Download Isolation Policy - Royal Cornwall Hospitals NHS Trust

Isolation Policy
V4
25.07.2016
Isolation Policy Flow Chart
Refer to Appendix 3
If „Notifiable Disease‟ Notification of diseases certificate to be completed
If Source Isolation Required
Explain to patient rationale for isolation
Transfer patient to side room with en-suite facilities where possible
Keep door closed
Display isolation precautions in use
Inside Room
Inside Room
Infectious waste bag/bin
Linen bag
Thermometer
BP cuff
Stethoscope
Outside Room
PPE in appropriate
dispenser
Nursing notes
Remove PPE prior to leaving room
Carry out hand hygiene prior to leaving room and immediately after leaving the
room
On discharge arrange a terminal clean of the room
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Table of Contents
Summary. ............................................................................ Error! Bookmark not defined.
1.
Introduction ................................................................................................................... 4
2.
Purpose of this Policy/Procedure .................................................................................. 4
3.
Scope ........................................................................................................................... 4
4.
Definitions / Glossary .................................................................................................... 4
5.
Ownership and Responsibilities .................................................................................... 4
5.1.
Role of the Chief Executive ................................................................................... 4
5.2.
Role of the Director of Infection Prevention and Control (DIPC) ............................ 4
5.3.
Role of the Managers ............................................................................................ 4
5.4.
Role of the Infection Prevention and Control (IPAC) Steering Group .................... 5
5.5.
Role of the Hospital Infection Prevention and Control Committee ......................... 5
5.6.
Role of individual staff members............................................................................ 5
5.7.
Consultant Medical Staff ........................................................................................ 5
5.8.
The Infection Prevention and Control Team .......................................................... 5
5.9.
Chief Operating Officer/Senior Manager on Call ................................................... 5
6.
Standards and Practice ................................................................................................ 5
6.1.
Source Isolation ..................................................................................................... 5
6.2.
Source Isolation Precautions ................................................................................. 6
6.3.
Protective Isolation .............................................................................................. 10
6.4
Psychological Effect of isolation .......................................................................... 13
6.5
Ward Rounds....................................................................................................... 13
7.
Dissemination and Implementation ............................................................................. 14
8.
Monitoring compliance and effectiveness ................................................................... 14
9.
Updating and Review.................................................................................................. 14
10.
Equality and Diversity .............................................................................................. 14
Appendix 1. Governance Information ................................................................................ 15
Appendix 2. Initial Equality Impact Assessment Form ....................................................... 19
Appendix 3. Table of Communicable Diseases and Appropriate Precautions .................. 21
Isolation Policy
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1. Introduction
1.1. Standard precautions are the principle strategy for the prevention and
control of healthcare associated infection. However, additional precautions are
required for the care of patients who are known or suspected to be infected (or
colonised) with highly transmissible or epidemiologically important pathogens
and those who have an increased susceptibility to infection because they have
a compromised immune system or extensive skin loss due to burns or other
trauma. Such precautions are known respectively as source isolation
precautions and protective isolation precautions.
2. Purpose of this Policy/Procedure
2.1. This policy has been designed to aid health care professionals when
looking after patients with compromised immunity to try and reduce the risk of
infection to these patients whilst in our care (Protective Isolation). This policy
also provides information on the management of patients who are known or
suspected to be infected or colonised with highly transmissible or
epidemiologically important pathogens thereby protecting others from infection
(Source Isolation)
3. Scope
3.1. This policy applies to all staff working in the Royal Cornwall Hospitals
NHS Trust.
4. Definitions / Glossary
4.1. Definitions are included in the text.
5. Ownership and Responsibilities
5.1. Role of the Chief Executive
The Chief Executive Officer (CEO) is responsible for ensuring that there are
effective arrangements for infection control within the Trust. This includes
determining the mechanisms by which the Trust Board ensures that there are
adequate resources available to secure effective prevention and control of healthcare
associated infections.
5.2. Role of the Director of Infection Prevention and Control (DIPC)
The DIPC is responsible for overseeing the implementation of the policy, for reporting
any concerns and performance in infection prevention and control to the Trust Board
and CEO, and for challenging inappropriate clinical practice and antibiotic
prescribing.
5.3. Role of the Managers
Divisional Management Teams and Directorates must ensure that resources are
available for health care workers to undertake effective standard and isolation
precautions.
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Clinical Matrons, Ward Sisters/Charge Nurses and departmental managers are
responsible for ensuring that staff are aware of this guidance and that the guidance is
implemented.
5.4. Role of the Infection Prevention and Control (IPAC) Steering
Group
The IPAC Steering Group is responsible for the implementation and monitoring of this
policy.
5.5. Role of
Committee
the
Hospital
Infection
Prevention
and
Control
The Hospital Infection Prevention and Control Committee is responsible for approving
this document.
5.6. Role of individual staff members
Each individual has a clinical and ethical responsibility to carry out effective Infection
prevention and control procedures and to act in a way, which minimises risk to the
patient.
All staff members working on Trust premises, including Trust employed staff,
contractor staff, agency and locum staff are responsible for:
 adhering to this policy, and
 for reporting breaches of this policy to the person in charge and to their line
manager
5.7. Consultant Medical Staff
Are responsible for ensuring their junior staff read and understand this policy, and
adhere to the principles contained in it at all times.
