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Infection control 

Infection control
Chapter:
Infection control
Author(s):

Natalie Vaughan

, and Mitch Clarke

DOI:
10.1093/med/9780199211043.003.0004
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date: 05 June 2020

  • Standard precautions [link]

  • Risk assessment [link]

  • Hand hygiene [link]

  • Aseptic non-touch technique (ANTT) [link]

  • Care of the isolated patient—source isolation [link]

  • Source isolation for airborne spread [link]

  • Source isolation for contact and/or air-borne route of spread [link]

  • Source isolation for faecal–oral spread [link]

  • Care of the isolated patient—protective isolation [link]

  • Sharps management [link]

  • Action to be taken following a sharps injury [link]

  • Waste management [link]

  • Management of peripheral intravenous cannulae [link]

  • Management of fluid administration sets [link]

  • Specimen collection [link]

  • Midstream urine [link]

  • Catheter specimen of urine collection [link]

  • 24-hour urine specimen collection [link]

  • Faecal specimen collection [link]

  • Wound specimen collection [link]

  • Nasal specimen collection [link]

  • Throat specimen collection [link]

  • Aural specimen collection [link]

  • Conjunctival specimen collection [link]

Standard precautions

Background

Standard precautions (formerly known as ‘universal precautions’) must be adopted at all times, to promote the safe practice of prevention and control of infection. The aim is to minimize the risk of infection to health care workers (HCWs), patients, and visitors. Standard precautions are as follows:

  • Effective hand hygiene.

  • Correct use of personal protective equipment.

  • Safe handling and disposal of sharps.

  • Safe handling and disposal of clinical waste.

  • Appropriate management of blood and other body fluids.

  • Effective decontamination of equipment.

  • Achieving and maintaining a clean clinical environment.

  • Appropriate use of medical devices.

  • Managing accidents and adverse incidents.

Practice tips

  • Prevention and control of infection is everyone’s responsibility and this includes all HCWs, patients, and visitors.

  • Good prevention and control of infection must be an integral part of all clinical practice.

  • A high standard of practice must be implemented routinely at all times.

  • A risk assessment should be conducted as part of the implementation of standard precautions for prevention and control of infection.

  • HCWs must be familiar with and consistently apply local policies, procedures, and guidelines for prevention and control of infection.

  • Any breach of practice must be reported according to the local reporting system.

  • Effective communication with other HCWs, patients, visitors, and the Infection Prevention and Control Team.

  • Ongoing training and education is required.

Risk assessment

Background

Risk assessment is a structured approach to ↓ or eliminate the transmission of infection.

Assessment

Ask:

  • What is the source of infection?

  • How is the infection transmitted?

  • Are additional risk factors involved?

  • What are the individual patient risk factors?

  • Who are the individuals at risk: health care workers (HCWs), patients, or visitors?

  • What facilities are available or unavailable?

  • Is the staffing mix appropriate?

  • What are the contamination risks?

Planning

Account for the following issues:

  • The primary aim is to ↓ or eliminate the risk of transmission of a pathogen, in addition to taking measures to avoid compromising patient care.

  • Implementation of the standard precautions for prevention and control of infection.

  • Local policies, procedures, and guidelines for prevention and control of infection must be followed.

  • Advice, support, and guidance should be obtained from the Infection Prevention and Control Team.

Implementation

When implementing care consider the following issues:

  • Ensure care is up to date and both evidence-based and research-based.

  • Implement the standard precautions for prevention and control of infection in a timely, consistent, and appropriate manner.

  • Documentation must be undertaken according to local policy.

  • Care must be reassessed at regular intervals and the necessary changes made to practice and the documentation.

Evaluation

Ask:

  • Is the patient still symptomatic?

  • Is the pathogen that caused the infection still present?

  • Has the pathogen spread to others or other clinical areas?

  • Do the standard precautions for prevention and control of infection still need to be in place?

  • Should further advice, support, and guidance be obtained from the Infection Prevention and Control Team?

