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ISOLATION POLICY DOCUMENT CONTROL: Version: Ratified by: Date ratified: Name of originator/author: Name of responsible committee/individual: Date issued: Review date: Target Audience: 6 Clinical Effectiveness Group 3 March 2015 Senior Infection Prevention and Control Nurse Specialist Infection Prevention and Control Committee 9 March 2015 March 2018 The policy applies to all staff providing care to all patients under the care of the Trust, whether in a direct or indirect patient care role. CONTENTS SECTION 1. INTRODUCTION PAGE NO 3 2. PURPOSE 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4 4.1 4.2 4.3 4.4 4.5 Chief Executive, Nurse Director, Deputy Director of Nursing Infection Prevention and Control Clinical Nurse Specialists Matrons and Ward/Department Managers Ward/Department Managers All staff 4 4 4 4 4 5. PROCEDURE/IMPLEMENTATION 4 5.1 5.2 5.3 5.4 Principles of isolation Guidelines for single room and cohort nursing Management of the isolated patient Confidentiality 5 6 6 8 6. TRAINING IMPLICATIONS 8 7 MONITORING ARRANGEMENTS 8 8. EQUALITY IMPACT ASSESSMENT SCREENING 9 8.1 Privacy, dignity and respect 9 8.2 Mental Capacity Act 9 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS 9 10 REFERENCES 10 11 APPENDICES Appendix 1 - Mode of Transmission Appendix 2 – Local Microbiologists contact details Appendix 3 – Isolation Precautions – Planning Guide Appendix 4 - Signage for Isolation Nursing Appendix 5 – Isolation – Cleaning Checklist Appendix 6 - Healthcare Associated Infection Risk Assessment form 11 11 12 16 18 19 Page 2 of 20 1. INTRODUCTION Isolation refers to the use of a single room as a barrier in order to prevent the transmission of organisms responsible for infection. Healthcare associated infections (HCAIs) such as MRSA, Clostridium difficile, Norovirus and other multi resistant organisms may be transmitted between patients and potentially between patients, staff and visitors. When a patient is suspected or known to be suffering from infection, an understanding of the source, route and mode of transmission (Appendix 1) of infection is essential in order to institute the appropriate infection prevention and control principles, including isolation measures. Standard precautions must be applied to all patients without exception, inclusive of environmental cleaning, use of personal protective equipment and hand hygiene. The isolation of patients must be based on the infection risk, symptoms and transmission route in accordance with the relevant infection prevention and control policy. Notification of certain infectious diseases is a statutory duty for the medical practitioner. Further information and notification forms can be obtained in the Surveillance, Prevention & Management of Infections policy. For patients living in their own homes isolation is not usually required, however, staff caring for patients with infections must adhere to the principles of infection prevention and control. Advice should be sought in the first instance from the Infection Prevention and Control Team (IPCT) on the appropriateness of isolating patients. Out of hours, at weekends and bank holidays the Manager on call should be contacted to obtain advice from the local Microbiology service (Appendix 2). 2. PURPOSE This policy has been developed to inform staff of the necessary isolation precautions needed to minimise the risk of cross infection. 3. SCOPE The policy applies to all staff providing care to all patients under the care of the Trust, whether in a direct or indirect patient care role. Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum, bank staff, volunteers and contractors working on Trust premises. Page 3 of 20 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Chief Executive, Nurse Director, Deputy Director of Nursing The Chief Executive has ultimate responsibility for Infection Prevention and Control (IPC) however; the Nurse Director has designated responsibility as Director of Infection Prevention and Control (DIPC). The DIPC will provide regular updates to the Board. The Deputy Director of Nursing also has designated IPC duties in support of the DIPC and is responsible for implementing infection prevention and control strategies throughout the Trust. 4.2 Infection Prevention and Control Clinical Nurse Specialists 4.3 To provide expert, specialist advice in accordance with policy to support staff in its implementation. To assist in the risk assessment process where complex decisions are required. Provide information to the Trust Board via the DIPC. Matrons and Ward/Department Managers It is the responsibility of Matrons and Ward/Department Managers to ensure implementation and compliance with this policy. 4.4 Ward/Department Managers It is the responsibility of ward/department managers to ensure: 4.5 All clinical staff can demonstrate compliance with the policy All relevant staff undertake mandatory infection prevention and control training Infection prevention and control responsibilities form part of the individuals annual Personal Development Plan All staff All staff must be aware of their personal responsibilities in preventing the spread of infection. Adherence to this policy is the responsibility of all staff. This applies to staff employed by the Trust, agency, locum, bank and volunteer staff and those contracted to the Trust. 