5.8. The Infection Prevention and Control Team
Is responsible for providing expert advice in accordance with this policy, for
supporting staff in its implementation, and assisting with risk assessment where
complex decisions are required. The team is also responsible for ensuring this policy
remains consistent with the evidence-base for safe practice, and for reviewing the
policy on a regular basis.
5.9. Chief Operating Officer/Senior Manager on Call
Is responsible for providing senior and executive leadership to ensure implementation
of this policy, and for ensuring infection risks are fully considered and documented
when complex decisions need to be made regarding capacity and patient flow.
6. Standards and Practice
6.1. Source Isolation
The infected/colonised patient, as the source of infection, is segregated from
unaffected patients, usually in a single room but, on occasions, within a cohort of
similarly affected patients. Physical segregation, combined with other precautions
such as the use of protective clothing, is aimed at reducing the likelihood of infections
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spreading via the airborne, droplet or contact routes. The extent of isolation depends
on:
 The infecting organism and the route of transmission
 The physical and mental abilities of the patient
 Risk assessment of susceptibility of other patients
 Facilities available for isolation
Wherever possible patients who require source isolation should be transferred to the
isolation ward in line with the Standard Operating Policy for the Isolation Ward.
6.2. Source Isolation Precautions
6.2.1. Communication
 Explain the rationale for isolation to the patient and, where possible, the
duration of isolation anticipated. Where available provide a patient
information leaflet.
 Ensure the Isolation Precautions sign on the door of the room/bay is
clearly displayed.
 Record in the patient's notes that isolation has been commenced and the
reason why.
 Revise the nursing care plan accounting for infection control precautions
to be maintained by staff, patient and visitors.
 Inform the Infection Prevention and Control Team that there is a patient
in isolation.
 Check whether the patient has a „Notifiable Disease‟ and if so a
Notification of Diseases Certificate must be completed by the medical
team. Notification Certificate Books are kept in each clinical area.
6.2.2. Accommodation
 Identify appropriate isolation facilities e.g. single room or cohort bay.
 A side room with negative pressure ventilation may be required for
airborne infections. Negative pressure ventilation is available in the ITU
side room; otherwise patients would need to be transferred to another
hospital.
 It is particularly important to keep the door closed when the side room is
used for isolating a patient with an airborne infection.
 If a single room is indicated it is preferable that it has en-suite toilet and
washing facilities.
 Remove all non-essential furniture and equipment.
 Ensure that appropriate equipment is available:
Inside the room
Hand washing facilities
Clinical waste bag holder/bin.
Linen receptacle with water soluble bag.
Sharps Bin (if safe to leave within room)
Thermometer, BP cuff & tourniquet
(preferably disposable)
Stethoscope (if required)
Toileting and wash facilities (if no en suite
bathroom).
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Outside the room
Appropriate
protective clothing
in dedicated
dispensers where
possible.
Alcohol hand rub
(except in cases of
diarrhoea).
Nursing notes to
be outside room.
NB The mental health of the patient may dictate that it is unsafe to leave
some of this equipment within the room.
Always undertake a risk assessment.
6.2.3. Hand Hygiene
Hands must be cleansed prior to leaving the isolation room. Hand hygiene
must also be performed between different patient care activities to prevent
cross contamination of different body sites. If the patient has diarrhoea soap
and water must be used for hand hygiene rather than alcohol rub.
Hands must be immediately cleansed after leaving the room
6.2.4. Protective Clothing
Protective clothing should be worn whenever there is any physical contact with
the patient.
Protective clothing must be removed immediately prior to leaving the room and
must be disposed of inside the room into a clinical waste bag (except when
leaving the room to dispose of used bedpans etc. when it is removed in the
sluice after placing bedpan in macerator/bedpan washer).
The type of protective clothing required is dependent on the mode of
transmission and the type of contact. All that is usually required is disposable
gloves and aprons. If it is anticipated that more than one apron or pair of
gloves are required during an episode of care, the additional gloves and
aprons should be taken into the room at that time. Boxes/rolls or aprons must
not be kept inside the room.
Occasionally additional protective clothing, such as masks and gowns, is
required. Where this is appropriate it has been identified in Section 4. It is
important to note that masks are rarely necessary and are of limited value in
protecting against infection spread by the airborne respiratory route. It is more
important that staff caring for patients with airborne infections are immune.
Where acute rooms are available PPE should be removed here.
6.2.5. Vulnerable Staff and Visitors
Some people may be more vulnerable than others to infection. In particular:
 Pregnant women
 Immunocompromised people (for any reason)
 Staff with eczematous/psoriatic or similar skin lesions (particularly
relevant with MRSA)
 Staff and visitors receiving antibiotics (relevant to C.difficile infection) and
must seek advice prior to caring for patients in isolation.
6.2.6. Equipment
Disposable equipment should be used whenever possible. Non disposable
equipment must be decontaminated in accordance with the Decontamination
Policy when removed from the room. Wherever possible equipment should be
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allocated for sole use of the patient and decontaminated or disposed of when
no longer required.
6.2.7. Linen
All laundry from isolation rooms must be managed as fouled/infected laundry
and therefore be placed in water soluble bags within the room and then into an
outer linen sack.