Hand hygiene

Background

Hand hygiene is the single most important factor in ↓ the spread of health-care-associated infection. Hand hygiene refers to the practices of both hand washing and hand disinfection using products such as alcohol hand rubs. Both methods decrease the colonization of transient bacteria on the hands.

Procedure (Fig. 4.1)

  • Remove all wrist jewellery (including wrist watches).

  • Remove stoned rings.

  • Turn on taps to a comfortable temperature and wet hands and wrists.

  • Apply enough cleaning product to cover surface of the hands.

  • Vigorously rub hands together (palm to palm).

  • Vigorously rub the back of each hand.

  • Interlace and interlock fingers to cover all surfaces.

  • Rotationally rub each thumb and wrist.

  • Ensure that all the cleaning product is effectively rinsed off.

  • Turn off taps with disposable paper towel.

  • Dry all parts of the hands and wrists thoroughly using disposable paper towel, paying particular attention to the inter-digital surfaces of the fingers and thumbs.

  • Dispose of the paper towel in a bin without re-contaminating your hands.

If decontaminating your hands using alcohol hand rubs, follow the above procedure using the alcohol hand rub in place of the soap, water, and paper towel. Allow to dry naturally for 30sec.

Practice tips

  • Hands must be decontaminated immediately before and after every episode of direct patient contact or care and after any activity or contact that potentially results in your hands becoming contaminated.

  • Hands that are visibly soiled or contaminated by dirt or organic material must be washed using liquid soap and water.

  • An alcohol hand rub can be used between caring for patients or different care activities, if your hands are not soiled.

  • When caring for a patient who has Clostridium Difficile use soap and water between caring for patients and between different care activities.

  • Cover any cuts and abrasions with waterproof dressings.

  • Avoid hot water as this can increase the risk of dermatitis.

  • Use running water whenever possible.

  • Nails must be kept short. Artificial nails and nail polish must not be worn.

  • Emollient hand creams can be used to protect hands from drying. If hand problems develop, advice should be sought from the Occupational Health Department.

Pitfalls

  • Gloves are often seen as a replacement for good hand hygiene. However, hands must be decontaminated before and after the removal of gloves.

  • Alcohol hand rub is often seen as a replacement for soap and water, however it is ineffective in reducing Clostridium Difficile spores.

Fig. 4.1 Hand decontamination. Technique based on procedure described by G.A.J Aycliffe et al. in Journal of Clinical pathology 1978; 31; 928. Reproduced with permission from the British Medical Journal Publishing Group.

Fig. 4.1
Hand decontamination. Technique based on procedure described by G.A.J Aycliffe et al. in Journal of Clinical pathology 1978; 31; 928. Reproduced with permission from the British Medical Journal Publishing Group.

Aseptic non-touch technique (ANTT)

Background

The aim of the ANTT is to prevent micro-organisms on hands, surfaces, or equipment from being introduced to body sites, such as surgical wounds or equipment (e.g. catheters or central venous lines). It is not necessary to use sterile gloves and a sterile dressing pack for all procedures requiring ANTT, for example when changing an intravenous infusion bag, but the aim of ANTT should still be adhered to. The following procedure relates to a wound dressing.

Equipment

  • Dressing trolley.

  • Alcohol hand rub.

  • Sterile dressing pack.

  • 2% chlorhexidine gluconate in 70% isopropyl alcohol application.

  • Sachets of 0.9% saline solution.

  • Dry dressing.

  • Sterile gloves.

  • Apron.

  • Additional dressings and equipment, as required for a specific procedure.

Procedure

Ideally this should be performed by two healthcare workers (HCWs).

HCW1/HCW2

  • Refer to the care plan or assessment so that the type of dressing and equipment can be prepared and added to the trolley.

  • Explain the procedure and gain consent.

  • Wash and dry their hands.

  • Ensure the dressing trolley is clean—if visibly dirty, clean using detergent and water.

  • Assemble equipment and put it on the bottom shelf of the trolley.

  • Put on a clean, disposable apron.

  • Decontaminate your hands.

  • Check the expiry date and that packaging is intact on sterile equipment.