5. PROCEDURE/IMPLEMENTATION Infection risks should be assessed (risk assessment) and managed accordingly (risk management). Advice should always be sought from a member of the IPCT. Page 4 of 20 Isolation of patients is undertaken for two reasons: Source Isolation This is when a patient poses a risk to others Protective Isolation This is when a patient is at risk from others. In some cases strict source isolation is required to prevent the spread of highly transmissible infections e.g. Diphtheria and Viral Haemorrhagic Fevers, using negative pressure facilities. Current facilities for isolation within the Trust include limited single room access. These facilities are not suitable for prolonged accommodation of patients with highly infectious diseases such as those indicated above. Guidance must be sought immediately from the Consultant Microbiologist and/or the IPCT. This will involve transfer of such patients to an identified infectious diseases unit in specially equipped ambulances. Principally this policy will refer to source isolation. 5.1 PRINCIPLES OF ISOLATION Ideally, the most effective form of isolation is a single room. Single rooms should always be the first choice for placement of an infected patient. Where this is not possible cohort nursing should be employed. Cohort nursing involves nursing patients with the same organism (or displaying similar signs and symptoms of infection) together as an alternative form of isolation nursing when single room capacity is exceeded. Cohort patients should be nursed by designated staff. Advice on the decision to isolate a patient and guidance on isolation management should always be sought from the IPCT. Additional planning guidance is provided (Appendix 3). Individual risk assessment should take into account the infection risk (mode of transmission and infectivity), severity of illness requiring close observation, patient’s mental state and the availability of single room accommodation. Staff must follow standard infection prevention and control procedures at all times in line with Trust policies. Whilst isolation precautions are in progress the number of staff entering the isolation room should be limited. Non-essential treatments or therapies should be postponed until the precautions are no longer in place. Medical staff and Allied Health Professionals should ideally visit the patient following completion of other duties if possible. For outbreaks of diarrhoea and vomiting please refer to the policy :- Management of patients and staff with diarrhoea and vomiting Page 5 of 20 5.2 GUIDELINES FOR SINGLE ROOM AND COHORT NURSING 5.3 Explanation of infection, isolation procedures and treatment must be given to affected patients. Any visitors must be made aware of the precautions they need to take to reduce the risk of transmission whilst maintaining patient confidentiality. There may be a need to restrict the number of visitors / relatives visiting the affected patient. The nurse in charge will inform the relatives of any restrictions following consultation with the IPCT. Rooms, bays and areas designated for isolated patients must have dedicated hand hygiene and toileting facilities: for example designated commodes. Use clear signage on doors or walls to alert staff and visitors of isolation precautions (Appendix 4). Doors must be kept closed at all times. If patient safety is compromised by closing doors a risk assessment must be undertaken and documented in the patient records. This should be reviewed at each shift change. Preparation of the single room/cohort bay will include: The removal of all unnecessary furniture and equipment. This reduces the potential for contamination and allows thorough cleaning to take place All equipment in the room must be dedicated to the patient in isolation The room must not be overstocked with consumables. Any items that are unable to be decontaminated following discontinuation of source isolation will need to be disposed of All personal belongings and equipment should be able to be decontaminated safely and should be kept to a minimum Patient notes and/or charts must be kept outside of the isolation room Hand washing facilities must be available including liquid soap and paper towels. Stock must be replenished on a regular basis MANAGEMENT OF THE ISOLATED PATIENT Hand Hygiene Refer to Hand Hygiene policy. High standards of hand hygiene minimise the risk of cross infection. Hand hygiene must be performed before and after each direct patient contact (regardless of glove use) and in accordance with WHO 5 moments for hand hygiene. Adequate hand washing facilities and alcohol hand gel must be available for use. Hand washing with soap and water must be undertaken when caring for a patient with known or suspected C.difficile infection. Alcohol hand gel is not effective in destroying C.difficile organisms. Patient hand hygiene must be encouraged especially before eating and after going to the toilet/using a commode. Hand washing using liquid soap and water or the use of soapy hand wipes is recommended. Visitors must be encouraged to decontaminate their hands before and after visiting. Page 6 of 20 Personal Protective Equipment (PPE) Refer to