6.2.8. Waste Disposal
All waste must be disposed of into clinical waste bags inside the room. Double
bagging is not necessary. The bag should be placed immediately at the
designated collection point.
6.2.9. Excreta
Excreta can be disposed of directly into the toilet adjoining the room. If ensuite facilities are not available, cover commode/bed pan and take directly to
the sluice. Pans and urinals must be placed directly into the macerator.
Gloves and aprons should then be removed and discarded in clinical waste bin
and hands washed.
6.2.10. Sharps
A sharps bin should be kept inside the room for sharps disposal, unless this
will be a hazard to the patient each case must be risk assessed.
6.2.11. Collection of Specimens
Specimens should be obtained within the room. Care must be taken to avoid
contaminating the outside of the specimen container. All clinical specimens
should be regarded as potentially infectious and handled as such. However,
since it is National Health and Safety Policy, specimens from patients likely to
or suspected of having the following infections must be treated as „high risk
„and identified on the accompanying form.
 Hepatitis B&C
 HIV
 Pulmonary TB
 Brucellosis
 Plague
 Anthrax
 Yellow Fever
6.2.12. Crockery and Cutlery
Crockery and cutlery is adequately decontaminated by dishwasher. Return
items to kitchen promptly.
6.2.13. Visits to Other Departments
Movement of infectious or potentially infectious patients should be kept to a
minimum. If it is possible to delay an investigation without adversely affecting
the patients management this should be considered. However the presence
of an infectious disease should not delay urgent clinical investigations.
The receiving department must be notified in advance so that arrangements
can be made to prevent possible spread of infection i.e. patients with
infections spread by the airborne route should be seen at the end of a
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list/session. Ward staff should advise of any necessary precautions. The
Infection Prevention and Control Nurse can also be contacted for advice. After
the investigation/treatment is completed, surfaces with which the patient has
had contact should be cleaned with hot water and detergent or detergent
wipes followed by actichlor (actichlor plus can also be used).
Portering staff and other staff accompanying the patient do not need to wear
protective clothing but must clean their hands thoroughly after having direct
contact with the patient.
Wheelchairs/trolleys used to transport patients to other departments must be
cleaned with hot water and detergent or detergent wipes.
6.2.14. Transfer/Discharge of Patients
All transfers must be restricted unless clinical need dictates. The receiving
area must be informed in advance of the nature of the infection to ensure that
the appropriate facilities are available and the required precautions are
applied. Movement for non-clinical reasons, is not advocated.
On discharge ensure that receiving hospital/nursing home or community
services are informed of any necessary precautions.
If transport by
ambulance is required, the Ambulance Service must be informed of any
necessary precautions.
6.2.15. Visitors
Visitors must report to the nurses‟ station prior to entering the room. It may be
necessary to ask about immunisation status prior to visiting. In some
circumstances visiting may be restricted. If visiting is allowed it is usually
unnecessary for visitors to wear protective clothing but they should be advised
to wash/clean their hands when leaving the room. Visitors may need to be
shown how to do this. Visitors should be advised not to visit other patients but
if this is necessary they should do so before visiting the patient in isolation.
They should be advised not to eat or drink whilst in the isolation room or bring
in food for the patient unless previously agreed. Visiting by young children
should be discouraged. If visitors chose to bring children to the hospital for
visits they must be informed of any risks.
6.2.16. Routine Cleaning
Isolation rooms must be cleaned at least as frequently as other patient areas
using standard cleaning procedures and Actichlor plus. Cloths must be
disposable. Mop heads must be removed and should be laundered after use
or disposable mop heads discarded. Isolation rooms used for source isolation
must be cleaned after all other areas.
6.2.17. Last Offices
Following death, the body may remain an infection risk to personnel and
therefore isolation precautions must be maintained whilst Last Offices are
performed.


Last Offices are performed in accordance with local Trust procedures.
All bodies should be sealed in a leak proof cadaver bag.
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6.2.18. Terminal Cleaning
Terminal cleaning of the environment and furniture can be arranged via the
Mitie Helpdesk: ext: 2468. The room must not be used for other patients until
a terminal clean has been completed.
All disposable items are to be discarded.
6.3. Protective Isolation
The purpose of protective isolation is to provide a safe environment for patients who
have an increased susceptibility to infection because they have a compromised
immune system or extensive skin loss due to burns or other trauma.
Generally these patients are most at risk from their own resident flora (endogenous
infection) but must also be protected from the risk of cross infection (exogenous
infection).
As most infections are endogenous, there should be an emphasis on patient
education regarding hand washing and basic hygiene.
The most common reason for placing a patient in protective isolation is if the blood
neutrophil count falls, or is expected to fall, below 0.5 x 109/L. Although
immunosuppression may occur for many reasons (including organ transplants, some
genetic disorders and infection with HIV), it is commonly encountered in cancer
services. This is due to high-dose chemotherapy and occurs particularly in patients
with haematological malignancies who are given bone marrow or stem cell
transplants. These patients may also receive prophylactic antifungals and/or
antibiotics to reduce the risk of endogenous infection.
The decision to institute protective isolation is made by the clinician caring for the
patient or on the advice of the infection prevention and control team, Haematologist
or Oncologist.
6.3.1.
