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CARBAPENEMASE-PRODUCING ENTEROBACTERIACEAE (CPE) POLICY Version 1.0 Name of responsible (ratifying) committee Infection Prevention Management Committee Date ratified 27 April 2016 Document Manager (job title) Director of Infection & Patient Safety, Infection Control Doctor Date issued 12 July 2016 Review date 11 July 2018 Electronic location Infection Prevention and Control Policies Related Procedural Documents Trust Policies: Hand Hygiene policy Isolation Policy Standard Precautions policy Decontamination policy Key Words (to aid with searching) CPE, Carbapenemase-producing Enterobacteriaceae Version Tracking Version Date Ratified 1.0 27.04.2016 Brief Summary of Changes Author New document Microbiology Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 1 of 25 CONTENTS QUICK REFERENCE GUIDE ................................................................................................ 3 1. INTRODUCTION ............................................................................................................... 5 2. PURPOSE ...................................................................................................................... 5 3. SCOPE ........................................................................................................................... 5 4. DEFINITIONS ................................................................................................................. 5 5. DUTIES AND RESPONSIBILITIES ................................................................................. 6 6. PROCESS ...................................................................................................................... 7 7. TRAINING REQUIREMENTS ....................................................................................... 11 8. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................. 11 9. EQUALITY IMPACT STATEMENT................................................................................ 12 10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................... 13 APPENDIX A ....................................................................................................................... 14 APPENDIX B ....................................................................................................................... 16 APPENDIX C ....................................................................................................................... 18 APPENDIX D ....................................................................................................................... 20 APPENDIX F ....................................................................................................................... 21 APPENDIX G ....................................................................................................................... 23 Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 2 of 25 QUICK REFERENCE GUIDE This policy must be followed in full when developing or reviewing and amending Trust procedural documents. For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. 1. Please risk-assess every patient on admission, re-admission and transfer to PHT for Carbapenemase-producing Enterobacteriaceae status (CPE). 2. A suspected case of CPE colonisation or infection is: (i) Any patient transferred directly from a healthcare facility abroad, and/or; (ii) Any patient who has been an inpatient in a hospital abroad within the last 12 months, and/or; (iii) Any patient who has been an inpatient in a UK hospital (except Portsmouth Hospitals NHS Trust) within the last 12 months, and/or; (iv) Any patient previously colonised or infected with CPE, and/or; (v) Any close contact of a person who currently is or previously has been colonised or infected with a CPE, and/or; (vi) Any close contact of a person who currently is or previously has been colonised or infected with a CPE, and/or; (vii) Renal Haemodialysis patients: Any patient who has undergone dialysis abroad or at another UK hospital should be routinely screened on their return. They must have 3 screens taken on consecutive dialysis sessions. 3. In a patient with suspected CPE colonisation or infection, please take the following actions: (i) Immediate isolation in a side-room with en-suite facilities. Strict standard precautions to prevent possible spread (see 6.2). Please contact the infection prevention and control team if insufficient side-rooms are available. (ii) Take rectal swabs for CPE screening on three consecutive days (day 0, day 1, day 2; see 5.3), except in Paediatric and Haematology-Oncology patients. In Paediatric and Haematology-Oncology patients, please obtain three stool samples for CPE screening. Patients from high prevalence countries/regions (see appendix D), please also send CPE screening swabs from wounds and device-related sites (see 5.3.1). (iii) Notify the Infection Prevention team promptly. (iv) Explain your assessment to the patient and provide a patient information leaflet (appendix A). (v) Inform other members of the team caring for the patient. (vi) Assess the need for appropriate antibiotic treatment if an infection is suspected (discuss with a medical microbiologist). (vii) Document the infection status (whether suspected or confirmed CPE) clearly in the patient’s records and communicate clearly to the receiving healthcare provider if the patient is transferred. 4. Any patient previously colonised or infected with CPE: (i) Patient must remain isolated throughout hospital stay, irrespective of current screening results. (ii) Manage as for confirmed case of CPE (see appendix G). Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 3 of 25 Flowchart for the detection, management and control of Carbapenemaseproducing Enterobacteriaceae Risk-assess every patient on; admission, re-admission and transfer to PHT for Carbapenemase-Producing Enterobacteriaceae status (CPE). Suspected case of CPE colonisation or infection 1. Any patient transferred directly from a healthcare facility abroad 2. Any patient who has been an inpatient in a hospital abroad within the last 12 months (this includes emergency and elective admissions) 3. Any patient who has been an inpatient in a UK hospital (other than PHT) within the last 12 months) 4. Any patient previously colonised or infected with CPE or close contact 5. Renal haemodialysis patients: Any patient who has undergone dialysis abroad or at another UK hospital (both elective ‘holiday dialysis’ and emergency dialysis) Actions if a suspected case of CPE colonisation or infection (See Appendix F) 1. Immediate isolation in a side-room with en-suite facilities 2. Strict standard precautions (see 6.2). Use a long-sleeved gown for care activities where an apron does not fully protect the uniform 3. Take rectal swabs for CPE screening on three