  • HCW1 open a sterile dressing pack on the top shelf of the dressing trolley, touching only the corners of the paper.

  • HCW1 take the clinical waste bag, without touching other equipment, and pass it to HCW2 to adhere it to the side of the trolley.

  • HCW1 decontaminate your hands.

  • HCW2 place any other sterile equipment onto the sterile field.

  • HCW1 wipe a sachet of 0.9% saline solution along the opening strip using 2% chlorhexidine gluconate in 70% isopropyl alcohol application and allow to dry.

  • HCW1 put on sterile gloves, ensuring they are put on by only touching the wrist end.

  • HCW2 remove the patient’s dressing.

  • HCW1/HCW2 visually assess the wound.

  • HCW1 commence the ANTT using the following principles:

    • Only sterile items should come into contact with susceptible sites.

    • Sterile items should not come into contact with non-sterile items.

  • HCW1 clean the wound, if appropriate.

  • HCW1 cover the wound with sterile dressing.

HCW1/HCW2

  • Dispose of clinical waste and any sharps correctly.

  • Decontaminate their hands.

  • Ensure the patient is comfortable.

  • Clean the trolley using detergent and water.

  • Document the care episode.

Practice tips

  • Effective hand decontamination is the most significant procedure in preventing cross-infection and should be used following contamination.

  • Although it is possible to perform this technique independently, consideration should be given to having an assistant, wherever possible, to place the equipment onto the sterile field and remove dressings. This enables the procedure to be completed more quickly and provide more support for the patient.

  • Forceps can be used during an ANTT in preference to sterile gloves, but they could damage tissue. If appropriate, irrigation may be preferred when cleaning the wound. Whichever method is used, a light, delicate touch should be used. The assessment that determines which method to use is dependent on the experience of the HCW and procedure to be undertaken.

  • Administer-prescribed analgesia before the procedure, if required.

Pitfall

  • Taking ‘short-cuts’ can result in contamination.

Care of the isolated patient—source isolation

Background

  • Source isolation aims to prevent infected patients from infecting others.

Procedure: underlying principles

  • Decontaminate your hands before and after any contact with the patient.

  • Wear the correct personal protective equipment. The choice of personal protective clothing should be determined by a risk assessment of the anticipated contact with the patient.

  • Explain the need for isolation and gain consent.

  • Isolate the organism, not the patient, and consider the psychological needs of the patient.

  • Maintain confidentiality of a patient’s diagnosis while ensuring that health care workers (HCWs) and visitors are aware of the appropriate precautions for prevention and control of infection.

  • Review the need for isolation regularly.

  • The most appropriate type of isolation room should be selected—ideally a room with en-suite facility or a designated isolation ward.

  • If isolation is not possible, patients can be cohorted in a bay, with appropriate precautions for prevention and control of infection.

  • Furniture and equipment should be kept to a minimum in an isolation room.

  • Equipment should, where possible, be single-use only, designated for single-patient use, or easily decontaminated.

  • A dedicated team of HCWs should be allocated to caring for the patient/s.

  • A trolley or dispenser for protective clothing must be allocated to an isolation room, to provide equipment relevant to the type of special precautions for prevention and control of infection.

  • The patient’s documents and charts should be kept outside the room.

  • Visitors should be encouraged to decontaminate their hands. They do not, generally, need to wear protective clothing, unless they are involved in the practice of care.

  • Avoid visits or transfers to other departments, where possible. The department should be notified in advance and the patient should follow other patients.

  • Regularly and thoroughly clean, complying with local guidance for cleaning and decontamination. Detergent and hot water are usually recommended.

  • Damp-dusting, normally using detergent and hot water, should be undertaken daily using a disposable cloth.

  • The floor must be mopped daily.

  • Soiled linen and clinical waste must be treated as infectious and bagged correctly and stored in a secure collection area.

  • Spillages must be dealt with promptly, according to local policy.

  • On discharge or death of the patient, ensure terminal cleaning of the room.

  • Change curtains if they are soiled or the room has been occupied by a patient with an airborne infection.

