SESLHD PROCEDURE COVER SHEET

SESLHD PROCEDURE
COVER SHEET
NAME OF DOCUMENT
Antiseptics and Disinfectants
TYPE OF DOCUMENT
Procedure
DOCUMENT NUMBER
SESLHDPR/354
DATE OF PUBLICATION
June 2014
RISK RATING
Medium
LEVEL OF EVIDENCE
NSW Ministry of Health Policy Directives;
Commonwealth of Australia Department of Health and
Aging Guidelines
NSW Work Health and Safety Act
NSW Work Health and Safety Regulations
National Standards 3.1, 3.3, 3.5, 3.10
REVIEW DATE
June 2017
FORMER REFERENCE(S)
Former SESLHNPD/126 ‘Antiseptic and Disinfectants’
EXECUTIVE SPONSOR or
Director Clinical Governance
EXECUTIVE CLINICAL SPONSOR
AUTHOR
Infection Control Manual Working Party
SESLHDInfectionControlIDL@sesiahs.health.nsw.gov.au
POSITION RESPONSIBLE FOR THE
DOCUMENT
Infection Prevention & Control Working Party
KEY TERMS
Antiseptic, disinfectant, sterilant
SUMMARY
To outline how to use, apply, manage and store
antiseptics and disinfectants as per guidelines and policy
SESLHDInfectionControlIDL@sesiahs.health.nsw.gov.au
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District.
Procedure content cannot be duplicated.
Feedback about this document can be sent to seslhdexecutiveservices@sesiahs.health.nsw.gov.au
SESLHD PROCEDURE
Antiseptics and Disinfectants
PR 354
1.
POLICY STATEMENT
To outline the principles for the safe management and use of antiseptics and disinfectants
for all staff
The procedure has been developed in line with the NSW Ministry of Health Infection
Control Policy Directive and National Safety and Quality Health Service Standard No. 3
‘Preventing and Controlling Healthcare Associated Infections, specifically Criterion 3.5.
2.
BACKGROUND
Antiseptic: a chemical for disinfection of the skin, mucous membranes or other living
tissue to decrease the number of microorganisms present
Disinfectant: any substance used on inanimate objects such as instruments and
environmental surfaces to kill or inhibit growth of microorganisms
Microorganism: a tiny form of life which can be bacterial, viral or fungal that may be
capable of causing infection or disease
Sterilant: a chemical agent, other than a gas, which is used to sterilise medical
devices. A sterilant kills all microorganisms
3.
RESPONSIBILITIES
3.1
Employees will:
Comply with management procedures for each Antiseptic and Disinfectant
Ensure risk assessment is done and appropriate PPE worn while cleaning spills
Comply with the procedure outlined for each Antiseptic and Disinfectant in line with
local Infection Control policies and procedures.
3.2
Line Managers will:
Ensure that antiseptics and disinfectants are available, stored safely and that HCW’s are
educated in the procedure for use.
4.
PROCEDURE
4.1
Antiseptics
Use only antiseptics supplied by the Pharmacy Department
Select the correct antiseptic for the use required (refer to Table: Antiseptic Guide)
Read label carefully before use, especially contact time recommendations
Check the tamper proof seal is intact
Check the use by date
Measure correctly
Wear gloves to avoid chemical contact
Revision 1
Trim No. T14/19749
Date: June 2014
Page 1 of 4
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PR 354
Avoid splashes to prevent harm to skin and eyes
Do not create an aerosol (fine mist) with solution
Do not combine antiseptics
Do not add detergent or any other substance to an antiseptic. This may inhibit the
antimicrobial effect
Use a clean, dry container for each solution
Do not contaminate the solution
Record date when opened and discard by designated use-by date (as indicated on the
manufacturer's label)
Do not "top up" antiseptic solutions
Discard single use containers immediately after use
Do not return decanted antiseptic solution to its original container. Discard the unused
solution
Discard antiseptic solution carefully after use
Close the lid after use (if applicable)
Antiseptics will not make dirt safe. The area may need to be cleaned first
Do not use an antiseptic for cleaning
Do not use an antiseptic as a disinfectant or a sterilant
Anaphylactic reactions can occur with antiseptics applied topically
4.2
Disinfectants
Chemical disinfection may only be used for items for which thermal methods are
unsuitable
Before use, check the manufacturer’s instructions for compatibility of the instrument or
equipment with the disinfectant
Relevant MSDS (Material Safety Data Sheet) must be consulted before use
Appropriate PPE as specified in the MSDS must be used
Only use disinfectants specified in the Australian Register of Therapeutic Goods
(ARTG) and these should only be used for the approved purpose
Follow the manufacturer’s instructions
Use only disinfectants supplied by the facility
Select the correct disinfectant for the use required (refer to Table: Disinfectant Guide)
Read label carefully before use
Check the tamper proof seal is intact (if applicable)
Check the use by date
Record date when opened and discard by designated use-by date (as indicated on the
manufacturer's label)
Measure correctly
Use the correct concentration/dilution
Instruments and equipment must be cleaned with a neutral detergent or enzymatic
solution prior to chemical disinfection
Avoid splashes to prevent harm to skin and eyes
Do not create an aerosol (fine mist) with solutions
Do not combine disinfectants
Do not add detergent to a disinfectant. This may inhibit the antimicrobial effect
Revision 1
Trim No. T14/19749
Date: June 2014
Page 2 of 4
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PR 354
Do not contaminate the solution
Use a clean, dry container for each solution
Ensure ventilation is adequate
Do not return a decanted disinfectant solution to its original container. Discard the
unused solution
Do not "top up" disinfectant solutions
Discard disinfectant solution carefully after use
Close the lid after use (if applicable)
Discard single use containers immediately after use
Do not use as an antiseptic or a sterilant
Do not use a disinfectant for cleaning
Disinfectants will not make dirt safe. The area will need to be cleaned first
Do not store instruments or cleaning tools in disinfectants before or after use
5.
