Services A to Z

This document has been prepared to provide guidance on the technical requirements for the decontamination of flexible endoscopes and the options available. The document is intended to summarise key information on best practice in a manner which is readily accessible to the user/manager.

This guidance has been prepared by utilising published guidance from expert bodies, existing best practice guidance and standards, both published and in draft form. Many of the referenced standards are harmonised standards in respect of the Medical Device Directive.

Endoscope Reprocessing: Guidance on the Requirements for Decontamination Equipment, Facilities and Management.

Caused by unconventional agents thought to be infectious proteins – known as prions. Disease in humans are:

• Sporadic – classical
• Familial – including Fatal Familial Insomnia (FFI) and Gerstmann-Straussler-Scheinker (GSS)
• Acquired – iatrogenic, variant.

There is evidence that these disorders can be transmitted in specific situations associated with medical interventions, e.g. transfusion of contaminated blood and blood products, surgery with contaminated instruments. During routine clinical care, Standard Precautions are sufficient to prevent cross-infection in healthcare settings. Transmission Based Precautions must be applied when operations or specific invasive procedures are to be undertaken on high-risk tissues or patients identified as being at risk of vCJD.

Guidance from the ACDP TSE Risk Management Subgroup (formerly TSE Working Group) is the most-up-to date guidance on this topic, provided by the Department of Health.

See also the NHSGCC CJD SOP.

This section contains completed Advice Request Forms (ARFs) that have been developed by the Decontamination Sub-Group following queries by NHSGGC staff in relation to the decontamination of specific pieces of equipment. ARFs for completion are available in the main Decontamination Section.

• Advice Request Form template
• Advice – Beatson – Ultrasound Probe
• Advice – Ortho – Plaster Room Instruments
• Advice – ITU – Flow Sensors
• Advice – Hand Baths used in Plastics
• Advice – Methameasure Tubing
• Advice – Optiflow THRIVE
• Advice – Ultrasound Probes
• Advice – Bard Breast Biopsy Guns
• Advice – Medical Devices – Neonatal Transport Incubator
• Advice – Dental – Decontamination of Powered Toothbrush
• Advice – Medical Devices Lancer Storage Cabinets
• Advice – Rezum Generator

• Titan Sanitiser Powder Wall Chart
• General Environment Titan Chlor Plus Poster
• Titan Chlor Plus Blood Spills Poster

• Cleaning up blood spills using Actichlor Plus (Actichlor)
• Cleaning up body fluids and the general environment using Actichlor Plus (Actichlor)

This section contains SOPs that have been developed by the Decontamination Sub-Group following queries by NHSGGC staff in relation to the decontamination of specific pieces of equipment.

The Decontamination Sub-Group will develop SOPs in response to queries from NHSGGC staff, as and when required.

• NHS Scotland Guidance on the decontamination of Semi-Critical (semi-invasivel and non-invasive) Ultrasound Probes: Appendix 7 Decontamination Algorithm
• SOP – Decontamination of Dental Suction Systems
• SOP – Decontamination of Dental Impression, Dental Appliances and Dental Laboratory Work
• SOP – Decontamination of Dental Water Lines and BWDS

Contact Name: Stefan Morton, LHBC, Infection Prevention and Control

Email: stefan.morton@nhs.scot

Our poster and video demonstrates the 5 moments of hand hygiene.

Infection Prevention and Control (IPC) staff collaborated to produce an informational video regarding 5 Moments of Hand Hygiene. This was developed to highlight the common failures that medical staff incur, as reported in audits of compliance. The video also highlights various anecdotal responses when challenged, given by existing medical staff members within NHSGGC. It features an introduction and closing statement by David Stewart, Lead Director for Acute Medical Services.

Staff involved in making this video were recruited from the North East IPC Team and Glasgow Royal Infirmary (GRI). Recording and post-production was carried out by GRI Medical Illustrations.