  • The room can be occupied by another patient after thorough cleaning has taken place.

Practice tips

  • Adhere to local guidance that designates specific responsibilities for enhanced and terminal cleaning of the room and equipment.

  • HCWs should use the correct colour-coded cleaning equipment.

Pitfalls

  • HCWs not fully understanding the procedures and policies relating to isolation.

  • Not considering the psychological needs of the patient with the result that they feel isolated and vulnerable.

Source isolation for airborne spread

Procedure

  • Use single/negative pressure room, with the door kept closed.

  • Decontaminate your hands using soap and water followed by an alcohol hand rub.

  • Use gloves and an apron for contact with respiratory secretions

  • Wear High Efficiency Particulate Air (HEPA) masks for close facial contact.

  • Use a soluble bag for all linen.

  • Refer to the Infection Prevention and Control Team for advice and to alert them of a case.

  • Inform the appropriate hotel services staff.

  • Ensure equipment is damp dusted daily with detergent and hot water but ensure floors are not buffed.

  • Use single-use equipment or decontaminate equipment after use with 1% sodium hypochlorite.

  • Change curtains on discharge.

  • Only stop precautions following consultation with the Infection Prevention and Control Team.

  • Inform relatives and visitors for the need for isolation.

  • Encourage relatives and visitors to wash/clean their hands.

Source isolation for contact and/or air-borne route of spread

Procedure

  • Use single room, with the door kept closed.

  • Decontaminate your hands using soap and water followed by an alcohol hand rub.

  • Use gloves and an apron during all patient contact.

  • Use a soluble bag for all linen.

  • Refer to the Infection Prevention and Control Team for advice and to alert them of a case.

  • Inform the appropriate hotel services staff.

  • Ensure equipment is damp-dusted daily with detergent and hot water but ensure floors are not buffed.

  • Use single-use equipment or decontaminate equipment after use with 1% sodium hypochlorite.

  • Change curtains on discharge.

  • Only stop precautions following consultation with the Infection Prevention and Control Team.

  • Inform relatives and visitors for the need for isolation.

  • Encourage relatives and visitors to wash/clean their hands.

Practice tip

  • Health care workers with hand lesions should avoid contact with the patient.

Source isolation for faecal–oral spread

Procedure

  • Use a single room if possible.

  • The patient must have their own toilet facilities—e.g. en-suite or designated toilet or commode.

  • Decontaminate your hands using soap and water followed by an alcohol hand rub.

  • Use gloves and an apron during contact with faeces.

  • Use a soluble bag for soiled linen.

  • Refer to the Infection Prevention and Control Team for advice and to alert them of a case.

  • Inform the appropriate hotel services staff.

  • Ensure equipment is damp-dusted daily with detergent and hot water but ensure floors are not buffed.

  • Use single-use equipment or decontaminate equipment after use with 1% sodium hypochlorite.

  • The patient must be free of diarrhoea for 48 hours before discontinuation of precautions and 72 hours if being transferred to another healthcare facility or a nursing home.

  • Only stop precautions following consultation with the Infection Prevention and Control Team.

  • Inform relatives and visitors for the need for isolation.

  • Encourage relatives and visitors to wash their hands.

Practice tip

  • Alcohol hand rub alone is not effective against all enteric organisms: hand washing with soap and water followed by the use of alcohol hand rub should be used.

Care of the isolated patient—protective isolation

Background

  • Protective isolation aims to protect a susceptible patient from acquiring an infection, either directly or indirectly, from an infectious source.

Procedure: underlying principles

  • The most appropriate type of isolation room should be selected—e.g. accommodation that has an en-suite facility. In some cases, the patient may be accommodated in a positive-pressure room.

  • Before the patient is admitted, the room should be thoroughly cleaned using detergent and hot water, and curtains changed.

  • Damp-dusting, using detergent and hot water, should be undertaken according to local policy.

  • No-one with a cough, cold, or any other transmissible infection should enter the room.

  • Hand hygiene is of the utmost importance for all those entering the room.