Accommodation
A single room helps to reinforce the need for rigorous attention to standard
infection prevention and control precautions. Immunocompromised individuals
should never be placed in the same room or adjacent to people with a known
infection. Therefore ideally patients should be nursed in a single room, preferably
with en-suite facilities and the door should be kept closed.
Patients with prolonged neutropenia should be nursed in isolation rooms with
HEPA filtered air at positive pressure as this may help to reduce exposure to
airborne infections, particularly Aspergillus. This is especially relevant when
refurbishment, building or demolition works are in progress nearby. In order for
the system to work effectively windows and doors must be kept closed at all
times. Single rooms with positive pressure ventilation will usually have an anteroom. For maximum effect, only one of the doors in the ante-room should be
open at any time when entering or leaving the cubicle.
Flowers and plants should not be allowed in the room. All persons entering the
room should practice strict hand washing procedures and visitors with active
infections should be discouraged from entering the room. Strict adherence to
bare below the elbows is required.
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Occasionally, an immunocompromised patient may acquire an infection and is
therefore potentially a hazard to other patients on the ward which means that
source isolation is also required. In this situation the positive pressure ventilation
should be switched off. At RCHT Lowen Ward is the only facility in the hospital
to have positive pressure facilities.
6.3.2. Communication
 The rationale for isolation must be explained to the patient and, where
possible the duration of isolation anticipated.
 The appropriate isolation notice must be placed on the door to the room.
 A record must be made in the patient‟s notes that isolation has been
commenced and the reason why.
 The nursing care plan must be revised accordingly.
 The patient‟s family and friends must be provided with education and
communication as to why their relative has been isolated and what
precautions they need to adhere to.
6.3.3. Infection Control Precautions
Standard infection control precautions must be applied when providing care to
Neutropenic or other severely immunosuppressed patients, in particular:
Hand Hygiene
Strict attention must be paid to hand decontamination prior to entering the
room. Hands must be cleansed before and after each episode of patient
contact. In order to reduce the risk of cross contamination of different body
sites hands must also be decontaminated between different tasks and
procedures undertaken on the same patient, e.g. between assisting a patient
with toileting and mouth care.
Relatives and visitors must be educated and advised with regard to good hand
hygiene when entering and leaving the isolation area.
Protective Clothing
Disposable, single use plastic aprons should be worn for all clinical procedures
to provide a protective barrier that will minimise the risk of transmission of
micro-organisms to the patient. Non-sterile gloves must be worn for contact
with body fluids as per standard infection control precautions. Staff should to
avoid the contamination of uniforms by not sitting on patients beds/chairs
unnecessarily. Gloves and aprons should be removed outside the isolation
room (unless further care/procedures are to be carried out) and placed inside
clinical waste bins.
Decontamination of Equipment
All unnecessary equipment should be removed from the room. Disposable
equipment should be used whenever possible. Non-disposable equipment
must be cleaned before and after use in accordance with the decontamination
policy. Wherever possible equipment should be allocated for the sole use of the
patient during their admission.
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Decontamination of the Environment
It is important that the room is kept as clean as possible. The room must be
cleaned prior to the admission of a patient and daily thereafter using standard
daily cleaning procedures. Protective isolation rooms should be cleaned before
other patient areas. Cloths must be disposable, and a freshly laundered or
disposable mop head used.
6.3.4. Patient Hygiene
Most infections are endogenous therefore measures to contain the body‟s
normal flora are important. These include good personal hygiene, regular mouth
care, and supportive care to maintain the integrity of skin and mucous
membranes.
Patients should preferably have en suite toilet and showering facilities. If this is
not possible a commode or toilet should be allocated for their sole use.
Patients can shower or bath in shared facilities as long as these areas are
thoroughly cleaned immediately prior to use.
Patients personal hygiene needs must be assessed on a daily basis and
assistance given where required to maintain an acceptable level of cleanliness.
Particular care needs to be given to the perineal area which is heavily colonised
with bacteria. Immunocompromised patients frequently suffer irritation or
infection of this area. It is felt that this can be exacerbated by the use of soap
which may irritate the mucous membranes. Therefore the use of warm water
alone is recommended (Lindell & Olsson 1989)
Disposable cloths rather than flannels must be used and towels must be
changed daily.
6.3.5. Diet
The immunocompromised patient is at increased risk of food-borne illness and
the acquisition of harmful micro-organisms from some food. Therefore
immunocompromised individuals are advised to avoid certain high risk foods for
example soft cheeses and foods made with raw eggs. For further information
please refer to local dietary guidelines for Neutropenic patients as recommended
by the Department of Nutrition & Dietetics for example Bloodwise booklet titled
„Dietary advice for haematology patients with neutropenia‟ or Neutropenic Diet
policy as compiled by the Nutrition and Dietetics Department.
In general, good food hygiene principles should be followed foods should be
well-cooked and reheated to an appropriate temperature. Fruit and vegetables
should be packaged or peeled and dairy products should be individually
packaged and pasteurised. Pate, liver, soft/blue cheeses, live yoghurts and
probiotics are not advised.
Drinking water should be from a tap with a tap filter. Taps without an identified
filter should not be used. Where filtered water is not available sterile water
should be used. This is available from pharmacy. Bottled water is not
permissible. Water should not be taken from any water fountains.
