Risk assessment

Applying standard precautions begins with ensuring that appropriate risk assessments are undertaken. When a patient arrives at a healthcare setting, a healthcare professional should check or assess their risk of acquiring and transmitting an infection (Cattini and Kiernan 2020). If an individual is identified as infected or colonised with an infectious agent, a risk assessment should be undertaken to determine how to prevent transmission to others. If additional precautions are required, these will vary according to the infectious agent’s mode of transmission, such as via contact, droplets or airborne routes (Cattini and Kiernan 2020). For example, additional precautions for a patient who has contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may include caring for them in isolation according to local policy and staff wearing additional personal protective equipment (PPE) such as a fluid-resistant mask or FFP3 mask, visor and long-sleeve gown (NHS England 2024).

Hand hygiene

Hand hygiene is a simple practice that should be common in healthcare settings to assist in preventing the transmission of microorganisms such as viruses, bacteria and fungi, all of which can lead to HCAIs (Ridley 2020). Nurses should undertake hand hygiene at certain moments during patient care, shown in Box 2. However, although this is recognised globally as best practice, hand hygiene is not always carried out at these recommended moments. According to the WHO (2021a), compliance with hand hygiene among healthcare staff in high-income countries rarely exceeds 70% despite optimal hand hygiene facilities. It is important to improve staff compliance with hand hygiene through formal education, clinical observation and performance feedback, methods which Wilson et al (2023) found to be beneficial in practice.

When the healthcare professional’s hands are visibly dirty or soiled, they should wash them with water and soap. This involves wetting one’s hands with water, applying soap and rubbing one’s hands together for 15-30 seconds, which enables the soap to lather. It is that mechanical rubbing action along with the lather that will remove the dirt and debris from the hands, which should then be rinsed with running water (Damani 2019). The healthcare professional should particularly attend to the thumbs and fingertips because these areas frequently come into contact with patients and the environment (WHO 2009). Thorough drying of the hands is essential because a wet surface will encourage bacterial growth (Gammon and Hunt 2020). A comprehensive handwashing procedure developed by the WHO (2009) is available at: https://www.who.int/docs/default-source/patient-safety/how-to-handwash-poster.pdf?sfvrsn=7004a09d_2

When the healthcare professional’s hands are not visibly dirty or soiled, they should use an alcohol-based hand rub because this is efficient, effective and better tolerated by the hands than washing them with soap and water (WHO 2024b).

Respiratory hygiene and cough etiquette

Respiratory hygiene has been defined as containing respiratory secretions to limit the spread of microorganisms transmitted by droplets or airborne routes (Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Scotland 2021). Its importance has been emphasised by the coronavirus disease 2019 (COVID-19) pandemic, which demonstrated the need for effective respiratory hygiene and cough etiquette, for example ensuring one’s mouth and nose are covered with a face mask, tissue, sleeve or the inner elbow during coughing or sneezing then performing hand hygiene (WHO 2014, Calcagni et al 2023).

The WHO (2014) has recognised that the quality of evidence for respiratory hygiene is low, which was supported by a Cochrane review by Jefferson et al (2023), indicating that there is uncertainty about whether wearing a face mask slows the spread of respiratory viruses. However, the WHO (2014) still recommends that respiratory hygiene is carried out since it could potentially reduce the exposure to respiratory pathogens in healthcare settings. Staff who have symptoms of a respiratory condition should maintain a social distance of at least one metre (Chu et al 2020), ensure their mouth and nose are covered with a tissue or mask when coughing or sneezing, and adhere to local policies regarding wearing a face mask. Used tissues and face masks should be disposed of in a clinical waste bag and hand hygiene should be performed to reduce the spread of pathogens (WHO 2014, Damani 2019).

Personal protective equipment

Two of the most commonly used forms of PPE in healthcare are disposable gloves and aprons. The inappropriate use of gloves should be avoided because it has the potential to transmit microorganisms and lead to cross-infection (Royal College of Nursing (RCN) 2020). However, glove use in healthcare has become conventional and habitual (RCN 2023). Healthcare professionals require education and information so they can ascertain whether or not there is a need to wear gloves during particular tasks, with recommendations stating that non-sterile disposable gloves should be worn for procedures that may involve contact with blood or body fluids (Damani 2019).

Wearing gloves does not mean that hand hygiene is unnecessary; it is vital that hand hygiene is performed immediately before donning gloves and immediately after removing them. The correct removal and disposal of gloves are also important. They involve pulling each glove off at the wrist and turning them inside out as they are removed, then placing them in a foot-pedal-operated clinical waste bin (Cattini and Kiernan 2020).

Disposable single-use aprons are donned to protect one’s clothing and should be worn when performing tasks that may lead to its contamination, for example cannulation and the insertion or removal of urinary catheters (Wigglesworth 2019). The healthcare professional should remove the apron and dispose of it appropriately once they have completed the task; they should not keep it on when they attend to other patients.

The inappropriate use of plastic aprons could potentially transmit microorganisms and cause cross-infection (Weston et al 2017). Phan et al (2020) concurred that contaminated PPE can assist pathogen dissemination throughout the healthcare environment. It is important that nurses act as role models for patient safety, as per the Code (NMC 2018), through positive practices such as the appropriate wearing of PPE.

Aseptic technique

According to Clare and Rowley (2018), an aseptic technique enables a procedure to take place in a way that reduces the risk of contamination and the introduction of pathogens in susceptible sites. For this to occur, healthcare staff need to take measures to reduce pathogens in the immediate vicinity of where the procedure will be performed and ensure that they do not to touch particular elements, such as needle tips, catheter tips or the inside surface of sterile dressings, since these will directly or indirectly come into contact with the patient and therefore pose a risk of infection (Cattini and Kiernan 2020).