• NHSGGC 6-Step Hand Hygiene poster (technique)

• Hand Hygiene FAQs
• Infection Control Hand Hygiene Medical Staff Presentation
• The CDC Guideline for Hand Hygiene in Health-Care Settings
• The WHO Guidelines on Hand Hygiene in Health Care
• Zero Tolerance to non Hand Hygiene Compliance (PDF)

Please click on the links below to view the NHS Greater Glasgow and Clyde Hand Hygiene Videos. The videos are best viewed with sound on.

• Hand Hygiene – What’s Stopping You (video with audio)
• Hand Hygiene – What’s Stopping You (video with no audio, subtitles)

• NHSGGC Top Tips to Prevent Infection poster
• ARHAI
• Scotland’s Health on the Web

Infection Control training modules, including those offered by NES, can be accessed via learnPro.

Hand Hygiene audits should be carried out on a monthly basis within NHSGGC wards and departments. The audit tool should be utilised in conjunction with the information contained in the documents. The audit should not be carried out by the SCN as awareness of senior staff can change practice in clinical areas. 2-3 auditors should be chosen from a mixture of grades, including Bands 5 and 6 and HCSWs.

The data gathered should then be uploaded to the CAIR Dashboard.

Please note, exactly 20 observations must be recorded to complete an audit; any more or less will result in an error.

For further information regarding this process, please contact Stefan.morton@nhs.scot

• Hand Hygiene Audit Background
• Hand Hygiene Audit Collation Information
• Hand Hygiene Monitoring Tool
• Common failures in Hand Hygiene
• Hand Hygiene Toolbox Talk

Please check all existing resources before creating any new patient information. It may be that someone has already developed information on the same or a similar subject, or there may a suitable online resource.

Public Health Resource Directory – an extensive range of booklets, leaflets and posters available to order via our Public Health Resources Directory

Print On The Web – patient information developed by Medical Illustration Services (this resources can only be accessed by NHSGGC staff)

NHS Inform – Scotland’s national health information service

You should be able to evidence:

• the need for a new resource. How has that need been identified?
• engagement with patients, families and carers. How will they would find the information useful?
• funding for the resource. Do you have agreement from a service manager that a resource is required?
• clinical governance input. Have you discussed the new resource with your local group?
• collaborating with colleagues in other localities, sectors or Health Boards
  Can the resource can be used GGC-wide, regionally or nationally?

Consider your content carefully, and be clear about the information you want to convey to your target audience. Be sure to explain any instructions in detail, and include facts about risks, side effects and benefits. If you are using any third-party information, make sure you have the correct permissions for use; for example, any text or illustrations used from another source.

It is important that your content is fit for purpose. You should engage with your target audience for feedback; they will be able to tell if what you have written is helpful, clear and answers their questions. Ask your peer group to do the same.

You should review your content against the Patient Information Checklist (pdf). When you are satisfied with your content, and have final agreement from all stakeholders, please complete this form and send this to: ggc.clear.toall@nhs.scot with a copy of the information leaflet?

The NHGGGC Web Team provide the following guidance on copyright issues:

Copyright is universal policy which states that anyone who has written or created original material owns it. It cannot be reused in whole or part without written permission from the owner. Copyright applies to text (digital and hard copy), images, audio and video, even if it is in the public domain.

To publish material in part or in full that is not copyright owned by NHSGGC then you must check with the copyright owner. Be cautious when publishing conference presentations or posters and get written consent from the authors to publish such material on any websites.

To use any content taken from online resources for purposes other than non-commercial research, study and teaching, you should read the terms and conditions associated with the use of the digital resource. If there is no information available you should assume that you cannot reuse the resources. (This includes search results from a Google images search for example.)

To find out more about copyright and the training available please contact library staff via library.network@ggc.scot.nhs.uk.

It is essential that patient information produced within NHSGGC meets the quality standards outlined in the Patient Information Management Policy. All patient information will be quality assured with regards Clear to All principles prior to progressing to production.

Clear Language

If you need support or guidance on writing information for patients, please contact the Clear to All team by emailing ggc.clear.toall@nhs.scot.

