Document Type:
Unique Identifier:
PROCEDURE
CORP/PROC/468
Title:
Version
Number:
Blood and Body Fluid Spillage
Status:
Ratified
Scope:
Classification:
Trust Wide
Organisational
Author/Originator and Title:
Responsibility:
Johanne Lickiss Clinical Infection Control Nurse
Control of Infection
Clinical Governance
Directorate
Replaces:
Description of amendments:
All previous Blood Spillage Policies
Throughout the Document comply with Trust format
Name of Committee/Directorate/
Working Group:
Date of Meeting:
Risk Assessment:
Not Applicable
Decontamination
Validated by:
Validation Date:
Clinical Governance Management Team Meeting
23/02/2007
Ratified by:
Ratified Date:
Date of Issue:
Clinical Effectiveness Committee
05/03/2007
05/03/2007
Review Date:
Review Dates:
2005 2006 2007 2008 2009 2010
01/09/2009
2011 2012
2013
Review dates may alter if
any significant changes are
mad
Does this document meet with the Race Relation Amendment Act (2000) Age
Discrimination Act , Disability Discrimination Act and Gender Equality
Regulations? Not Applicable
2014
PURPOSE.
The purpose of this procedure is to ensure that all staff groups follow the Blood and
Body Fluid Spillage Procedure in conjunction with the Blood and Body Fluid Spillage
Policy. (See Section 7)
SCOPE.
This procedure applies to all staff employed by Blackpool Fylde and Wyre Hospitals
NHS Trust the Trust (BFWH).
PROCEDURE
3.1 Management of Blood and Body Fluid Spillage
When dealing with Blood and Body Fluid Spillage all staff must wear personal
protective clothing (gloves and aprons) at all times.
All Personal Protective Clothing must be disposed of into Clinical Waste bags.
Further Personal Protective Equipment must be used appropriately when there is a risk
of extensive splashing of blood and body fluids e.g. body fluid repellent gowns, face
visors and footwear.
Never use mops to clear up body fluid spillages.
All body fluid spillage must be cleaned up immediately and effectively.
Hypochlorite releasing agents can be a hazard especially if used in large volumes in
confined spaces, or mixed with other chemicals or urine. A risk assessment and
Control of Substance Hazardous to Health (COSHH) assessment must be carried out
if using these chemicals.
Wear disposable gloves and aprons.
Glove choice must be Nitral or Latex gloves please refer to Guideline on Non-Sterile
Examination Glove (Corp/Guid/052). Vinyl gloves are not suitable for use when
dealing with blood and or body fluids.
Wounds and lesions on exposed skin should be covered with a waterproof dressing.
Ensure adequate ventilation is required when using Hypochlorite to clean areas.
(Ensure windows and doors are open)
By following instructions Hypochlorite solution must be prepared and used within
24 hours any remaining fluid must be discarded into the drainage system.
Spills on the body
Splashes of blood or body fluid on to the skin must be washed off immediately with
soap and water.
Please Note A warning sign must be displayed and clearly visible at all times around the
affected area.
Blackpool Fylde and Wyre Hospitals NHS Trust
Revision No: 1
I.D. No: CORP/PROC/468
Title: Blood and Body Spillage
Review Date: 01/10/2009
Do you have the up to date version? See the intranet for the latest version
Page 2 of 5
Strong Hypochlorite Solution 1% (10,000) for use when dealing with blood and other
blood stained body fluids.
-
Dissolve 4 (four) Haz-tabs in Cold Tap Water in a One Litre Dilutor
Screw the cap firmly onto the dilutor
Agitate the dilutor gently to dissolve the Haz-Tabs.
Discard any excess solution immediately after use.
Small Spills
Must be wiped up with a paper towel soaked in Hypochlorite (10,000 ppm available
chlorine)
Wash area with general-purpose detergent and warm water.
Gloves, aprons and paper towels must be disposed in Clinical Waste.
Wash hands as per Hand Hygiene Policy.
Large Spills
Cover the spill with disposable paper towels.
Pour Hypochlorite (10,000 ppm available chlorine) over the towels.
Leave for 2 minutes.
Remove towels and discard into yellow waste bag.
Wash area with general-purpose detergent and warm water.
Gloves, aprons and paper towels must be disposed of in Clinical Waste.
Wash hands as per Hand Hygiene Policy.
Extensive Large Spills
It may be impractical to treat large spills of blood or body fluid with Hypochlorite. In
this instance the spill must be soaked up with disposable paper towels and discarded
into Clinical Waste bags.
The area must then be cleaned with Hypochlorite 10,000ppm followed by generalpurpose detergent and warm water.
Gloves and Aprons must be disposed into Clinical Waste.
Wash hands as per Hand Hygiene Policy.
Please Note: Do not use Hypochlorite on large spillages of Urine
ATTACHMENTS.
Appendix 1 References
ELECTRONIC AND MANUAL RECORDING OF INFORMATION.
Held By: Clinical Governance
Held in format: Electronic and/or hard copy
Database for Policies, Procedures, Protocols and Guidelines
Archive/Policy Co-ordinators office
Blackpool Fylde and Wyre Hospitals NHS Trust
Revision No: 1
I.D. No: CORP/PROC/468
Title: Blood and Body Spillage
Review Date: 01/10/2009
Do you have the up to date version? See the intranet for the latest version
Page 3 of 5
LOCATIONS THIS DOCUMENT ISSUED TO.
Copy No
1
Date Issued
05/03/2007
05/03/2007
OTHER RELEVANT /ASSOCIATED DOCUMENTS.
Procedure No.
Title
Corp/Pol/ 149
Management of the Control of Substance Hazardous to Health
(COSHH) Regulations
Carrying out a Risk Assessment and developing a Risk Register
Corp/Proc/ 006
Corp/Proc/ 421
Location
Intranet
Wards and Departments
Corp/Pol/ 056
Implementation of the Personal Protective Equipment (PPE)
Regulations 1992
Hand Hygiene Policy
Corp/Proc/ 418
Hand Hygiene Procedure
Corp/Pol/186
Blood and Body Fluid Spillage Policy
AUTHOR/DIRECTORATE MANAGER APPROVAL.
Issued By
Mrs J Lickiss
Job Title
Clinical Nurse Specialist Job Title
In
Signature
Date
M Aubrey
Head
of
Governance
Signature
January 2007
Blackpool Fylde and Wyre Hospitals NHS Trust
Revision No: 1
Checked By
Date
March 2007
I.D. No: CORP/PROC/468
Title: Blood and Body Spillage
Review Date: 01/10/2009
Do you have the up to date version? See the intranet for the latest version
Page 4 of 5
Clinical
Appendix 1 References:
Good Practice Guidelines for Renal Dialysis/transplantation Units Prevention and control of
Blood-Borne Virus infection Public Health Laboratory Service on behalf of Department of Health.
2002. Page 33 8.25 8.26
Wilson J (2006) 3rd Edition. Infection Control in Clinical Practice. Bailliere Tindall Elsevier.
Royal College of Nursing (2005) Good practice in Infection Prevention and Control. Cavendish
Square. London.
Blackpool Fylde and Wyre Hospitals NHS Trust
Revision No: 1
I.D. No: CORP/PROC/468
Title: Blood and Body Spillage
Review Date: 01/10/2009
Do you have the up to date version? See the intranet for the latest version
Page 5 of 5