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Commercially available non-carbonated bottle water may contain large numbers
of gram-negative bacteria and therefore should be avoided. Carbonated bottled
water is considerably safer than non-carbonated because of the low pH of these
products; the low pH can however result in poor patient acceptability in patients
with chemotherapy associated mucositis.
Ward staff must inform the Mitie ward host of a patient‟s neutropenic status
verbally and by updating the „ward host handover sheet‟.
6.3.6. Flowers
Flowers and plants have not been directly linked to infection in
immunocompromised patients; however they could potentially be a reservoir for
gram negative bacteria or fungal spores. Therefore pot plants and flowers are
not recommended.
6.3.7. Staff Illness
Particular caution is required when working with immunocompromised patients
and therefore staff with upper-respiratory tract infections or oral-facial herpes
simplex should be excluded from direct contact with these patients.
6.3.8. Visitors
The patient may receive visitors, however visitors should report to a member of
staff before entering the room so that precautions can be explained and any
infections in the visitor which might be dangerous to the patient can be identified.
Visitors must be excluded if they have any form of transmissible infection.
The efficiency of the ventilation system will be severely compromised by large
numbers of visitors. Numbers should be restricted to no more than two at a time.
Coats and jackets should be removed before entering the room. It is not
necessary for visitors to wear protective clothing, unless they are performing
assistance with personal care, when a disposable plastic apron should be worn.
Visitors must be advised of the importance of hand hygiene before entering the
room.
6.4
Psychological Effect of isolation
Many studies have shown the detrimental effect of isolation on patients‟ psychological
well-being (Gammon 1998, Knowles 1993). Some patients may find it beneficial to
leave their isolation room for short periods of time or for mobilisation purposes.
Patients can leave their isolation rooms for short periods as long as they avoid contact
with crowds, other patients or people with infections. This may be easier to achieve
during quieter periods on the ward, such as rest periods. This must be carefully
explained to patients who may find it confusing.
6.5
Ward Rounds
All staff must be bare below the elbows and hands decontaminated before entering
the room using soap and water or alcohol gel.
The number of people entering the isolation room should be kept to an absolute
minimum.
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Wherever possible, equipment such as stethoscopes should be allocated to each
patient for sole use throughout their stay. Where this is not possible equipment, such
as palette hammers must be cleaned with a detergent impregnated wipe before and
after use.
Disposable single use ear-pieces should be used with auroscopes. The external
surfaces of the auroscope must be cleaned before and after use with a detergent
impregnated wipe.
7. Dissemination and Implementation
This policy will be implemented via the following routes:


The policy will be included in the Trust‟s Document Library
Details of the policy will be circulated to all Link Practitioners, Ward Sisters/Charge
Nurses and Matrons
8. Monitoring compliance and effectiveness
This part must provide information on the processes and methodology for monitoring
compliance with, and effectiveness of, the policy/procedure using the table below.
Element to be
monitored
Lead
Isolation of patients with known infections.
Tool
Guidance in appendix 3
Frequency
During ward visits
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
The need for isolation will be reported to the nurse/medical team
caring for the patient.
Isolation to be carried out immediately unless risk assessment
deems otherwise.
Infection Prevention and Control Team
Required changes to practice will be identified and actioned
immediately where necessary. The ward Sister/Charge Nurse will
be identified to take each change forward where appropriate.
Lessons will be shared with all the relevant stakeholders.
9. Updating and Review
9.1. This policy will be reviewed within three years.
10. Equality and Diversity
10.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Isolation Policy
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Diversity & Human Rights Policy' or the Equality and Diversity website.
10.2. The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Appendix 1. Governance Information
Document Title
Isolation Policy
Date Issued/Approved:
Corporate: Clinical
Date Valid From:
1st November 2016
Date Valid To:
31st October 2019
Directorate / Department
responsible
(author/owner):
Louise Dickinson
Contact details:
01872254969
Brief summary of
contents
These guidelines provide the information required to
determine appropriate isolation precautions based on
the route of transmission.
Suggested Keywords:
Target Audience
Executive Director
responsible for Policy:
Use this section to suggest keywords to be added
by the Uploader to aid document retrieval.
RCHT
CFT
KCCG

Director of Nursing
Date revised:
This document replaces
(exact title of previous
version):
Isolation Policy V3
Approval route (names of
Hospital Infection Prevention and Control Committee
committees)/consultation:
Divisional Manager
confirming approval
processes
Louise Dickinson
Name and Post Title of
additional signatories
Not Required
Name and Signature of
Divisional/Directorate
Governance Lead
confirming approval by
specialty and divisional
management meetings
{Original Copy Signed}
Name:
Isolation Policy
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Signature of Executive
Director giving approval
Publication Location
(refer to Policy on
Policies – Approvals and
Ratification):
Document Library
Folder/Sub Folder
Links to key external
standards
{Original Copy Signed}
Internet & Intranet
 Intranet Only
Clinical / Infection Prevention & Control
Regulation 12.
The British Committee for Standards in Haematology
(1995) Guidelines on the provision of facilities for the
care of adult patients with haematological
malignancies. (including leukaemia, lymphoma and
severe bone marrow failure.), Clinical and Laboratory
Haematology 1995; 17, 3-10
https://www.nice.org.uk/guidance/csg3/resources/impr
oving-outcomes-in-haematooncology-cancer-update773373709
The drinking water inspectorate (2009) Drinking Water
Safety: Guidance to health and water professionals.