  • Health care workers should wear the appropriate personal protective equipment.

Sharps management

Background

Sharps include any item that has the potential to cause a penetration injury, as follows:

  • Needles.

  • Lancets.

  • Scalpel blades.

  • Syringes.

  • Glass vials.

  • Broken glass.

  • Slides.

  • Biopsy needles.

  • Disposable razors.

  • Intravascular guide wires.

  • Intravenous giving sets.

  • Cannulae.

  • Arterial blood sample packs.

  • Other disposable sharps.

Procedure: underlying principles

  • Avoid the use of sharps wherever possible.

  • It is the responsibility of the sharps user to ensure that sharps are correctly used and disposed of.

  • Dispose of sharps immediately after use.

  • Dispose of the entire needle and syringe—the needle should not be bent, broken, or disconnected.

  • Ensure that the sharps containers are available in close proximity to where the sharp is to be used.

  • Sharps containers must conform to approved standards and be correctly assembled.

  • Sharps containers should be emptied when three-quarters full or once weekly, labelled with the ward, department, or location, and securely closed for removal.

  • Containers must be removed by designated staff wearing appropriate personal protective equipment.

  • Do not re-sheath used needles under any circumstances.

  • Do not re-sheath clean needles, unless there is safe means—e.g. a capping device.

Practice tips

  • If performing an invasive procedure, gloves should be worn for some protection.

Pitfalls

  • Resheathing needles

  • Attempting to put sharps into nearly full containers.

  • Sharps being trapped in the entrance to containers with flaps and injuring subsequent users.

Action to be taken following a sharps injury

Procedure

  • Encourage the wound to bleed, but do not suck.

  • Wash the wound under running water and apply a dry waterproof dressing.

  • Obtain advice from the Occupational Health or Emergency Departments, depending on local policy. Further advice can be obtained from the Infection Prevention and Control Team.

  • Report to line manager and complete an adverse incident form.

  • If the injury is from a used sharp, medical advice should be sought to assess the potential risk of transmission of blood-borne viruses.

  • Retain the sharp item, if known, and identify the source patient, if possible.

  • Blood samples can be collected from the patient and healthcare worker if they consent.

Waste management

Background

‘Waste’ refers to substances or objects that are no longer part of a cycle or chain. The disposal of waste is regulated by statutory regulations, and health care workers (HCWs) have legal and moral duties to dispose of waste properly.

Procedure: underlying principles

  • Household waste (e.g. packaging, paper towels, flowers, and other waste uncontaminated by potentially infectious substances) is disposed of in black plastic bags.

  • Clinical waste (e.g. body fluids and human tissue) is disposed of in an orange plastic bag.

  • Infectious or grossly contaminated waste is disposed of in a red plastic bag, with hazard warning tape.

  • All bags should only be filled to two-thirds full, to protect colleagues from over-spillages.

Practice tips

  • In the community, the responsibility for waste disposal is the householder’s, but clinical waste can be collected, on request, by the local authority.

  • If the householder is treated by a HCW, the clinical waste produced as a result of the treatment is the responsibility of the HCW.

  • Sharps bins are provided to patients who are required to use sharps as part of their treatment. These must be returned for disposal to the patient’s doctor, who will need to be registered with the local environment agency.

  • Alternatively, householders can request that their local authority collect and dispose of clinical waste and/or sharps. The local authority might charge householders for this service.

  • Advise patients and householders using sharps in the community not to dispose of sharps in soft drink cans, plastic bottles, or similar containers, because this can present serious hazards to staff disposing of domestic waste.

Pitfall

  • Disposing of clinical waste and sharps in domestic waste.

Management of peripheral intravenous cannulae

Background

Peripheral intravenous cannulae (PICs) are used to administer fluids, blood products, and nutritional support. Infection control p.162–170 for insertion, changing and removal of PICs

Procedure: underlying principles

  • Decontaminate your hands before and after touching PICs and any PIC insertion site.

  • Use a strict aseptic technique when handling PICs.