DOCUMENTATION
Nil
6.
AUDIT
Central Line Catheter Insertion Checklist
Aseptic technique audits
7.
REFERENCES
NSW Ministry of Health ‘Infection Control Policy Directive’ PD 2007_036
Australian Commission on Safety and Quality in Healthcare: Australian Guidelines for
the Prevention and Control of Infection in Health Care. 2010
http://www.nhmrc.gov.au/node/30290
Tortora, G., Funke, B. and Case, C.(2010) Microbiology. An Introduction. 10th Ed. The
Benjamin Cummins Publishing Company Inc, USA.
Australian College of Operating Room Nurses Ltd. ACORN Standards, Guidelines
and Policy Statements. 2013
National Standard 3 Prevention of Healthcare Associated Infections
NSW Health Department. Skin Penetration Code of Best Practice. 2001
Marscall, J. et al. Strategies to Prevent Central Line-Associated Bloodstream
Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology. 2008;
29: S22-S30
Revision 1
Trim No. T14/19749
Date: June 2014
Page 3 of 4
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
8.
PR 354
REVISION AND APPROVAL HISTORY
Date
Revision No.
Author and Approval
May 2003
0
IAHS Infection Control Coordinators
Feb 2005
1
Approved by Area Policy and Procedure Committee on 10 Feb 2005 and
ratified by Area Executive 21 Feb 2005 for a six month period – review
August 05
May 2006
Draft
Former IAHS policy reviewed and merged for SESIH in collaboration
with SESIH Infection Control Manual Working Party
July 2010
Draft
Presented to SESIH Area Infection Prevention and Control Committee
R. Bourke – Sutherland Hospital
Apr 2011
2
May-Jun
2014
2.5
Minor amendments made by Infection Prevention Control Working Party.
Re-formatted by District Policy Officer
Jun 2014
2.5
Approved by Executive Clinical Sponsor, Prof. George Rubin
Revision 1
Amended to reflect change to Local Health Network
Trim No. T14/19749
Date: June 2014
Page 4 of 4
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PRODUCT
H CHLORHEXIDINE 0.5% in
A 70% Alcohol handrub
N with emollients
D
C
L
E
A
N
S CHLORHEXIDINE 2%
E
R
S TRICLOSAN 1%
Revision 1
PR 354
RECOMMENDED USES
Hand disinfection when
hands are not visibly soiled
Hand wash prior to an
aseptic procedure
INSTRUCTIONS
If hands are visibly soiled,
running water must be used
Vigorously rub hands for a
minimum 15 seconds with
enough solution to
completely wet hands
Prior to aseptic procedures
minimum 30 seconds rub
required
Refer to Infection Control
Manual: Hand Washing,
Hand Cleansing and Hand
Care policy
NOTES
FLAMMABLE
Not suitable if hands are
visibly soiled
Should not be relied on to
be effective against C.
difficile and some viruses
Refer to C.diff procedure
Not to be used for
environmental cleaning
Hand wash in areas as
determined by the local
Infection Control Committee
Trim No. T14/19749
Date: June 2014
Page 1 of 6
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PR 354
PRODUCT
RECOMMENDED USES
H Hand gel 66% w/w ethanol Hand disinfection when
A
hands are not visibly soiled
N
D
C
L
E
A
N Hand foam ethanol
S absolute 60% with
E propan-1-ol 10%
R
S
S ALCOHOL 70% tinted
K
I
N
Revision 1
Hand disinfection when
hands are not visibly soiled
Skin preparation prior to
procedures
Trim No. T14/19749
INSTRUCTIONS
If hands are visibly soiled,
running water must be used
Vigorously rub hands for a
minimum 15 seconds with
enough solution to
completely wet hands
Prior to aseptic procedures
minimum 30 seconds rub
required
If hands are visibly soiled,
running water must be used
Vigorously rub hands for a
minimum 15 seconds with
enough solution to
completely wet hands
Prior to aseptic procedures
minimum 30 seconds rub
required
Ensure skin is clean
Swab site carefully
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Date: June 2014
NOTES
FLAMMABLE
Not suitable if hands are
visibly soiled
Should not be relied on to
be effective against C.
difficile and some viruses
Refer to C.diff procedure
Not to be used for
environmental cleaning
FLAMMABLE
Not suitable if hands are
visibly soiled
Should not be relied on to
be effective against C.