Hawker, J. Begg, N. Blair, I. Reintjes, R. Weinberg, J.
(2012) Communicable Disease Control Handbook 3rd
Edition. Wiley-Blackwell Publishing. Oxford.
Related Documents:
Heymann, D.
(2014) Control of Communicable
Diseases Manual 20th Edition. American Public Health
Association. Washington.
The Royal Marsden NHS Trust (2015) Manual of
Clinical Nursing Procedures Ninth Edition. WileyBlackwell Publishing. Oxford
Wilson, J. (2006) Infection control in Clinical Practice
3rd Edition. Bailliere Tindall. London.
Department of Health (2015). The Health and Social
Care Act; Code of Practice for the Prevention and
Control of Health Care Associated Infections.
Department of Health. London
Cole, M. & Lai, L. (2009) Reviewing the efficacy of
infection control isolation. British Journal of Nursing.
Vol.18, No.7. pg 403-407.
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and
the Healthcare Infection Control Practices Advisory
Committee, 2007 Guideline for Isolation Precautions:
Isolation Policy
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Preventing Transmission of Infectious Agents in
Healthcare Settings
http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.
Accessed 29.10.13
Jones D, (2010) How to deal with the negative
psychological impact of MRSA isolation on patients.
Nursing Times, 106:36.
Abad C, Fearday A, Safdar N (2010) Adverse
effects of Isolation in hospitalised patients; a
systematic review. Journal of Hospital Infection 76:
97-102.
Department of Health (2010) Isolating patients with
healthcare associated infection. A summary of best
practice. DOH, London.
Health Promotion Scotland (2014) Transmission
Based Precautions Literature Review: Patient
Placement (Isolation/Coherting). HPS
http://www.nipcm.scot.nhs.uk/documents/tbp-patientplacement-isolation-and-cohorting/
Training Need Identified?
No
Version Control Table
Version
No
November
1
2007
Date
Summary of Changes
Final amendments approved. Document
published.
Changes Made by
(Name and Job Title)
Infection Prevention
and Control Team
January
2011
2
Incorporated protective isolation policy. Full
review and format update
Louise Dickinson
December
2013
3
Full review and format update
Louise Dickinson
June 2016
4
Full review. Changes made to:
6.2.13; 6.3.1; 6.3.5; References
Louise Dickinson,
Consultant Nurse,
Joint DIPC
[Please complete all boxes and delete help notes in blue italics including this note]
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Isolation Policy
Page 17 of 26
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Isolation Policy
Page 18 of 26
Appendix 2. Initial Equality Impact Assessment Form
Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter
referred to as policy) (Provide brief description): Isolation Policy
Directorate and service area: Corporate
Is this a new or existing Policy? Existing
Infection Prevention and Control
Name of individual completing
Telephone: 01872 254969
assessment: Louise Dickinson
1. Policy Aim*
To ensure staff have access to appropriate information to enable them
Who is the strategy /
to make decisions about the isolation of infected patients.
policy / proposal /
service function
aimed at?
2. Policy Objectives*
Appropriate isolation of infected and immunocompromised patients in
order to protect other patient‟s staff and visitors.
3. Policy – intended
Outcomes*
All patients are risk assessed for the need for isolation & appropriate
action taken.
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
Via auditing, practice review and carrying out work place inspections.
b) If yes, have these
*groups been
consulted?
Yes
C). Please list any
groups who have
been consulted about
this procedure.
Infection Prevention and Control Steering Group
Hospital Infection Prevention and Control Committee
All staff and patients.
Yes
Isolation Policy
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7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Yes
No

Rationale for Assessment / Existing Evidence

Sex (male, female, transgender / gender
reassignment)
Race / Ethnic
communities /groups

Disability -

Learning disability, physical
disability, sensory impairment
and mental health problems
Religion /
other beliefs

Marriage and civil
partnership

Pregnancy and maternity

Sexual Orientation,

Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
9. If you are not recommending a Full Impact assessment please explain why.
Signature of policy developer / lead manager / director
Names and signatures of
members carrying out the
Screening Assessment
Date of completion and submission
1.
2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust‟s web site.
Signed _______________
Date ________________
Isolation Policy
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Appendix 3. Table of Communicable Diseases and Appropriate
Precautions
It is the responsibility of the clinical team to complete a Notification of Diseases Certificate.
Disease or
Organism
Anthrax
Cutaneous
Pulmonary
Mode of
transmission from
person to person
In the health care
setting
Visitor
Restrictions
Duration of
isolation
Contact with lesions
None.
Duration of
disease
Person to person
spread unknown.
Advise not to
touch any
lesions.
Comments
NOTIFIABLE DISEASE
Infection Prevention and Control
Team must be informed if
anthrax is suspected.
All laboratory samples must be
labelled „high risk‟
In the event of a deliberate release
of anthrax spores the patient,
his/her belongings and the
environment may be
contaminated. Refer to HPA
guidelines www.hpa.org.uk
Candida Auris
Contact
Limit visitors
Chickenpox
Airborne via
respiratory secretions
and vesicle fluid
Contact with vesicle
exudate
Exclude those
who are nonimmune
7 days after
onset or until
lesions are
dry
CPE
Contact
Exclude those
who are nonimmune
Duration of
stay
Creutzfeldt Jakob
Disease (CJD) and
related disorders
Contact via
instruments used for
invasive procedures
None
Not required
Croup
Droplet
Contact via
contaminated
hands and
equipment.