Standard Infection Prevention and Control Precautions policy. Disposable aprons must be worn by all staff and visitors assisting in the care of the patient or having contact with their immediate environment. PPE does not need to be worn by visitors routinely for social visiting. Disposable gloves must be worn where there is anticipated contact with body fluids and when handling contaminated items. Face protection may be necessary where there is a risk of splash from body fluids in to the face or for certain airborne infections. Personal protective clothing worn in the isolation room should be disposed of in the room unless dealing with body fluids that require disposal in the sluice. It must be discarded immediately following body fluid disposal. Hand decontamination must take place following removal of PPE. Cleaning and Decontamination Refer to the Decontamination policy. Where possible single patient use equipment should be used e.g. commodes, blood pressure cuffs, hoist slings. Multiple patient use equipment must be thoroughly decontaminated in accordance with the decontamination policy to minimise the risk of cross infection. Protective covers should be used on both disposable and non-disposable bedpans/urinals. Reusable bedpans, holders, and urinals must be emptied and placed immediately into a bedpan washer disinfector. The decontamination cycle should reach a temperature of 80 degrees Celsius. Single use pulp products should be disposed of in to a macerator where available. If not, body fluids must be disposed of in toilets or sluice hopper facilities. The pulp products should then be placed in to a hazardous waste bag for disposal. Treat all linen as infected/contaminated (Refer to Laundry policy). Waste must be categorised as hazardous waste and orange waste bags used (Refer to Waste policy). Cleaning procedures must be rigorously applied. Enhanced cleaning must be performed twice daily and documented accordingly (Appendix 5). All staff must be aware of individual responsibilities for undertaking regular cleaning. Patient Movement Transfer and movement of patients must be kept to a minimum to reduce the risk of cross infection and must be based on the clinical needs of the patient. If transfer is necessary inform the IPCT prior to transfer or at earliest convenience. Inform the receiving area/organisation of patient’s infection status to ensure infection control measures can be instigated upon transfer. Ensure the Healthcare Associated Infection Risk Assessment form is fully completed and is transferred with the patients notes (Appendix 6). Equipment used for transfer of patient must be thoroughly decontaminated after use. Adherence to relevant IPC policies is essential throughout the process. Page 7 of 20 Discontinuation of Isolation 5.4 The need for isolation must be reviewed regularly and should be discontinued once deemed safe to do so. Where practicably possible the decision to discontinue isolation should be discussed with the IPCT Nursing and domestic staff must adhere to the terminal cleaning procedure and complete the associated documentation. The nurse in charge must be satisfied the room has been cleaned to a high standard before the documents are signed off and the room can be used again. CONFIDENTIALITY All patients have a right to dignity, privacy and respect. It is essential to maintain confidentiality regarding the patient's illness. Certain infections or outbreaks of infection arouse interest and speculation by the media and staff must not divulge such information within or outside the hospital. 6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but all staff will need to be aware of its contents. Staff will be made aware through: 7. Line Manager Team Brief Team Meetings One to one meetings/supervision Trust Policy web site MONITORING ARRANGEMENTS Area for How monitoring Breaches policy Who by of IR1 Staff knowledge of when to Isolate Modern Matrons and IPCT Incorporated in IPCT IPC audit tool Page 8 of 20 Reported to Frequency ICC Committee As they occur Audit results to Annually Modern Matron and Ward Managers 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 8.2 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. No issues have been identified in relation to this policy. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. 9. Indicate how this will be met Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) LINKS TO OTHER PROCEDURAL DOCUMENTS This policy should be read in conjunction with other Trust infection prevention and control policies, particularly: Standard Infection Prevention & Control Precautions Hand Hygiene Laundry Waste Management Decontamination Surveillance, Prevention & Management of Infections Management of patients and staff with diarrhoea and vomiting And policies relating to a specific infection/disease eg: Clostridium difficile, MRSA, Chickenpox. Page 9 of 20 10. REFERENCES 1. Hospital Infection Society (2001) - Review of Hospital Isolation and Infection Control Related Precautions - Report of the Joint Working Group. 2. Wilson, J. (2001) - Infection Control in Clinical Practice. London: Bailliere Tindall. 3. Department of Health (2008). The Health and Social Act: Code of Practice for health and adult social care on the prevention and control of infections and related guidance. London. Crown Copyright. 