difficile and some viruses
Refer to C.diff procedure
Not to be used for
environmental cleaning
FLAMMABLE
Do not use prior to electric
cautery
Page 2 of 6
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PRODUCT
CHLORHEXIDINE 0.015%
with CETRIMIDE 0.155%
Aqueous (Sterile)
P
R
E
P
A
R
A
T
I
O
N
CHLORHEXIDINE 0.05%
Aqueous (Sterile)
CHLORHEXIDINE 0.5%
Aqueous (Sterile)
CHLORHEXIDINE 0.5% in
70% Alcohol
Revision 1
PR 354
RECOMMENDED USES
Initial cleaning of dirty
wounds in Emergency
Department
Soaking off adhered
dressings
Perineal swabbing
For use as skin antisepsis in
neonates less than 28 weeks
gestation and less than 1500
grams until 7 days old
Pre-operative skin
preparation of hypersensitive
areas and patients allergic to
povidone iodine
For use as skin antisepsis in
infants less than 2 months
Skin preparation prior to
insertion of intravascular
devices for neonates greater
than 28 weeks gestation
Trim No. T14/19749
INSTRUCTIONS
Ensure skin is clean
Use undiluted. Single use
container
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Ensure skin is clean
Use undiluted. Single use
container
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Ensure skin is clean
Use undiluted. Single use
container
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Ensure skin is clean
Do not apply to broken skin
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Date: June 2014
NOTES
Good detergent / cleaning
action. Avoid contact with
meninges or middle ear.
Keep out of eyes
Avoid contact with
meninges or middle ear.
Keep out of eyes
Avoid contact with
meninges or middle ear.
Keep out of eyes
FLAMMABLE
Use chlohexidine 2% in
70% alcohol for adults
Page 3 of 6
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PRODUCT
S CHLORHEXIDINE 2% in
K 70% Alcohol
I
N
P
R
E
P
A
R
A CHLORHEXIDINE 2% and
T 70% Isopropyl Alcohol
I (Solu I.V. MAXI swabstick)
O
N
CHLORHEXIDINEGlucona
te2% swab stick (alcohol
free)
PR 354
RECOMMENDED USES
Skin preparation prior to
procedures
Skin preparation prior to
insertion of intravascular
devices
Skin antisepsis prior to
insertion of intravascular
devices
Skin antisepsis in infants
Cleaning of bungs in infants
CHLORHEXIDINE 4% in
Ethanol 70% IV prep
(Persist Plus)
Revision 1
Skin preparation prior to
insertion of intravascular
device
Trim No. T14/19749
INSTRUCTIONS
Ensure skin is clean
Do not apply to broken skin
or mucous membranes
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Ensure skin is clean
Do not apply to broken skin
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Ensure skin is clean
Disinfect insertion site for
one minute, turn swab over
and apply antiseptic to site
for further one minute
Allow site to air dry
Ensure skin is clean
Disinfect insertion site for
one minute, turn swab over
and apply antiseptic to site
for further one minute
Allow site to air dry
Ensure skin is clean
Do not apply to broken skin
CONTACT TIME - allow site
to air dry prior to procedure
(DO NOT WIPE DRY)
Date: June 2014
NOTES
FLAMMABLE
FLAMMABLE
FLAMMABLE
Do not use if child is less
than 2 months
FLAMMABLE
Page 4 of 6
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PRODUCT
S CHLORHEXIDINE 2 or 4%
K
I
N
POVIDONE IODINE 5%
P (1/2
R
E strength Betadine)
P (Biodene)
A POVIDONE IODINE 10%
R Solution (Betadine,
A Novadine S)
T This may be packaged as
I a swab, swab stick,
O steritube or bottle
N
TRICLOSAN 1%
S CHLORHEXIDINE 4%
U
R
G
I
C
A
L
Revision 1
PR 354
RECOMMENDED USES
Pre-operative body wash
Skin preparation prior to
specific surgical procedures
e.g. eye lids (Operating
Theatre use only)
Skin preparation prior to
surgical procedures/blood
culture collection/skin
puncture
INSTRUCTIONS
Can be provided as
individual patient use
sachets, disposable cloths
or liquid wash
Apply to clean skin, mucous
membranes
CONTACT TIME - refer to
manufacturer's instructions
Apply to clean skin, mucous
membranes
CONTACT TIME 3 - 5
minutes - refer to
manufacturer's instructions
NOTES
DO NOT USE FOR
NEONATES
If patient allergic to iodine,
Chlorhexidine 0.5% to be
used
Avoid regular use in
patients on lithium or with
thyroid disorders
Pre-operative body wash
Surgical hand wash before
entering normally sterile
tissue
Trim No. T14/19749
Refer to SESIH Infection
Control Manual: Hand
Washing, Hand Cleansing
and Hand Care policy
Date: June 2014
Page 5 of 6
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
SESLHD PROCEDURE
Antiseptics and Disinfectants
PRODUCT
PR 354
RECOMMENDED USES
INSTRUCTIONS
NOTES
S
C
R
U
B
Revision 1
Trim No. T14/19749
Date: June 2014
Page 6 of 6
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.