consecutive days (i.e.day 0, day 1 and day 2; see 5.3), except in Paediatric and Haematology-oncology patients. In paediatric and haematology-oncology patients, please obtain three stool samples for CPE screening 4. Patients from high prevalence countries/ regions (see appendix D) 5. please also send CPE screening swabs from wounds and device-related sites 4. Notify the Infection Prevention team 5. Provide the patient with an information leaflet (appendix A) 6. Inform other members of the team looking after the patient 7. Discuss appropriate antibiotic treatment with a microbiologist 8. Document the infection status in the patient’s records and communicate results when patient is transferred or discharged 9. Extra care taken to clean the environment after the patient had an investigation and before another patient is seen 10. Contact Infection Prevention and microbiology if surgical intervention is required No risk factor for CPE Normal admission process, including MRSA screening Positive Result Initial screening samples negative Patient to remain isolated until three sets of screening sample are negative (taken on day 0, day 1, day 2). All three sets of screening swabs negative and NOT previously ‘known’ CPE positive Can be removed from isolation, following risk assessment by Infection Prevention Positive Result Laboratory-confirmed CPE (See Appendix G) Patient to remain isolated throughout hospital stay. Previously ‘known’ CPE positive, irrespective of screening results Patient must remain isolated throughout hospital stay, irrespective of current screening results Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 4 of 25 1. INTRODUCTION Enterobacteriaceae, such as E.coli, Klebsiella spp. and Enterobacter spp., are bacteria that usually live harmlessly in the human gastrointestinal tract. However, these organisms can also cause urinary tract, intra-abdominal and bloodstream infections (bacteraemias). Occasionally they cause hospital-acquired pneumonias, line infections or other types of infections. Some strains of Enterobacteriaceae produce carbapenemases, which are enzymes that break down carbapenem antibiotics (meropenem, ertapenem, imipenem, doripenem). Such carbapenemproducing bacteria are often also resistant to most other antibiotics and hence infections are extremely difficult to treat and cause high mortality. The emergence of Carbapenemproducing Enterobacteriaceae (CPE) is a major public health concern and it is essential that person-to-person spread in the healthcare setting is prevented or minimised. Whilst multi-drug resistant and Carbapenem-producing Enterobacteriaceae have become endemic in several countries (see appendix D), increasing numbers of these strains have also been reported in the UK. 2. PURPOSE This policy defines the actions taken by Portsmouth Hospitals NHS Trust to reduce the risk of transmission and hence limit the risk of colonisation or infection with Carbapenemproducing Enterobacteriaceae. It recommends a risk assessment at every patient admission, readmission or transfer. It describes the actions that need to be taken if a suspected case of Carbapenemasepoducing Enterobacteriaceae (CPE) is identified, as well as providing advice on screening and isolation of patients with either suspected or confirmed Carbapenemase-producing Enterobacteriaceae (CPE). This policy should be read in conjunction with: Standard Precautions policy Hand Hygiene policy Isolation policy 3. SCOPE This policy should be followed by all Portsmouth Hospitals NHS Trust staff, including agency, bank and locum staff. It should be applied to all patients admitted to the Trust, including children as well as patients dialysed in the renal dialysis unit. 4. DEFINITIONS Carbapenemases: Some bacteria produce Carbapenemase enzymes (such as KPC, OXA48, NDM and VIM), which cause destruction of the carbapenem antibiotics. This results in resistance to the carbapenem antibiotics (meropenem, ertapenem, doripenem, imipenem) as well as many other broad-spectrum antibiotics. Carrier: A person who is colonised with Carbapenemase-producing Enterobacteriaceae (CPE). These organisms can live harmlessly in the human gastrointestinal tract, without clinical manifestations of infection. A carrier can transmit the organism to another person or may subsequently develop an infection. Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 5 of 25 Close contact: A person living in the same house, sharing the same sleeping space (room or hospital bay), or a sexual partner. Colonisation: The presence of Carbapenemase-producing Enterobacteriaceae (CPE) living harmlessly on the skin or within the human gastrointestinal tract and causing no signs or symptoms of infection. A carrier is colonised with Carbapenemase-producing Enterobacteriaceae (CPE). CPE: Carbapenemase-producing Enterobacteriaceae (CPE) is the name given to the strains Enterobacteriaceae which produce a Carbapenemase enzyme. Enterobacteriaceae: This is a large family of bacteria (including; Escherichia coli, Klebsiella spp. and Enterobacter spp.) that usually live harmlessly in the human gastrointestinal tract. However, these organisms can cause opportunistic urinary tract infections, intra-abdominal infections, bloodstream infections (bacteraemias) and hospital-acquired pneumonias. Infection: Carbapenemase-producing Enterobacteriaceae (CPE) can cause serious infections, including urinary tract infections, intra-abdominal infections, blood stream infections (bacteraemias) and hospital-acquired pneumonias. Patients with infections caused by Carbapenemase-producing Enterobacteriaceae (CPE) require treatment. These infections are very challenging to treat and should be discussed with a medical microbiologist. Modes of transmission: Carbapenemase-producing Enterobacteriaceae (CPE) is spread person to person by faecal contamination of the hands or transfer from an environmental source or contaminated equipment. Rectal swab: A rectal swab is a specimen taken by gently inserting a swab inside the rectum 3-4cms (1 – 1.5 inch) beyond the anal sphincter, rotating gently and removing. Normal saline can be used to moisten the swab prior to insertion. After a rectal swab is taken, it should have visible faecal material on it. The swab should be sent to the microbiology laboratory in the swab transport tube with a request for “CPE screening”. 