Aseptic technique is an essential competency required of nurses who undertake routine procedures such as catheterisation and wound dressings (Loveday et al 2014, Damani 2019). A literature review by Kent et al (2018) found no significant difference in the rate of wound infection when using either an aseptic or a clean technique, suggesting that aseptic technique may not be required for all wound dressings; however, not all types of wounds were included in the review. Nurses should make a clinical assessment to decide whether an aseptic or a clean technique is required. An aseptic technique aims to completely prevent the transfer of microorganisms using sterile equipment, whereas a clean technique aims to reduce the transmission of microorganisms using appropriate hand hygiene and clean gloves (Joint Commission 2013).

Safe injections and sharps injury prevention

Gloves are not always required when administering injections because this is a minimal contact procedure; however, nurses should assess their risk of harm and decide whether or not they need to wear gloves when carrying out injections (RCN 2023).

Sharps injuries remain a known risk for healthcare professionals, despite measures being put in place to reduce their occurrence (RCN 2023). Healthcare staff need to be vigilant when handling sharps such as needles and ensure that the appropriate sharps container is at hand for disposal immediately after use. The handling of sharps should be kept to a minimum and needles should not be re-capped because of the risk of harm. Various safety-engineered devices – for example, a retractable needle or a mechanism attached to cover the needle – may be used to reduce the risk of sharps injury. Staff need to be familiar with the safety-engineered devices used in their area, since these can vary (Jackson et al 2020).

Environmental cleaning

The environment in healthcare settings can serve as a reservoir for microorganisms (Suleyman et al 2018), including areas such as sinks, drains and medical equipment, where biofilms can form. Biofilms are usually composed of a multispecies microbial community embedded in an extracellular polymeric matrix. They have a reduced susceptibility to antimicrobials and are associated with HCAIs (Maillard and Centeleghe 2023).

Cleaning surfaces and medical equipment, many of which are frequently touched by patients and healthcare staff, is an important step in reducing the transmission of infection (Doll et al 2018). Cleaning may be undertaken using detergents or disinfectants, and healthcare professionals need to be familiar with the difference between the two. Detergents do not kill microorganisms and should be used to remove visible contaminants before undertaking disinfection (Dancer and Kramer 2019). Disinfectants are approved chemicals used to inactivate or kill microorganisms; however, this is becoming increasingly challenging because biofilms can be resistant to some disinfectants (Maillard and Centeleghe 2023).

Healthcare staff need to receive training from their organisation in using approved chemicals to clean surfaces and medical equipment, since concentrations may vary and products may change to ensure appropriate disinfection. All patient care areas should be cleaned in accordance with local policies, with the frequency of cleaning depending on factors such as level of clinical risk, patient turnover and visible contamination (Dancer 2014).

Handling of laundry and linen

The three main categories for linen are ‘clean or unused’, ‘used’ and ‘infectious’. According to ARHAI Scotland (2020), clean linen should be covered with an impervious protective covering and stored above floor level to protect it from contamination. When transported, clean linen should be physically separated from used and infectious linen. When handling used and/or infectious linen, healthcare professionals should wear disposable gloves and a disposable apron.

Linen should be segregated correctly to ensure it goes through the appropriate laundering process. Infectious linen should be placed in a water-soluble bag before being placed in the correct fabric linen bag (ARHAI Scotland 2020). Staff need to be aware of the local policies and procedures regarding the colour coding of bags for segregation, since this may vary. However, the overall handling of linen will remain the same, along with the purpose of reducing the transmission of infection.

Waste management

A literature review by Li et al (2021) identified that around 75-80% of healthcare waste is classed as general waste and 20-25% is deemed hazardous. Hazardous waste would include items that have come into contact with blood, body fluids or reagents and cytotoxic waste. Disposal methods for hazardous waste include incineration, autoclaving, steam treatment and microwaving (Duong 2023).

It is essential that hazardous waste is disposed of correctly to minimise the risk of transmitting infection. If hazardous waste is disposed of with general waste, it could end up in landfills and pathogens and toxic substances could be released into the environment, potentially leading to infection transmission via sharps injuries, drinking water pollution or air pollution (Robat et al 2022). Conversely, if all healthcare waste is disposed of as hazardous waste, this can be expensive for healthcare organisations and have a negative effect on the environment due to the potential release of toxins (WHO 2018). Nurses need to be aware of, and follow, the relevant procedures for waste segregation and management in their local area to minimise the risk of infection transmission (WHO 2022a).

Decontamination and reprocessing of reusable patient care items and equipment

The decontamination and reprocessing of reusable patient care items and equipment involves cleaning, disinfecting and in some cases re-sterilising. The WHO (2022b) recommends using Spaulding’s risk classification system (Table 1) when considering which decontamination method to use for a medical device. This is a widely used system that divides medical devices into three categories based on the possible risk of infection to the patient from their use (Rowan et al 2023). Healthcare staff should receive education and training to ensure safe practice in the decontamination of equipment such as flexible endoscopes, which may be carried out by medical device manufacturers (Medicines and Healthcare products Regulatory Agency 2013). Staff need to be aware that single-use items are not suitable for decontamination and should dispose of them accordingly.

The environment where decontamination takes place should be clean and fit for purpose, with a one-way flow of working, access to soft water with a low salt and mineral content, and separation of dirty and clean activities (WHO 2022b). Dirty activities include preparing used devices for decontamination; clean activities involve handling medical devices that have been decontaminated and are ready for re-use. When decontaminating equipment, staff should wear appropriate PPE, for example disposable gloves, an apron, and possibly a face mask and visor when undertaking dirty activities involving the use of chemicals.