4. Department of Health (2009) Clostridium difficile infection : How to deal with the problem 5. Department of Health (2007a) Saving Lives: Reducing Infection, Delivering Clean and Safe Care. www.dh.gov.uk 6. Department of Health (2007b) High Impact Intervention No 7. Care Bundle to Reduce the Risk from Clostridium Difficile. www.dh.gov.uk 7. Department of Health (2007c). A Simple Guide to Clostridium Difficile. www.dh.gov.uk 8. Department of Health (2006). Essential Steps to Safe, Clean Care. London. Crown Copyright. 9. Department of Health (2006). A Health Technical Memorandum: Safe Management of Healthcare Waste. London. Crown Copyright. 10. Department of Health (2006). Saving Lives Programme. Isolating patients with healthcare associated infection. A summary of best practice. London. Crown Copyright. 11. Healthcare Commission and the Health Protection Agency (2005). Management, prevention and surveillance of Clostridium Difficile: Interim findings from a national survey of NHS acute trusts in England. December 2005. 12. Healthcare Commission (2007) Investigation in to outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust. London. October (2007). 13. Pratt RJ, Pellowe CM, Wilson JA, LovedayHP et al (2007) epic2: National evidence based guidelines for preventing healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 65 (Supplement). 14. National Institute for Health and Clinical Excellence (2012) Prevention of healthcareassociated infection in primary and community care. NICE.London 15. World Health Organisation (2009) Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge, Geneva. Page 10 of 20 11. APPENDICES APPENDIX 1 Mode of Spread and Means of Transmission Mode of Spread Direct Skin/mucous membrane exposure to blood/body fluid infected with organism Indirect Exposure via contaminated equipment, environment or food Parenteral Exposure via needlestick/sharps injury or contaminated infusion fluids Means of Transmission Hand Hygiene Isolation Precautions Standard Precautions Decontamination Ventilation Filters Masks Decontamination Contact Direct & Indirect (Fomites) Airborne Dust, droplet & aerosols Food & Water Hands, cloths, equipment & surfaces Food Hygiene Practices APPENDIX 2 Microbiologist Contact Number Doncaster 01302 366666 ask for on call Microbiologist N & NE Lincs 01302 366666 ask for on call Microbiologist Rotherham 01709 820000 Bleep holder 221 and ask for on call Microbiologist Page 11 of 20 APPENDIX 3 ISOLATION PRECAUTIONS - PLANNING GUIDE This guide outlines measures to prevent cross-infection within the hospital environment. Notifiable to CCDC Disease Acquired Immune Deficiency Syndrome (AIDS) or HIV infection What is infected Blood and body fluids Route of Spread Campylobacter* Faeces Chickenpox Respiratory secretions and discharge from vesicle fluid CJD and vCJD Brain, eye, nerves and lymphoid tissue Single room Period of precaution Comments Full face visor if risk of splashes or sprays No -unless bleeding profusely Yes - for contact with blood & body fluids On-going throughout admission Yes Yes - for contact with diarrhoea Until symptom free for 48 hrs Direct contact with vesicles Droplet/airborne Indirect contact with freshly soiled clothing/linen Yes with door closed Yes For direct patient contact Until lesions are crusted and dry Direct and indirect contact Not usually Yes for contact with blood & body fluids On-going throughout admission Blood or infected tissue Sexual exposure Vertical transmission Breast milk Occupational exposure e.g. sharps injury Faecal oral ingestion of organism Personal Protective Equipment Page 12 of 20 Non immune staff to avoid contact with affected patient * - Disease What is infected Route of Spread Single room Personal Protective Equipment Period of precaution Comments Clostridium difficile Faeces Faecal oral ingestion of organism Yes – with door closed Yes - for close contact with patient and diarrhoea Until symptom free for 48 hrs Review antibiotic use. Stringent environmental cleaning Diarrhoea +/Vomiting, known or suspected food poisoning * E coli 0157 Faeces and vomit Faecal oral ingestion of organism from faeces or vomit Yes – with door closed Yes - for close contact with patient and diarrhoea Until symptom free for 48 hrs Refer to outbreak policy if more patients affected Faeces Group A Streptococcus Saliva and wound exudate Faecal oral ingestion of organism Respiratory secretions andfluid from lesions Yes – with door closed Yes - – with door closed Yes - for contact with diarrhoea Yes - for direct patient contact Can cause haemolytic uraemic syndrome Staff developing a sore throat refer to Occupational health Hepatitis A * Faeces Yes Hepatitis B * Blood and body fluids Yes - for contact with diarrhoea Yes - for contact with blood &body fluids Hepatitis C * Blood and body fluids Faecal oral ingestion of organism Blood or infected tissue Sexual exposure Vertical transmission Breast milk Occupational exposure e.g. sharps injury Blood or infected tissue Sexual exposure Vertical transmission Breast milk Occupational exposure e.g. sharps injury Until symptom free for 48 hrs Until 48 hrs of appropriate antibiotics or advised by IPCT Until symptom free for 48 hrs On-going throughout