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Worcestershire Key Documents
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Infection Prevention Key Documents

Please note that the clinical key documents are not designed to be printed, but to be viewed on-line.  This is to ensure that the correct and most up to date version is being used.  If, in exceptional circumstances, you need to print a copy, please note that the information will only be valid for 24 hours and should be read in conjunction with the Key Document Supporting Information and/or Key Document intranet page, which will provide additional information including approval and review dates

Using the Key Document page

Adult Antimicrobial Guide

Aseptic technique policy

Review date - 19th December 2020 

This is the most current document and should be used until a revised version is in place

Worcestershire Acute Hospitals NHS Trust Urinary Catheter Insertion, Care, Management and Removal Policy

Appendix 1 – Trial Without Catheter

Appendix 2 – Autonomic Dysreflexia

Appendix 3 – Procedure Requirements

Appendix 4 – Male Catheterisation

Appendix 5 – Female Catheterisation

Appendix 6- Suprapubic Catheter Change

Appendix 7- Intermittent Self-Catheterisation (Male)

Appendix 8 - Intermittent Self-Catheterisation (Female)

Appendix 9 – Obtaining a Catheter specimen of Urine

Appendix 10 – Using a Catheter Maintenance Solution

Appendix 11 – Emptying a Catheter Drainage Bag

Appendix 12 – Changing a Catheter Drainage Bag

Appendix 13- Removal of an Indwelling Catheter

Appendix 14 – Urinary Catheter High Impact Intervention

Appendix 15 – Urinary Catheter Assessment and Monitoring Form

Appendix 17 – Catheter Discharge Checklist

Review Date – 29th January 2021

This is the most current document and should be used until a revised version is in place

Central venous access devices (CVAD) guideline for insertion and management

Review date - 7th September 2019 

This is the most current document and should be used until a revised version is in place

Cleaning policy

Review date - 18th December 2019   

This is the most current document and should be used until a revised version is in place

Cleaning, decontamination and validation of flexible endoscopes

Review date - 13th October 2019 

This is the most current document and should be used until a revised version is in place

Protocol for the management of clostridium difficile and prevention and spread

Review date- 24th July 2020

This is the most current document and should be used until a revised version is in place

Creutzfeldt-jakob disease (CJD) and variant CJD (vCJD) - minimising the risk of transmission

Review date - 30th October 2019 

This is the most current document and should be used until a revised version is in place

Decontamination policy

Review date - 7th September 2019 

This is the most current document and should be used until a revised version is in place

Decontamination Protocol

Review date - 30th October 2019

This is the most current document and should be used until a revised version is in place

Decontamination of endoscopes

Review date - 30th October 2019

This is the most current document and should be used until a revised version is in place

Policy for the management of carbapenamase producing Enterobacteriaceae

Review date - 17th July 2020

This is the most current document and should be used until a revised version is in place

Food and Fluid hygiene policy

Review date - 31st May 2020

This is the most current document and should be used until a revised version is in place

Standard Infection Control Precautions – NHSI National Policy on Hand Hygiene and PPE Policy

Review date – 29/04/2022

This is the most current document and should be used until a revised version is in place

Quick Guide for the Management of Viral Haemorrhagic Fevers (VHFs)

Appendix 1 - Viral Haemorrhagic Fevers and Risk Assessment 

Appendix 2 - Registered Medical Practitioner Notification Form

Review date - 16th December 2022

This is the most current document and should be used until a revised version is in place

Guideline for post exposure prophylaxis for HIV following sexual exposure

Review date - 16th December 2022

This is the most current document and should be used until a revised version is in place

Infection control policy

Review date - 30th october 2019

This is the most current document and should be used until a revised version is in place

Infection prevention and control protocol for seasonal influenza

Review date - 3rd October 2019  

This is the most current document and should be used until a revised version is in place

Notifying Suspected Infectious Diseases and Causative Organism

Appendix One - Registered Medical Practitioner Notification Form

Appendix Two - PHE Notifiable Diseases Poster 

Appendix Three - Additional Microbiology Laboratory Notifiable Organisms 

Appendix Four - Notification Aide Memoire 

Review date - 16th December 2022

This is the most current document and should be used until a revised version is in place