Clear Design

Medical Illustration Services provide a free service for the design of all patient information. They can also advise on the most appropriate and cost-effective method of distribution.

Contact: 0141 211 8580 or email medillgri@ggc.scot.nhs.uk.

We have a legal obligation to ensure that all patients are communicated with in a way they understand and that best meets their needs, including the use of accessible formats. Consider your target audience to ensure that the needs of equality groups have been taken into consideration.

The Equality and Human Rights Team (EHRT) hold the central budget for translations and other accessible formats. To request information in an alternative format, please download and complete the form and submit for approval (ggc.clear.toall@nhs.scot).

Urgent requests, such as appointment letters, clinical instructions or health records for a patient in active care, should be emailed directly to the EHRT (nuzhat.mirza@ggc.scot.nhs.uk). This form does not need to be completed for urgent requests.

If your translation is needed within the next 4 days please send direct to nuzhat.mirza@ggc.scot.nhs.uk (you will be redirected if Nuzhat is out of the office)

We only translate information that has been produced by NHS Greater Glasgow and Clyde. If you need a translated version of a charity or Public Health Scotland publication, please indicate this on the form.

Insert Statement

A statement has been produced that should be placed in all leaflets.  It states the following in English plus the ‘top six’ community languages (currently Polish, Mandarin, Romanian, Arabic, Urdu and Farsi).
 
‘If you require this information in an accessible format, such as large print or braille, or in a community language, please use the contact details on your patient information leaflet or letter.’

Ordering as an insert

This insert should be included with appointment letters and pre-attendance information posted to the patient, and can be given to patients on attendance at clinics or on admission. It is supported by posters displayed within hospitals and GP surgeries and is also offered on Solus Screens.
 
The leaflet is available from stock in packs of 100 and can be ordered via the PECOS system or by any method used to order goods from stock (e.g. paper indent). It is available in 2 formats to suit varying distribution methods – as a single sided A5 sheet or as a one-third A4 sheet (compliments slip format) suitable for DL type envelopes.
 
Order codes are as follows:

• 97106 – Size 1/3 A4 (compliments slip format)
• 97107 – Size A5

Printing the statement within a publication

If you would like to include the statement in your document (as opposed to using an insert), you can use image 1 (portrait) or image 2 (landscape) and adjust to size.

Other formats

This statement is also available in other formats, including words and pictures, audio and British Sign Language.

Please note, interpreters should be used to communicate information which is normally given verbally to English speaking patients; translated materials are for written materials only.

You can get advice on translation and accessible formats from the NHSGGC Equalities and Human Rights Team (0141 201 4560) or email: cleartoall@ggc.scot.nhs.uk).

The NHSGGC Patient Information Policy states that patient information should be reviewed at least every three years. It is the responsibility of both the service and the document owner to ensure that information made available to patients, families and carers within any healthcare setting is accurate and current.

If your information is due for review, you should re-assess its need.

• Is there any new and more relevant information available elsewhere?
• Have you consulted your target audience about the usefulness of the resource?​

Changes should only be made to content if they:

• Reflect changes in practice or evidence
• Correct factual inaccuracies
• Improve or enhance the users understanding
• Reflect feedback from users

Remember to check that all addresses, phone numbers and external web links are correct.

When you are satisfied with your content, and have final agreement from all stakeholders, please complete this form and send this to: cleartoall@ggc.scot.nhs.uk with a copy of the existing document.

Your amendments will be quality assured in relation to Clear to All Principles before progressing to production.

Documents

Clear to All

•  Accessible Information Tips for Authors
•  Patient Information Planner Flowchart
•  Patient Planner Request Form
•  Review of Existing Information Form
• Request for translations and accessible formats form

Useful Resources

• NHSGGC Web Team – Guidance on copyright , video, images and model consent
• Best practice guidance on patient information leaflets
• Plain English Campaign
• Equalities in Health

If you need support or guidance on writing information for patients, please contact the Clear to All team at:  ggc.clear.toall@nhs.scot