Contact via faecal
oral route
Children and
the elderly
Whilst
symptoms
persist
Exclude those
who are
immunosuppressed.
Variable.
Usually 72
hours after
cessation of
symptoms
(Varicella zoster)
Diarrhoea
(suspected infective)
Non immune staff must be
excluded.
Negative pressure isolation room
preferred
Infectious up to 5 days before
appearance of rash
Special precautions required for
invasive procedures.
Also refer to CJD policy
Refer to Management of Patients
with Diarrhoea policy and
Norovirus policy.
Some diarrhoeas eg food
poisoning are NOTIFIABLE
DISEASES
Isolation Policy
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Disease or
Organism
Diphtheria
Respiratory
Mode of
transmission from
person to person
In the health care
setting
Droplet
Visitor
Restrictions
Duration of
isolation
Comments
Restrict to
those who
have already
had contact.
NOTIFIABLE DISEASE.
Gas Gangrene
No person to person
spread
None
3 days of
antibiotic
therapy or 4
weeks
untreated
N/A
Glandular fever
Contact via saliva
(kissing)
None
N/A
Cutaneous
Direct contact with
skin lesions
Gonococcal
Infection
Genito-urinary tract
(GT)
Ophthalmia
neonatorum
Hepatitis
Undiagnosed
Hepatitis A
Hepatitis B, C, E
Herpes simplex
Type I and II
Inform infection prevention on
suspicion.
Infection is usually endogenous
NOTIFIABLE DISEASE
Contact with
exudate from
mucous membranes
of the GT
Contact via
unwashed hands
Contact with blood,
faeces and other
body fluids
(percutaneous
expsure)
Contact (faecal-oral)
None
24 hours of
antibiotic
therapy
None
NOTIFIABLE DISEASE
None
7 days after
onset of
jaundice
NOTIFIABLE DISEASE
Contact with blood
and body fluids
(usually
percutaneous
exposure via used
sharps)
Contact with lesions
and
via shared towels
etc.
Droplet
None
Not required
NOTIFIABLE DISEASE (if
None
N/A
Direct or indirect
contact with blood
and body fluids
(usually
percutaneous
exposure via used
sharps)
None
N/A
acute)
*Single room required if bleeding
uncontrollably or has large open
wounds or receiving
haemodialysis.
* Single room may be required if
patient has extensive lesions
Herpes zoster
Refer Shingles
Human Immunodeficiency Virus
Impetigo
Refer streptococcal
infection
Isolation Policy
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Patients with AIDS may have
additional infectious conditions that
require isolation
Disease or
Organism
Mode of transmission from
person to person
In the health care setting
Visitor
Restrictions
Duration of
isolation
Comments
Infestations
Human Fleas
Contact with patient and
bedding and clothing
None
N/A
Human fleas are extremely
uncommon.
Cat/dog fleas
N/A
None
N/A
Treat animals and environment
Contact with patients,
clothing, bedding, towels etc
None
N/A
Repeat treatment one week
Contact (head to head)
and via shared combs, head
wear, pillows
Contact (usually sexual)
None
N/A
Repeat treatment one week
None
N/A
As this is usually STD consider
referral to GUM clinic for screening
Scabies
Contact with skin (prolonged
skin contact usually required)
None
Not required
Patient not considered infectious
following first application of
treatment. Apply second
application after one week. Itching
may continue for several
days/weeks. Close contacts will
need treatment.
Crusted/atypical
scabies
Contact with skin, bedding,
clothing etc
Recommend
limiting visitors
to those who
have already
had contact
until treated
None
As advised
by the IPAC
team
Refer to Dermatologist. Contacts
will need treatment.
Until treated
Family contacts or equivalent may
need treatment
Lice (Body)
Lice (Head)
Lice (pubic)
Contact via faecal oral route
Worms
Isolation Policy
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Disease or
Organism
Mode of transmission from
person to person
In health care setting
Visitor
Restrictions
Duration of
isolation
Comments
Influenza,
Seasonal
Droplets
4 days after
onset
Alert IPAC if more than one case on
same ward. FFP3 masks may be
required to be worn by staff during
aerosol generating procedures.
Legionnaires’
Disease
No person to person spread
Advise at risk
visitors to be
immunised.
Those in
contact should
not visit.
None
N/A
Microbiologist MUST be contacted
to arrange for rapid diagnostic
methods to be set up.
Leptospirosis
(Weil‟s Disease)
Listeriosis
Contact with blood and urine
None
N/A
Mother to baby in utero and
during delivery
None
Clinical
recovery
Microbiologists should be
informed as potentially
food borne
None
Not required
NOTIFIABLE DISEASE
Always consider the possibility of
other tropical infections which may
be infectious.
Exclude non immune
4 days after
rash appears
NOTIFIABLE DISEASE.
Recommend
limiting visitors
to those who
have already
had contact.
48 hours of
appropriate
antibiotics
No person to person
transmission
None
Not
necessary
NOTIFIABLE DISEASE
Contact (faecal oral)
+/- Droplet
None
Not
necessary
NOTIFIABLE DISEASE
Depends on site of colonisation.