Innoculation incident protocol

Review date - 19th December 2020

This is the most current document and should be used until a revised version is in place

Isolation and Bed Management policy

Appendix 1 - Patient with unexplained Diarrhoea/Vomiting: 4 hours to isolation algorithm 

Appendix 2 - Aide Memoire General Principles of Isolation 

Appendix 3 - Rapid Risk Assessment for Patients with Diarrhoea and Vomiting 

Appendix 4 - A-Z of Infectious Diseases 

Appendix 5 - Process for locating a Bed for patients with infections 

Appendix 6 - Monitoring of isolation rooms at WRH

Appendix 7 - NHS England Respiratory Protection Poster 

Appendix 8 - Risk Assessment Tool for Patients being discharged from a ward affected by Gastroenteritis 

Appendix 9 - Care Home Discharge Information Letter 

Review date - 16th December 2022

This is the most current document and should be used until a revised version is in place

Infection due to parasites

Review date - 19th December 2020

This is the most current document and should be used until a revised version is in place

Insertion and management of peripheral vascular devices

Review date - 30th October 2019

This is the most current document and should be used until a revised version is in place

Prevention of Inoculation Incidents Policy

Review date – 19th December 2020

This is the most current document and should be used until a revised version is in place

Management of linen and laundry services

Review date - 30th October 2019

This is the most current document and should be used until a revised version is in place

Management of Meticillin Resistant Staphyloccocus aureus (MRSA)

Review date - 13th October 2019 

This is the most current document and should be used until a revised version is in place

Admission screening MRSA including elective, non elective, orthopaedic and vascular surgery

Review date - 18th August 2019 

This is the most current document and should be used until a revised version is in place

Hospital staff for the contol of Meningococcal Meningitis/Septicaemia and other forms

Review date - 30th October 2019

This is the most current document and should be used until a revised version is in place

Policy for Outbreak Reporting and Control, Including Major Outbreaks

Appendix 1 - Meetings of the OCT 

Appendix 2- Aide Memoire of Matters to be discussed 

Appendix 3 -Terms of reference for the OCT 

Appendix 4 - Responsibilities and tasks of the OCT members 

Appendix 5 - Rapid diarrhoea and vomiting risk assessment 

Appendix 6 - Alexandra Hospital fast response team protocol 

Appendix 7 - Flowchart of the contact in the event of a major outbreak

Review date- 16th December 2022

This is the most current document and should be used until a revised version is in place

Pest control policy

Review date - 13th October 2019 

This is the most current document and should be used until a revised version is in place

Preventing, identifying and managing wound infection

Review date - 1st December 2018 

This is the most current document and should be used until a revised version is in place

Protocol for the performance of Venepuncture

Review date - 30th October 2019 

This is the most current document and should be used until a revised version is in place

Protocol for the management of extended spectrum beta-lactamase (ESBL) producing organisms, and also vancomycin (glycopeptide) resistant enterococci (VRE) protocol for their management and prevention of spread

Review date - 19th December 2020

This is the most current document and should be used until a revised version is in place

Severe acute respiratory syndrome (SARS) avian influenza and other severe viral respiratory infections

Review date - 1st December 2018 

This is the most current document and should be used until a revised version is in place

Tuberculosis (TB) in Hospital: Infection Prevention Policy

Appendix A - Countries with a high incidence of MDR-TB

Appendix B - Draft letter to Patient (for non-immunocompromised patient contacts) 

Appendix C- Draft letter to GPs (for non-immunocompromised patient contacts) 

Appendix D- Immunocompromised patients as defined by 'immunisation against infectious disease)

Appendix E - TB Quick Action Guide 

Appendix F - FFP3 Mask Fitting 

Review date - 16th December 2022

This is the most current document and should be used until a revised version is in place

Contact Information

HEATHER GENTRY                                                                                             

Lead Infection Prevention and Control Nurse                                                          

Email: heather.gentry@nhs.net                                                                             

Phone: 01527 512185, Internal Extension 43869

IAIN JOHNSTON                                                                                                  

Senior Infection Prevention and Control Nurse                                                         

Email: iainjohnston@nhs.net                                                                          

Phone: 01905 733092, Internal Extension: 38765

Page last updated: 04 March 2020