5. DUTIES AND RESPONSIBILITIES Infection Prevention Team: Give specialist advice with regards to the isolation, screening and contact tracing of patients with suspected or confirmed infection or colonisation with Carbapenemaseproducing Enterobacteriaceae (CPE) As part of the outbreak control team, advise on the screening and isolation in the event of an outbreak, suspected outbreak or cluster of Carbapenemase-producing Enterobacteriaceae (CPE) Review and update the Carbapenemase-producing Enterobacteriaceae policy Develop a Carbapenemase-producing Enterobacteriaceae Management Plan with the input from the microbiology team Include Carbapenemase-producing Enterobacteriaceae in all induction and update training for clinical staff. Provide training to medical and nursing staff, enabling them to recognize patients who meet the criteria for a recent laboratory confirmed case or suspected case of Carbapenemase-producing Enterobacteriaceae (CPE) Conduct regular audits and provide feedback with regards to the adherence to this policy Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 6 of 25 Microbiologists: Review laboratory policies and SOPs on screening and detection of Carbapenemase-producing Enterobacteriaceae (CPE) Together with the Infection Prevention team, develop a Carbapenemase-producing Enterobacteriaceae Management Plan Alert Infection Prevention Team and clinical teams of patients with presumptive or confirmed Carbapenemase-producing Enterobacteriaceae isolated from clinical samples or screens Advise on the antimicrobial management of patients infected or colonised with Carbapenemase-producing Enterobacteriaceae Patient Flow / Duty Hospital Managers: Prioritise placement of patients with suspected or confirmed Carbapenemaseproducing Enterobacteriaceae (CPE) into appropriate isolation rooms Ensure an electronic system is in place for flagging the patient’s Carbapenemaseproducing Enterobacteriaceae status Matrons / Ward Managers: Ensure effective communication of patients risk and carriage status Medical Staff: Include a risk assessment for Carbapenemase-producing Enterobacteriaceae (CPE) in every admission and transfer documentation Follow advice of the Infection Prevention Team and microbiologists relating to patients infected or colonised with Carbapenemase-producing Enterobacteriaceae (CPE) Ensure compliance with Infection Prevention and antimicrobial prescribing policies with emphasis on limiting use of carbapenem antibiotics Ensure prudent antimicrobial prescribing and stringent use/removal of indwelling devices All Healthcare Staff: Must be familiar with and adhere to the relevant infection prevention policies to reduce the risk transmission of Carbapenemase-producing Enterobacteriaceae (CPE) 6. PROCESS 6.1 Risk assessment and screening for Carbapenemase-producing Enterobacteriaceae (CPE) Every patient admitted, readmitted or transferred from another healthcare facility requires a risk assessment during the admission procedure. Early identification and screening of patients at risk of CPE is essential. It is the responsibility of the admitting clinician and nursing staff to assess every patient with regards to the risk of colonisation or infection with CPE. A suspected case of Carbapenemase-producing Enterobacteriaceae (CPE) is: (i) Any patient transferred directly from a healthcare facility abroad, and/or; (ii) Any patient who has been an inpatient in a hospital abroad within the last 12 months (this includes emergency and elective admissions), and/or; Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 7 of 25 (iii) Any patient who has been an inpatient in a UK hospital (other than Portsmouth Hospitals NHS Trust) (see appendix D), and/or; (iv) Any patient previously colonised or infected with Carbapenemase-producing Enterobacteriaceae (CPE), and/or; (v) Any close contact of a person who currently is or previously has been colonised or infected with Carbapenemase-producing Enterobacteriaceae (CPE). A close contact is a person living in the same house, sharing the same sleeping space or a sexual partner of a person with Carbapenemase-producing Enterobacteriaceae (CPE), and/or; CONTINUE FROM HERE!!! (vi) Renal Haemodialysis patients: Any patient who has undergone dialysis abroad (both elective ‘holiday dialysis’ and emergency dialysis) or at another UK hospital should be routinely screened on their return. They must have 3 screens taken on consecutive dialysis sessions. If the patient is a recent laboratory confirmed case of Carbapenemase-producing Enterobacteriaceae infection or colonisation during this admission or confirmed from a transferring hospital within the UK, then isolate the patient immediately and treat as a confirmed case (please see 5.4 and appendix G). If a patient is identified as a suspected case of Carbapenemase-producing Enterobacteriaceae (CPE), the following actions need to be taken (see appendix F); (vii) Immediate isolation in a side-room with en-suite facilities; strict standard precautions to prevent possible spread (see 5.2); (viii) Take screening swabs for Carbapenemase-producing Enterobacteriaceae (CPE) (see 5.3); (ix) Please notify the Infection Prevention team promptly; (x) Provide information and explain your assessment of possible colonisation / infection with Carbapenemase-producing Enterobacteriaceae (CPE) to the patient. Give the patient a patient information leaflet (appendix A). Please advise the patient to practice good hand hygiene; (xi) Inform other members of the team caring for the patient; (xii) Assess the need for appropriate antibiotic treatment if an infection is suspected (discuss with a medical microbiologist); (xiii) Document the infection status (whether suspected or confirmed CPE) clearly in the patient’s records. Ensure that the diagnosis is clearly communicated if the patient is transferred to another healthcare provider; (xiv) Investigations should be performed as clinically required with extra care taken to cleaning the environment after the patient has left and before another patient is seen – please discuss with the infection prevention team; (xv) Please contact Infection prevention and microbiology if surgical intervention is required. 6.2 Early isolation of suspected or laboratory-confirmed cases of Carbapenemase-producing Enterobacteriaceae (CPE) 6.2.1 Isolation: Immediately place the patient into a single room with en suite facilities. All suspected patients should be isolated until three sets of screening samples taken on consecutive days (i.e. day 0, day 1 and day 2) are negative. 6.2.2 Strict standard precautions: Apply strict standard precautions, including good hand hygiene and appropriate use of personal protective equipment (PPE). Staff must wear gloves and a single use disposable apron for all contact with the patient and his/her environment. Use a long-sleeved disposable gown for care activities where an apron does not fully protect the uniform e.g. when assisting movement for a dependent patient. A mask is not required. Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 8 of 25 6.2.3 Hand hygiene: Staff must strictly adhere to the Hand hygiene policy. In addition, please ensure that the patient as well as any visitors observes good hand hygiene. 6.2.4 Non-essential staff: Non-essential staff (e.g. Medical students) should be excluded from contact with a patient confirmed or suspected of having Carbapenemase-producing Enterobacteriaceae (CPE). 