  • Use a phlebitis grading chart to observe for signs of tenderness, erythema, swelling, or palpable cord at the insertion site during every shift and document your observations.

  • Routinely replace PICs every 72–96 hours.

  • If inserted in an emergency, replace PICs within 24 hours.

  • Document the insertion date and time in the prescription chart and medical and nursing notes.

  • Cover the insertion site with a transparent sterile dressing.

  • Replace the dressing using an aseptic non-touch technique ANTT 78 when the PIC is removed or replaced, or when the dressing becomes damp, loosened, or soiled, and at least every 72–96 hours.

Practice tips

  • Avoid shaving at the insertion site because this causes micro-abrasions. This ↑ risk of bacterial colonization, which ↑ the risk of infection.

  • If a patient has extermely poor venous access and there is a need for continuing IV theraphy, the cannula can be left in situ for more than 72 hours (this should be disscussed with the treating medical team).

Management of fluid administration sets

Procedure: underlying principles (Infection control preparation for IV therapy, p. [link])

  • Decontaminate your hands before and after using administration sets.

  • Check the expiry date and packaging of the administration set. Dispose of the administration set if the date has expired or the packaging is not intact.

  • Use an ANTT (Infection control on p. [link]) when handling the catheter hub, connections ports, and sterile parts of the administration set.

  • Avoid contact with non-sterile surfaces.

  • Label peripheral lines with the date and time.

  • Change the administration set every 72–96 hours and document the change.

  • Change the administration set after the administration of blood products.

  • Clean access points using an isopropyl-impregnated swab or povidone–iodine solution before accessing the system.

  • Administer intravenous drugs through the latex membrane on peripheral lines and avoid the use of ports.

Practice tips

  • If administration sets are accessed frequently, they will need changing every 24–48 hours.

  • Keep the number of access points to a minimum. If they are not in use, remove them.

Specimen collection

Background

The correct collection of specimens for investigations is essential to accurate diagnosis.

Procedure: underpinning principles

  • Explain the procedure and gain consent.

  • Inform the patient when the results will be available.

  • Decontaminate your hands before and after the procedure.

  • Personal protective clothing might be required following a risk assessment.

  • Specimens should be collected at the appropriate time, using the correct technique and equipment.

  • Transport the specimens to the laboratory without delay or store them in a fridge or incubator.

  • To ↑ the chance of isolating an organism, gain a sufficient specimen, wherever possible, before antibiotic therapy.

  • Different specimens require different media and methods of sampling. If unsure, contact the receiving laboratory for advice before proceeding.

  • Before taking a specimen, ensure any corresponding specimen documentation, request form, and container label is fully completed, including the patient’s details, date, specimen taken, and what investigations are required.

  • Do not contaminate specimens during transfer to the container.

Midstream urine

Background

A urine culture is a test to find and identify micro-organisms (usually bacteria) that may be causing a urinary tract infection (UTI). A urine specimen is kept under conditions that allow bacteria and other organisms to grow. If few organisms grow, the test is negative. If organisms grow in numbers large enough to indicate an infection (100,000 or more bacteria per millilitre), the culture is positive. The type of organism causing the infection is identified with a microscope or by chemical tests. A midstream urine (MSU) sample is used to confirm the diagnosis of an urine infection and/or to decide the most appropriate antibiotic to be used. Urine is sterile so the presence of bacteria is indicative of an infection. The midstream is used as the first stream of urine may be contaminated with bacteria from the skin.

Procedure

  • Explain the procedure and gain consent.

  • Decontaminate your hands.

  • If possible obtain sample immediately after the patient has showered or bathed, asking the patient to clean:

    • The vulva,(if female) from front to back.

    • Glans penis and behind the prepuce (if male).

    • Ask patient to decontaminate their hands.

    • If the patient is unable to perform this activity ensure the vulva or the glans penis and behind the prepuce is cleaned.

  • Ask the patient to void an initial stream into the toilet or bedpan. The MSU sample should then be collected in a sterile receiver, allowing the final stream into the toilet or bedpan.

  • Place the specimen directly into a sterile container.

