to report all sharps
injuries and near misses to line managers/employers.

A significant occupational exposure is:

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  A percutaneous injury eg injuries from needles, instruments, bone fragments, or bites
which break the skin; and/or

 Exposure of broken skin (abrasions, cuts, eczema, etc); and/or

 Exposure of mucous membranes including the eye from splashing of blood or other high
risk body fluids.

Safety devices

Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 are concerned with
reducing and eliminating the number of ‘sharps’ related injuries which occur within healthcare.
Its basic guidance is:

 avoid unnecessary use of sharps

 if use of medical sharps cannot be avoided, source and use a ‘safer sharp’ device;

 if a safer sharp device is not available then safe procedures for working with and disposal
must be in place eg sticky mats, sharps bins, safety procedures and training.

Sharps handling must be assessed, kept to a minimum and eliminated, if possible, with the use of
approved safety devices.

 manufacturers’ instructions for safe use and disposal must be followed

 needles must not be re-sheathed/recapped or disassembled after use

 sharps must not be passed directly hand to hand

 used sharps must be discarded at the point of use by the person generating the waste

 always dispose of needles and syringes as 1 unit

 if a safety device is being used safety mechanisms must be deployed before disposal.

When transporting sharps boxes for community use these must be transported safely with the use
of temporary closures.
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Table 1. Color-coded bags & Category wise Treatment

Color coding Waste category Treatment option as per

schedule
Yellow (Plastic bag) Cat. 1, 2. 3, 6 Incineration/deep burial
Blue(plastic bag/puncture Cat. 4,7. Autoclaving/Chemical
proof container) Treatment /Microwaving and
Shredding
Black (Plastic bag) Cat. 5, 9 and 10 (solid) Disposal in secured landfill

References/Further Readings

1. St John Ambulance, St Andrew’s First Aid, British Red Cross (2011). First Aid Manual.
Dorling Kindersley Limited. London UK

2. St John Ambulance (2013). First Aid Course Manual, The order of St John, Priory
House, London, UK

3. St John Ambulance (2013). First Aid Course Manual, The order of St John, Priory
House, London, UK

4. St John Ambulance (2000). Life saver international First Aid, St John Ambulance.
London, UK.

5. Storr J, et al. Core components for effective infection prevention and control
programmes: new WHO evidence-based recommendations. Antimicrobial Resistance &
Infection Control. 2017

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