6.2.5 Equipment: Single use / single patient use equipment is preferable. Equipment should be designated for the sole use of the patient in isolation. This includes a blood pressure monitor, tympanic thermometer, dressing trolley and commode. Once patient is discharged the Infection Prevention team should be informed so that the room and all equipment can be safely and adequately decontaminated. 6.2.6 Medical devices and equipment: Scrupulous infection control practices are extremely important when caring for devices (including peripheral and central lines, urinary catheters) or equipment (such as ventilators, renal dialysis or enteral feeding equipment, colostomy or ileostomy or any re-usable diagnostic equipment). 6.2.7 Duration of isolation: A patient with suspected Carbapenemase-producing Enterobacteriaceae (CPE) must remain isolated until all three sets of screening samples are negative and the Infection Prevention team has made an assessment whether there are any other reasons for the patient to remain isolated. A patient with laboratory-confirmed CPE must remain isolated throughout his or her hospital stay. A patient with previously laboratory-confirmed CPE at another hospital or during a previous hospital admission must remain isolated throughout his or her hospital stay, irrespective of the current screening results. Renal dialysis patients, who are either previously or newly diagnosed with laboratoryconfirmed Carbapenemase-producing Enterobacteriaceae (CPE), should remain isolated whilst receiving dialysis at the dialysis unit. 6.2.8 Diagnostic tests and procedures should be planned for the end of the day’s list, if the patient has confirmed Carbapenemase-producing Enterobacteriaceae (CPE). The procedure room and equipment must be appropriately decontaminated after use. 6.2.9 Terminal cleaning and hydrogen peroxide decontamination: Once patient is discharged, the Infection Prevention team should be informed and the room must have terminal cleaning, followed by hydrogen peroxide decontamination. 6.3 Screening of suspected cases and contacts of carbapenemase-producing Enterobacteriaceae (CPE) 6.3.1 If a patient meets the criteria for a suspected case of Carbapenemase-producing Enterobacteriaceae (CPE) infection or colonisation, the following samples should be taken: i) After providing appropriate information to the patient and obtaining verbal consent, please take a rectal swab, except in paediatric and haematology-oncology patients. The rectal swab must have faecal material on it (see ‘definitions’) and be stated on the form clearly as ‘Carbapenemase-producing Enterobacteriaceae (CPE) screening’. A rectal swab is the most important screening sample. Alternatively, a stool sample can be sent, provided it can be obtained within 24 hours. In paediatric and haematology-oncology patients, please obtain three stool samples for CPE screening; AND Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 9 of 25 If patient is known to have been hospitalised in the last 12 months in a country with reported high prevalence (or area known to have a Carbapenemase-producing Enterobacteriaceae problem, see appendix D) include samples from any wounds and device-related sites as follows: ii) Wound swab – any surgical wounds, leg ulcers and breaks in skin or other lesions. Please label these specimens on the form clearly as ‘Carbapenemase –producing Enterobacteriaceae (CPE) screening’. AND iii) Swabs from manipulated sites (device-related sites) – lines, cannula, tracheostomy, percutaneous endoscopic gastrostomy (PEG) and drain sites. Please label these specimens on the form clearly as ‘Carbapenemase –producing Enterobacteriaceae (CPE) screening’. Timing of screening samples Three sets of screening samples must be taken on consecutive days i.e. day 0, day 1 and day 2. 6.3.2 Screening of laboratory-confirmed cases of carbapenemase-producing Enterobacteriaceae (CPE) Patients with laboratory-confirmed infection or colonisation with Carbapenemase-producing Enterobacteriaceae should be screened on readmission (see 5.3.1). 6.3.3 Screening of contacts Provide a carbapenemase-producing Enterobacteriaceae (CPE) contact leaflet (appendix C) and undertake screening for contacts of a positive case as directed by the Infection Prevention team. The recommendations are to screen weekly for a period of four weeks after the last case of carbapenemase-producing Enterobacteriaceae was detected. This is generally required if a patient colonised or infected with carbapenemase-producing Enterobacteriaceae was in an open ward or bay before the diagnosis was made. 6.3.4 Screening in the event of an outbreak, suspected outbreak or cluster of Carbapenemase-producing Enterobacteriaceae (CPE) As directed by the Incident/Outbreak Control Team and Infection Prevention team. 6.4 Management of a confirmed case of Carbapenemase-producing Enterobacteriaceae i) ii) iii) iv) Immediate isolation in a side-room with en-suite facilities, if the patient is not already isolated. The patient must remain isolated throughout their hospital stay or whilst receiving dialysis at the renal dialysis unit. Strict standard precautions to prevent possible spread (see 6.2). Use a long-sleeved disposable gown for care activities where an apron does not fully protect the uniform; Inform the patient of the infection or carrier status with Carbapenemase-producing Enterobacteriaceae (CPE). Give the patient a patient information leaflet (appendix B). Please remind the patient that it is important to practice good hand hygiene; Inform all other members of the team caring for the patient, including physiotherapists if applicable; Discuss the need for antibiotic treatment, including surgical prophylaxis with a Medical Microbiologist. Review the clinical management and ensure strict infection control practices when caring for medical devices; Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 10 of 25 v) Document the confirmed Carbapenemase-producing Enterobacteriaceae (CPE) status clearly in the patient’s records. Flag the patient notes with the result as well as the electronic system; vi) Instigate the Carbapenemase-producing Enterobacteriaceae Management Plan; vii) Consider arranging an incident control team; viii) Screen any contacts as directed by the infection control team (see 6.3.3); ix) Ensure that the patient’s Carbapenemase-producing Enterobacteriaceae (CPE) status is clearly communicated to the receiving hospital and ambulance team if the patient is transferred. Also notify the GP and other community care providers when the patient is transferred or discharged; x) Investigations should be performed as clinically required with extra care taken to cleaning the environment as well as decontaminating the equipment after the patient has left and before another patient is seen; xi) Please contact Infection prevention and microbiology if a surgical intervention is required. 