  • Decontaminate your hands.

  • Label the sample and send to the laboratory immediately or store in refrigerator until ready to send.

  • Document the episode of care.

Practice tips

  • 5–10mL of urine is sufficient for microbiological examination.

  • If the patient is unable to control the flow, collect the whole specimen and advise the laboratory that the specimen is a ‘clean catch’.

  • Always use soap and water and not disinfectants for cleaning the vulva or glans penis.

  • In the female, cleaning of the vulva is very important.

Pitfall

  • Failing to document if the patient is on antibiotics when the sample was taken.

Catheter specimen of urine collection

Background

A urine culture is a test to find and identify micro-organisms (usually bacteria) that may be causing a urinary tract infection (UTI). A urine specimen is kept under conditions that allow bacteria and other organisms to grow. If few organisms grow, the test is negative. If organisms grow in numbers large enough to indicate an infection, the culture is positive. The type of organism causing the infection is identified with a microscope or by chemical tests. A catheter specimen of urine (CSU) is used to confirm the diagnosis of an urine infection and/or to decide the most appropriate antibiotic to be used. Urine is sterile so the presence of bacteria is indicative of an infection. Using a catheter to collect a urine specimen reduces the chance of getting bacteria from the skin or genital area in the urine specimen, but catheter use sometimes causes a UTI.

Procedure

  • Explain procedure and gain consent.

  • Clamp the urinary drainage tube, if necessary, just below the sampling point and wait 15min.

  • Wipe the sample point with an 2% chlorhexidine gluconate in 70% isopropyl alcohol application.

  • Aspirate the required amount of urine.

  • Release the clamp, if used.

  • Transfer the urine to a sterile container and label as ‘CSU’.

  • Document the episode of care.

Practice tips

  • Patients who have a urinary catheter in place for a long time are at a high risk of UTI.

24-hour urine specimen collection

Background

This collection measures the amount of urine produced in a day.

Equipment

  • 24-hour urine collection container.

  • Disposable bedpans or urinals.

Procedure

  • Explain the procedure and gain consent.

  • At the allocated time to start collection, ask the patient to empty their bladder into a toilet—this specimen must be discarded.

  • Collect all subsequent voided urine into the 24-hour specimen container.

  • At the start label the container with the date, time and patient’s details.

  • Discontinue collection after 24 hours and label the container.

Faecal specimen collection

Background

Many intestinal disorders are due to intestinal parasites, bacteria, viruses and toxins which require laboratory investigation.

Procedure

  • Explain the procedure and gain consent.

  • Ask the patient to defecate in a bedpan.

  • Decontaminate your hands.

  • Wear gloves and an apron.

  • Observe the stool for colour, consistency, and volume.

  • Using a spatula, spoon a portion of faeces into a container. In the case of liquid faeces, a syringe might be required to obtain a specimen.

  • Decontaminate your hands.

  • Label the sample and send it to the laboratory with an appropriate request form.

  • Offer patient hand cleaning facilities.

  • Document the episode of care.

Wound specimen collection

Background

  • Wound swabs should only be taken if:

    • there is clinical evidence of infection;

    • there is unexplained deterioration of the wound

    • the wound fails to heal.

Procedure

  • Explain the procedure and gain consent.

  • Decontaminate your hands.

  • Wearing gloves or using a dressing bag, remove the wound dressing.

  • Rotate the swab in the wound, working from the middle outwards or zig-zag across to cover the full expanse of the wound. Do not touch the surrounding skin. For large wounds, swab the most contaminated area.

  • Place the swab in the appropriate transport medium.

  • If copious pus is present, aspirate a quantity using a syringe and transfer into a sterile container.

  • Decontaminate your hands.

  • Label the sample and send it to the laboratory with an appropriate request form.

  • Document the episode of care.

Practice tips

  • If the site being swabbed is dry, the swab can be moistened using 0.9% saline solution.

  • Swabs should be taken before wound cleaning at which time the maximum number of bacteria is present; however, the dressing residue should be removed.