admission No - unless bleeding profusely No -unless bleeding profusely Page 13 of 20 Yes for contact with blood & body fluids On-going throughout admission Disease What is infected Route of Spread Single room Personal Protective Equipment Influenza Respiratory secretions Respiratory Airborne Yes with door closed Yes for direct patient contact Legionnaires Lung tissue Airborne Water No No Measles Respiratory secretions Droplet spread Indirect contact Yes with door closed Meningococcal Meningitis (bacterial) Respiratory secretions Droplet spread Direct contact – mucous membrane Yes – with door closed Yes for contact with respiratory secretions Yes for contact with respiratory secretions Pneumococcal Meningitis Respiratory secretions Droplet spread Direct contact withmucous membrane Yes – with door closed Yes for contact with respiratory secretions MRSA Dependent on site and extent of colonisation / infection Respiratory secretions Direct contact Yes – with door closed Mumps Rotavirus Faeces, vomit and respiratory secretions Droplet spread Direct contact withmucous membrane Droplet spread Faecal oral Period of precaution Comments Duration of illness Masks must be worn Refer to HPA pandemic flu guidance Not thought to be transmissible person to person Non immune staff to avoid contact with affected patient Yes - for direct patient contact For 4 days after the rash has appeared Until patient has received 24 hrs of appropriate antibiotic therapy Until patient has received 24 hrs of appropriate antibiotic therapy Until advised by IPCT Yes – with door closed Yes for contact with respiratory secretions For 9 days after onset of swollen glands Non immune staff to avoid contact with affected patient Yes – with door closed Yes for contact with diarrhoea and respiratory secretions Until symptom free for 48 hrs Refer to outbreak policy if many babies affected Page 14 of 20 Prophylaxis indicated for close family contacts discuss with Microbiologist Refer to MRSA policy Disease What is infected Route of Spread Respiratory secretions Rubella * Respiratory secretions Salmonella * Faeces Scabies Skin SARS * Respiratory secretions Shingles Vesicle fluid Respiratory virus (RSV) Syncytial Pulmonary TB* Whopping (pertussis) cough* Sputum Respiratory secretions Single room Personal Protective Equipment Period of precaution Droplet spread Direct contact with respiratory secretions Droplet spread Direct contact with respiratory secretions Faecal oral Yes – with door closed Until symptom free Scabies mite Direct skin to skin contact Droplet spread Direct contact with respiratory secretions Airborne Direct contact with vesicle fluid Indirect contact with contaminated equipment and linen Airborne Direct contact with respiratory secretions No Yes for contact with respiratory secretions Yes for contact with respiratory secretions Yes for contact with diarrhoea Yes - for direct patient contact Airborne Direct contact with nasal and throat secretions Yes – with door closed Yes Comments For 7 days after onset of rash Until 48 hrs symptom free Until successfully treated Duration of illness Dermatology referral is recommended for in patient areas. Masks must be worn. Seek urgent advice from IPCT Yes with door closed Yes Yes – with door closed Yes for direct contact with vesicle fluid Until lesions are crusted and dry Staff who are not immune to chickenpox to avoid contact with affected patient Yes with door closed Yes for contact with respiratory secretions Until 2 weeks after effective compliant treatment Yes with door closed Yes for contact with respiratory secretions Until 5 days appropriate antibiotic therapy Staff should wear special filter masks when exposed to respiratory droplets Only immune staff to attend patient Restrict contact with infants and young children until patient has received at least 5 days treatment Page 15 of 20 APPENDIX 4 Signage for Isolation Nursing STOP AND THINK! Isolation Nursing All Visitors: All Staff Please wash and dry your hands before entering and on exiting the room Please ask the nurse before entering so that she/he can explain any precautions you need to take Please close the door behind you Please ask the nurse/matron or member of the infection control team to explain anything you are unsure of Page 16 of 20 Please adhere to standard infection control precautions at all times Please check care plan/ward guidance if you are unsure about any infection control procedure Page 17 of 20 APPENDIX 5 ISOLATION – CLEANING CHECK LIST Domestic Services provided by_____________________________________ Ward: Room/Bay: Date Isolation Cleaning Commenced: Domestic/Service/Ward Assistants should wear a yellow plastic apron and yellow gloves to carry out the cleaning. All cleaning equipment should be colour coded yellow. Chlor-clean ( or alternative antimicrobial detergent) must be used as per manufacturer’s instructions Patient Environment - 2 x Daily Clean On discharge full terminal clean to be performed Responsibility –Domestic services Date Time Signature Day 1 Frequency 1 Frequency 2 Day 2 Frequency 1 Frequency 2 Day 3 Frequency 1 Frequency 2 Day 4 Frequency 1 Frequency 2 Day 5 Frequency 1 Frequency 2 Day 6 Frequency 1 Frequency 2 Day 7 Frequency 1 Frequency 2 Page 18 of 20 Print Name APPENDIX 6 Page 19 of 20 Page 20 of 20