6.5 Environmental Cleaning Once the patient is discharged or transferred, the Infection Prevention team should be informed so that the room and all equipment can be safely and adequately decontaminated. A high standard of cleaning is necessary and should be audited. Terminal cleaning following transfer or discharge of the patient includes scrupulous cleaning and disinfection of all surfaces. The cleaning and disinfection of mattresses is especially important. Dynamic mattresses require disassembly, cleaning and disinfection. Terminal cleaning must be followed by hydrogen peroxide decontamination. 7. TRAINING REQUIREMENTS Specific training with regards to the carbapenemase-producing Enterobacteriaceae policy will be provided by the Infection Prevention team during Trust induction, mandatory training sessions as well as via Infection Prevention Link Practitioners Clinical and non-clinical staff will receive practical hand hygiene training on induction and every 2 years thereafter (Infection Prevention Team) Clinical and non-clinical staff will receive face-to0face induction training on aspects of infection prevention, MSSA/MRSA, Clostridium difficile and Carbapenemaseproducing Enterobacteriaceae (Infection Prevention Team) Update training to be delivered as part of Patient Safety & Quality Days, departmental and drop in days, Link Advisor days and Senior Doctors Training (Infection Prevention Team) 8. REFERENCES AND ASSOCIATED DOCUMENTATION Centres for Disease Control (2009) Guidance for Control of Infections with CarbapenemResistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities, 2009 Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm Accessed 23.9.2015. European Centre for Disease Prevention and Control (2011) Risk assessment on the spread of Carbapenemase-producing Enterobacteriaceae (CPE), ECDC, available at: http://ecdc.europa.eu/en/publications/Pages/Publications.aspx Accessed 23.9.2015. Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection and the Health Protection Agency. Advice on Carbapenemase Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 11 of 25 Producers: Recognition, infection control and treatment. London: Health Protection Agency; 2011, available at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1294740725984 Loveday, H. Wilson, J. Pratt, R. et al (2014). EPIC 3 National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. S1 – S70. Public Health England. (2013). Acute trust toolkit for the early detection, management and control of Carbapenemase-producing Enterobacteriaceae. PHE, London. Public Health England. (2014). Patient Safety Alert ‘Addressing rising trends and outbreaks in Carbapenemase-producing Enterobacteriaceae’. NHS/PSA/Re/2014/004. Public Health England (2014) Letter, Re: Addressing the infection risk from Carbapenemaseproducing Enterobacteriaceace and other Carbapenem-resistant organisms, PHE Gateway number: 2013 – 499. UK Five Year Antimicrobial Resistance Strategy 2013 to 2018 (2013) published at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130 902_ UK_5_year_AMR_strategy.pdf 9. EQUALITY IMPACT STATEMENT Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been assessed accordingly. Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust: Respect and dignity Quality of care Working together Efficiency This policy should be read and implemented with the Trust Values in mind at all times. Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 12 of 25 10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS Minimum requirement to be monitored Lead Tool Frequency of Report of Compliance Reporting arrangements Lead(s) for acting on Recommendations Surveillance of cases of CPE infection or colonisation Infection prevention and control team Apex, VitalPAC Quartery report to Infection prevention management committee Policy audit report to: Infection Prevention Management Committee Infection prevention and control team Review of new acquisitions of CPE infection or colonisation Infection prevention and control team Apex, VitalPAC Quartery report to Infection prevention management committee Policy audit report to: Infection Prevention Management Committee Infection prevention and control team This document will be monitored to ensure it is effective and to assurance compliance. Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 13 of 25 APPENDIX A Carbapenemase-producing Enterobacteriaceae: I may be a carrier (or have an infection) – what does this mean? What does ‘Carbapenemase-producing Enterobacteriaceae’ mean? Enterobacteriaceae are bacteria that usually live harmlessly in the gut of humans. This is called ‘colonisation’ (a person is said to be a ‘carrier’). However, if the bacteria get into the wrong place, such as the bladder or bloodstream they can cause infection. Carbapenems are one of the most powerful types of antibiotics. Carbapenemases are enzymes (chemicals), made by some strains of these bacteria, which allow them to destroy carbapenem antibiotics and so the bacteria are said to be resistant to the antibiotics. Why does carbapenem resistance matter? Carbapenem antibiotics can only be given in hospital directly into the bloodstream. Until now, doctors have relied on them to successfully treat certain ‘difficult’ infections when other antibiotics have failed to do so. Therefore, in a hospital, where there are many vulnerable patients, spread of these resistant bacteria can cause problems. Does carriage of Carbapenemase-producing Enterobacteriaceae need to be treated? If a person is a carrier of Carbapenemase-producing Enterobacteriaceae (sometimes called CPE), they do not need to be treated. As mentioned, these bacteria can live harmlessly in the gut. However, if the bacteria have caused an infection then antibiotics will be required. How will I know if I am at risk of being a carrier or having an infection? Your doctor or nurse may suspect that you are a carrier if you have been in a hospital abroad, or in a UK hospital that has had patients carrying these bacteria, or if you have been in contact with a carrier elsewhere. If any of these reasons apply to you, screening will be arranged for you and you will be accommodated in a single room with your own toilet facilities at least until the results are known. How will I be screened for Carbapenemase-producing Enterobacteriaceae? Screening usually entails taking a rectal swab by inserting it just inside your rectum (bottom). Alternatively, you may be asked to provide a sample of faeces. The swab/sample will be sent to the laboratory and you will normally be informed of the result within two to three days. If the result is negative, the doctors or nurses may wish to check that a further two samples are negative before you can be accommodated on the main ward. These measures will not hinder your care