Contact via unwashed hands
most significant route of
transmission.
Droplet
Contact with urine/saliva
None
On the
advice of the
IPAC Team
Exclude non
immune
9 days after
onset
NOTIFIABLE DISEASE
Mycoplasma
pneumonia
Droplet
None
10 days after
onset
Parvo virus
(human)
(Slapped Cheek)
Droplet
Exclude
pregnant
women
Usually once
rash appears
but see
comments.
Patients are usually no longer
infectious by the time the diagnosis
is confirmed.
Patients in aplastic crisis may be
infectious for 1 week after onset.
Malaria
Measles
Meningitis
Bacterial
Meningococcal
(Neisseria
meningitidis)
Other bacterial
causes e.g.
pneumococcal,
haemophilus
influenzae
Viral
Multi-Resistant
Gram Negative
Organisms
Mumps
Psittacosis
Contact (faecal oral) although
very rare
Transmitted by mosquito bite or
via percutaneous exposure
Airborne
Droplet
Person to person spread very
rare
None
Isolation Policy
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NOTIFIABLE DISEASE
NOTIFIABLE DISEASE
Exclude non immune staff
NOTIFIABLE DISEASE
Masks for airway management and
close prolonged contact.
Antibiotic prophylaxis may be
required for household and mouth
kissing contacts, those involved with
airway management. CCDC or
Health Protection Nurse will advise
N/A
Commonly caused by enterovirus
For ESBL refer to ESBL policy
Exclude pregnant members of staff.
Disease or
Organism
Mode of transmission from
person to person
In the health care setting
Visitor
Restrictions
Duration of
isolation
Comments
Pyrexia of
Unknown Origin
with recent travel
abroad
As cause is unknown all
modes of transmission must
be considered
Limited to
previous
contacts and
close family
Variable –
clinical
recovery if
cause not
confirmed
Malaria, typhoid and Hepatitis A are
the commonest causes of PUO in
returned travellers BUT
always consider possibility of
Viral Haemmorhagic Fever.
Quinsy
Droplet
48hrs from
commencing
antibiotics
Rabies
Contact via percutaneous
exposure to saliva
Exclude
children and
any visitor with
a wound
Limited to
previous
contacts and
close family
Droplets of saliva to
conjunctiva/mucosa.
For duration
of illness.
NOTIFIABLE DISEASE
Contact Microbiologist and IPAC
team if suspected.
Person to person transmission is
only a theoretical risk but because
of the implications of acquisition
strict adherence to isolation
precautions must be observed.
Own bath shower facilities
desirable.
Ringworm
(extensive)
Contact with skin scales,
nail and hair and
via associated equipment
e.g.hair clippers, shavers
None
Variable
Rubella
(German Measles)
Droplet
Exclude non
immune
4 days after
onset of
rash.
NOTIFIABLE DISEASE
Shingles
Contact with exudate
Airborne via vesicle fluid (in
disseminated shingles)
Exclude if non
immune to
chickenpox
Exclude staff non-immune to
chicken pox
Streptococcal
(Group A) Infection
Including sore throat
scarlet fever,
impetigo, erysipelas,
wound Infection,
toxic shock
syndrome, puerperal
fever.
Streptococcal
Group B (Neonatal)
Contact with lesions
Droplets
Recommend
excluding
children and
any visitor with
a wound.
1 week after
onset or until
lesions are
dry
48 hrs from
commencing
appropriate
antibiotics
Toxoplasmosis
Contact via faeces, skin sites
None
N/A
Restrict to
those who
have already
been exposed
only.
Two weeks
following
commencing
treatment
None
None
Scarlet Fever – NOTIFIABLE
DISEASE
Staff with sore throats should seek
advice from Occupational Health
No person to person spread
Tuberculosis
Pulmonary (open) ie
sputum smear
positive
Airborne via respiratory
droplet nuclei
Pulmonary (closed)
No spread
NOTIFIABLE DISEASE
Refer to TB policy
NOTIFIABLE DISEASE
Extrapulmonary
(excluding open
abscess and other
drainage lesions)
Typhoid &
Paratyphoid
NOTIFIABLE DISEASE
No spread
None
None
Indirect contact faecal/urine/oral spread
Advise
visitors not to
eat or drink in
the isolation
room
Variable
Isolation Policy
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NOTIFIABLE DISEASE
Ensure blood cultures and stools
are labelled with risk of infection
stickers
Vancomycin
Resistant
Enterococcus
(VRE)
Viral Haemorrhagic
Fever (eg Lassa,
Ebola, Marburg)
Whooping Cough
Contact with
colonised/infected sites
None
Until
informed by
IPAC Team
Contact - percutaneous
exposure to blood and body
fluids
?Droplet - pharyngeal
secretions
Airborne - respiratory
secretions
Immediate
family/ partner
Exclude
children.
As advised
by IPAC
Team
NOTIFIABLE DISEASE
Exclude non
immune
5 days after
antibiotics
started
NOTIFIABLE DISEASE
Modes of transmission
Contact - direct (touching, kissing, biting) or indirect via exposure with used sharps)
Droplet - large respiratory droplets propelled a short distance only
Airborne - via droplet nuclei or skin
Isolation Policy
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CONTACT IPAC TEAM
IMMEDIATELY ON SUSPICION