Nasal specimen collection

Background

A nasal swab may be helpful in indicating the causes of any infection, and is of particular assistance in guiding appropriate antibiotic therapy. They can also be taken for surveillance purposes in order to prevent transmission and to identify individuals who are at risk for developing infection e.g. meticillin-resistant Staphylococcus aureus (MRSA).

Procedure

  • Explain the procedure and gain consent.

  • Decontaminate your hands.

  • Ask the patient to blow their nose and tilt their head slightly back.

  • Swab the anterior nares of the nostrils by gently rotating and directing the swab upwards into the nostril.

  • One swab can be used for both nostrils.

  • Place the swab in the appropriate transport medium.

  • Decontaminate your hands.

  • Label the sample and send it to the laboratory with an appropriate request form.

  • Document the episode of care.

Practice tip

  • If the site being swabbed is dry, the swab can be moistened using 0.9% saline solution.

Throat specimen collection

Background

Throat (oropharynx) swabs are taken in order to isolate organisms known to cause upper respiratory tract infections.

Equipment

  • Strong light.

  • Tongue depressor.

  • Tissues.

  • Sealed plastic container.

Procedure

  • Explain the procedure and gain consent.

  • Ask the patient to sit in such a position that they are facing a strong light source.

  • Decontaminate your hands.

  • Explain to the patient that the procedure might cause a gagging reaction.

  • Obtain a good view of the oropharynx before swabbing.

  • Depress the tongue with a tongue depressor or ask the patient to stick their tongue out.

  • Gently slide the swab down the side of the throat until you make contact with the tonsil/posterior pharynx.

  • Gently but firmly rotate the swab in any exudates from the tonsillar area and/or posterior pharynx.

  • Avoid touching the lips, cheeks, tongue, or teeth.

  • Place the swab in the appropriate plastic container.

  • Label the container and send it to the laboratory with an appropriate request form.

  • Decontaminate your hands.

  • Document the episode of care.

Practice tips

  • Specimens should be transported and processed as soon as possible.

  • If process is delayed, refrigeration may be suitable.

  • Ensure specimens are processed within 48 hours.

Pitfall

  • If the patient gags they can contaminate the swab.

Aural specimen collection

Background

Swabs are taken to see if infection is present in the ear canal.

Procedure

  • Explain the procedure and gain consent.

  • Decontaminate your hands.

  • Direct a light into the patient’s ear.

  • Gently grasp the pinna of the ear, lifting it upwards and backwards.

  • Gently rotate the swab into the external auditory canal.

  • Place the swab in the appropriate transport medium.

  • Label the container and send it to the laboratory with an appropriate request form.

  • Decontaminate your hands.

  • Document the episode of care.

Practice tip

  • Do not push the swab any further into the external auditory canal beyond what you can see.

Conjunctival specimen collection

Background

Conjunctival swabs are taken in an attempt to identify the causative organism in infective conjunctivitis and determine the most effective treatment after organisms are cultured.

Equipment

  • Appropriate swabs.

  • Culture medium.

Procedure

  • Explain the procedure and gain consent.

  • Decontaminate your hands.

  • Ask the patient to sit down and tilt their head slightly backwards.

  • Pull the lower lid down so that the conjunctiva is exposed and ask the patient to look upwards.

  • Run the swab firmly along the surface of the exposed conjunctiva, from the medial canthus towards the lateral canthus (Fig. 4.2).

  • On completion, remove the swab from the lid and ask the patient to blink or close their eyes briefly, to help dispel any discomfort.

  • Place the swab securely in the appropriate media and send it off to the laboratory.

  • Decontaminate your hands.

  • Document the episode of care.

Fig. 4.2 Taking a conjunctival swab for culture.

Fig. 4.2
Taking a conjunctival swab for culture.

Practice tips

  • Advise the patient that the procedure could feel a little uncomfortable.

  • Take swabs before the use of eye drops for examination purposes and the commencement of any treatment.

  • Twisting the swab will help ensure that epithelial cells are picked up.

  • If you are unable to send the swab to the laboratory immediately, it can be refrigerated.