in any way. If all results are negative no further actions are required. Advice for patients who have a positive result What happens if the result is positive? If the result is positive, ask your doctor or nurse to explain this to you in more detail. You will continue to be accommodated in a single room whilst in hospital. If you have an infection, you will need to have antibiotics. However, if there are no signs of infection and you are simply ‘carrying’ the bacteria, no treatment is required. How can the spread of Carbapenemase-producing Enterobacteriaceae be prevented? Accommodating you in a single room (if the result is positive) helps to prevent spread of the bacteria. Healthcare workers should wash their hands regularly. They will use gloves and aprons when caring for you. The most important measure for you to take is to wash your Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 14 of 25 hands well with soap and water, especially after going to the toilet. You should avoid touching medical devices (if you have any) such as your urinary catheter tube and your intravenous drip, particularly at the point where it is inserted into the body or skin. Visitors will be asked to wash their hands on entering and leaving the room and may be asked to wear an apron. What about when I go home? Whilst there is a chance that you may still be a carrier when you go home, quite often this will go away with time. No special measures or treatment are required; any infection will have been treated prior to your discharge. You should carry on as normal, maintaining good hand hygiene. If you have any concerns you may wish to contact your GP for advice. Before you leave hospital, ask the doctor or nurse to give you a letter or card advising that you have had an infection or been colonised with Carbapenemase-producing Enterobacteriaceae. This will be useful for the future and it is important that you make health care staff aware of it. Should you or a member of your household be admitted to hospital, you should let the hospital staff know that you are, or have been, a carrier and show them the letter/card. Where can I find more information? If you would like any further information please speak to a member of your care staff, who may also contact the Infection Prevention and Control Team for you. The Public Health England website is another source of information: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/CarbapenemResistance/ (Adapted from Public Health England ‘Acute trust toolkit for the early detection, management and control of Carbapenemase-producing Enterobacteriaceae’) Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 15 of 25 APPENDIX B Carbapenemase-producing Enterobacteriaceae: I am colonised / have an infection – what does this mean? What does ‘Carbapenemase-producing Enterobacteriaceae’ mean? Enterobacteriaceae are bacteria that usually live harmlessly in the gut of humans. This is called ‘colonisation’ (a person is said to be a ‘carrier’). However, if the bacteria get into the wrong place, such as the bladder or bloodstream they can cause infection. Carbapenems are one of the most powerful types of antibiotics. Carbapenemases are enzymes (chemicals), made by some strains of these bacteria, which allow them to destroy carbapenem antibiotics and so the bacteria are said to be resistant to the antibiotics. Why does carbapenem resistance matter? Carbapenem antibiotics can only be given in hospital directly into the bloodstream. Until now, doctors have relied on them to successfully treat certain ‘difficult’ infections when other antibiotics have failed to do so. In a hospital, where there are many vulnerable patients, spread of resistant bacteria can cause problems. Does carriage of carbapenemase-producing Enterobacteriaceae need to be treated? If a person is a carrier of carbapenemase-producing Enterobacteriaceae (sometimes called CPE), they do not need to be treated. However, if the bacteria have caused an infection then antibiotics will be required. How did I ‘pick up’ carbapenemase-producing Enterobacteriaceae? Do ask your doctor or nurse to explain this to you in more detail. As mentioned above, sometimes these bacteria can be found, living harmlessly, in the gut of humans and so it can be difficult to say when or where you picked it up. However, there is an increased chance of picking up these bacteria if you have been a patient in a hospital abroad or in a UK hospital that has had patients carrying the bacteria, or if you have been in contact with a carrier elsewhere. How will I be cared for whilst in hospital? You will be accommodated in a single room with toilet facilities whilst in hospital. You may be asked to provide a number of samples, depending on your length of stay, to check if you are still carrying the bacteria. These will probably be taken on a weekly basis. The samples might include a number of swabs from certain areas, such as where the tube for your drip (if you have one) enters the skin, a rectal swab i.e. a sample taken by inserting a swab briefly just inside your rectum (bottom), and / or a faecal sample. You will normally be informed of the results within two to three days. How can the spread of carbapenemase-producing Enterobacteriaceae be prevented? Accommodating you in a single room helps to prevent spread of the bacteria. Healthcare workers should wash their hands regularly. They will use gloves and aprons when caring for you. The most important measure for you to take is to wash your hands well with soap and water, especially after going to the toilet. You should avoid touching medical devices (if you have any) such as your urinary catheter tube and your intravenous drip, particularly at the point where it is inserted into the body or skin. Visitors will be asked to wash their hands on entering and leaving the room and may be asked to wear an apron. What about when I go home? Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 16 of 25 Whilst there is a chance that you may still be a carrier when you go home quite often this will go away with time. No special measures or treatment are required; any infection will have been treated prior to your discharge. You should carry on as normal, maintaining good hand hygiene. If you have any concerns you may wish to contact your GP for advice. Before you leave hospital, ask the doctor or nurse to give you a letter or card advising that you have had an infection or been / are colonised with carbapenemase-producing Enterobacteriaceae. This will be useful for the future and it is important that you make health care staff aware of it. Should you or a member of your household be admitted to hospital, you should let the hospital staff know that you are, or have been a carrier and show them the letter / card. Where can I find more information? If you would like any further information please speak to a member of your care staff, who may also contact the Infection Prevention and Control Team for you. The Public Health England website is another source of information: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/CarbapenemResistance/ (Adapted from Public Health England ‘Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae’) Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 17 of 25 APPENDIX C Carbapenemase-producing Enterobacteriaceae – I am a contact of someone who is a carrier or has an infection – what does this mean? What does ‘Carbapenemase-producing Enterobacteriaceae’ mean? Enterobacteriaceae are bacteria that usually live harmlessly in the gut of humans. This is called ‘colonisation’ (a person is said to be a ‘carrier’). However, if the bacteria get into the wrong place, such as the bladder or bloodstream they can cause infection. Carbapenems are one of the most powerful types of antibiotics. Carbapenemases are enzymes (chemicals), made by some strains of these bacteria, which allow them to destroy carbapenem antibiotics and so the bacteria are said to be resistant to the antibiotics. Why does carbapenem resistance matter? Carbapenem antibiotics can only be given in hospital directly into the bloodstream. Until now, doctors have relied on them to successfully treat certain ‘difficult’ infections when other antibiotics have failed to do so. Therefore, in a hospital, where there are many vulnerable patients, spread of resistant bacteria can cause problems. Does carriage of Carbapenemase-producing Enterobacteriaceae need to be treated? If a person is a carrier of Carbapenemase-producing Enterobacteriaceae (sometimes called CPE), they do not need to be treated. As mentioned, these bacteria can live harmlessly in the gut. However, if the bacteria have caused an infection then antibiotics will be required. How is Carbapenemase-producing Enterobacteriaceae spread? If a patient in hospital is carrying these bacteria it can get into the ward environment and can also be passed on by direct contact with that particular patient. For that reason, the patient will normally be accommodated in a single room. Effective environmental cleaning and good hand hygiene by all, staff and patients, can reduce the risk of spread significantly. Do I need to be screened? Occasionally, it isn’t immediately known that a patient is carrying these bacteria and so they may not be placed into a single room straight away. Screening will be offered if you have shared the same bay (or ward) with a patient who has been found to be carrying Carbapenemase-producing Enterobacteriaceae. This screening is offered as there is a slight chance that you could have picked up the bacteria and are carrying it too. How will I be screened for Carbapenemase-producing Enterobacteriaceae? Screening usually entails taking a rectal swab by inserting it just inside your rectum (bottom). Alternatively, you may be asked to provide a sample of faeces. The swab/sample will be sent to the laboratory and you will normally be informed of the result within two to three days. If the result is negative nothing further is required unless you are staying in hospital for some time. In that case, you will probably be asked to provide a sample on a regular basis e.g. once a week, as a precautionary measure. What if the result is positive? If the result is positive do ask your doctor or nurse to explain this to you in more detail and to provide a leaflet relating to positive results (Card C.4).You will be given a single room until you leave hospital. No treatment is necessary unless you have an infection when antibiotics will be given. Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 18 of 25 Where can I find more information? The Public Health England web site is another source of information: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/CarbapenemResistance/ (Adapted from Public Health England ‘Acute trust toolkit for the early detection, management and control of Carbapenemase-producing Enterobacteriaceae’) Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 19 of 25 APPENDIX D Countries and regions with reported high prevalence of healthcare-associated Carbapenemase-producing Enterobacteriaceae Bangladesh The Balkans China Cyprus Greece India Ireland Israel Italy Japan North Africa (all) Malta Middle East (all) Pakistan South East Asia South/Central America Turkey Taiwan USA This is not an exhaustive list; admission to any hospital abroad should be considered when making a risk assessment. Lack of data from a country not included in this list may reflect lack of reporting/detection rather than lack of a carbapenemase problem UK regions areas where problems have been noted in some hospitals: North West especially: Manchester London IMPORTANT: Healthcare providers have a ‘duty of care’ to proactively communicate any problems they are experiencing with Carbapenemase-producing Enterobacteriaceae, not only with colleagues in healthcare settings which are co-terminus, but with any organisation they deal with on the patient pathway, either routinely or sporadically Please refer to www.hpa.org.uk for updates. (Adapted from Public Health England ‘Acute trust toolkit for the early detection, management and control of Carbapenemase-producing Enterobacteriaceae’) Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 20 of 25 Flowchart for the detection, management and control of Carbapenemaseproducing Enterobacteriaceae Risk-assess every patient on; admission, re-admission and transfer to PHT for Carbapenemase-Producing Enterobacteriaceae status (CPE). Suspected case of CPE colonisation or infection 6. Any patient transferred directly from a healthcare facility abroad 7. Any patient who has been an inpatient in a hospital abroad within the last 12 months (this includes emergency and elective admissions) 8. Any patient who has been an inpatient in a UK hospital (other than PHT) within the last 12 months) 9. Any patient previously colonised or infected with CPE or close contact 10. Renal haemodialysis patients: Any patient who has undergone dialysis abroad or at another UK hospital (both elective ‘holiday dialysis’ and emergency dialysis) Actions if a suspected case of CPE colonisation or infection (See Appendix F) 6. Immediate isolation in a side-room with en-suite facilities 7. Strict standard precautions (see 6.2). Use a long-sleeved gown for care activities where an apron does not fully protect the uniform 8. Take rectal swabs for CPE screening on three consecutive days (i.e.day 0, day 1 and day 2; see 5.3), except in Paediatric and Haematology-oncology patients. In paediatric and haematology-oncology patients, please obtain three stool samples for CPE screening 9. Patients from high prevalence countries/ regions (see appendix D) 10. please also send CPE screening swabs from wounds and device-related sites 4. Notify the Infection Prevention team 5. Provide the patient with an information leaflet (appendix A) 6. Inform other members of the team looking after the patient 7. Discuss appropriate antibiotic treatment with a microbiologist 8. Document the infection status in the patient’s records and communicate results when patient is transferred or discharged 9. Extra care taken to clean the environment after the patient had an investigation and before another patient is seen 10. Contact Infection Prevention and microbiology if surgical intervention is required No risk factor for CPE Normal admission process, including MRSA screening Positive Result Initial screening samples negative Patient to remain isolated until three sets of screening sample are negative (taken on day 0, day 1, day 2). All three sets of screening swabs negative and NOT previously ‘known’ CPE positive Can be removed from isolation, following risk assessment by Infection Prevention Positive Result Laboratory-confirmed CPE (See Appendix G) Patient to remain isolated throughout hospital stay. Previously ‘known’ CPE positive, irrespective of screening results Patient must remain isolated throughout hospital stay, irrespective of current screening results Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 21 of 25 APPENDIX F Actions to be taken if a patient is identified as having a suspected infection or colonisation with carbapenemase-producing Enterobacteriaceae (CPE) 1. Immediate isolation in a side-room with en-suite facilities. Strict standard precautions to prevent possible spread (see 5.2); 2. Take screening swabs for Carbapenemase-producing Enterobacteriaceae (CPE) on days 0, 1 and 2 (see 5.3); 3. Notify the Infection Prevention team promptly; 4. Provide information and explain your assessment of possible colonisation/infection with Carbapenemase-producing Enterobacteriaceae (CPE) to the patient. Give the patient a patient information leaflet (appendix A). Please advise the patient to practice good hand hygiene; 5. Inform other members of the team caring for the patient. Assess the need for appropriate antibiotic treatment if an infection is suspected (discuss with a medical microbiologist); 6. Document the infection status (whether suspected or confirmed CPE) clearly in the patient’s records. Ensure that the diagnosis is clearly communicated if the patient is transferred to another healthcare provider; 7. Investigations should be performed as clinically required with extra care taken to cleaning the environment after the patient has left and before another patient is seen; 8. Contact Infection prevention and microbiology if surgical intervention is required; 9. If all three sets of screening samples are negative, discuss with the Infection Control team whether the patient can be removed from isolation, provided there are no other reasons for the patient to remain isolated; 10. If one of the screens or other clinical samples are positive with Carbapenemaseproducing Enterobacteriaceae, please follow the actions for laboratory-confirmed Carbapenemase-producing Enterobacteriaceae (CPE) (see 5.4 and appendix G). Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 22 of 25 APPENDIX G Actions to be taken if a patient is a confirmed case of carbapenemaseproducing Enterobacteriaceae (CPE) 1. Immediate isolation in a side-room with en-suite facilities, if the patient is not already isolated. The patient must remain isolated throughout their hospital stay or whilst receiving dialysis at the renal dialysis unit. Strict standard precautions to prevent possible spread (see 5.2). Use a long-sleeved disposable gown for care activities where an apron does not fully protect the uniform; 2. Inform the patient of the infection or carrier status with Carbapenemase-producing Enterobacteriaceae (CPE). Give the patient a patient information leaflet (appendix B). Please remind the patient that it is important to practice good hand hygiene; 3. Inform all other members of the team caring for the patient, including physiotherapists if applicable; 4. Discuss the need for antibiotic treatment, including surgical prophylaxis with a Medical Microbiologist. Review the clinical management and ensure strict infection control practices when caring for medical devices; 5. Document the confirmed Carbapenemase-producing Enterobacteriaceae (CPE) status clearly in the patient’s records. Flag the patient notes with the result as well as the electronic system; 6. Instigate the Carbapenemase-producing Enterobacteriaceae Management Plan; 7. Consider arranging an incident control team; 8. Screen any contacts as directed by the infection control team (see 5.3.3); 9. Ensure that the patient’s Carbapenemase-producing Enterobacteriaceae (CPE) status is clearly communicated to the receiving hospital and ambulance team if the patient is transferred. Also notify the GP and other community care providers when the patient is transferred or discharged; 10. Investigations should be performed as clinically required with extra care taken to cleaning the environment as well as decontaminating the equipment after the patient has left and before another patient is seen; 11. Contact Infection prevention and microbiology if a surgical intervention is required. Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 23 of 25 Equality Impact Screening Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments. Stage 1 - Screening Title of Procedural Document: CPE Policy Date of Assessment 11/05/2016 Responsible Department Infection Prevention Name of person completing assessment Kathryn Noble Job Title Infection Prevention Manager/Analyst Does the policy/function affect one group less or more favourably than another on the basis of : Yes/No Age No Disability Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia No Ethnic Origin (including gypsies and travellers) No Gender reassignment No Pregnancy or Maternity No Race No Sex No Religion and Belief No Sexual Orientation No Comments If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2 More Information can be found be following the link below www.legislation.gov.uk/ukpga/2010/15/contents Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 24 of 25 Stage 2 – Full Impact Assessment What is the impact Level of Impact Mitigating Actions (what needs to be done to minimise / remove the impact) Responsible Officer Monitoring of Actions The monitoring of actions to mitigate any impact will be undertaken at the appropriate level Specialty Procedural Document: Specialty Governance Committee Clinical Service Centre Procedural Document: Corporate Procedural Document: Clinical Service Centre Governance Committee Relevant Corporate Committee All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee Carbapenemase-producing Enterobacteriaceae (CPE) policy Version: 1 Issue Date: 12 July 2016 Review Date: 11 July 2018 (unless requirements change) Page 25 of 25