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SH CP 23 Care of the Deceased Patient in Relation to Infection Control Procedure (Infection Prevention and Control Policy: Appendix 19) This Appendix must be read in conjunction with the Infection Prevention and Control Policy. This policy may also be read with the Trust “Care of the service user after their Death Policy (SH CP 145) and “Care of the service user after their Death Procedure” (SH CP 146). Version: 2 Summary: Keywords (minimum of 5): (To assist policy search engine) The Health Act (2008) stipulates that NHS bodies must, in relation to preventing and controlling the risk of Health Care Associated Infections (HCAI), have in place core policies, including care of the deceased person. Implementation of this policy will contribute to the achievement of compliance with the Health Act(2008) Last offices, body bag, cadaver, infection notification sheet Target Audience: All staff of all disciplines, Non-Executive Directors, Volunteers, Governors and Contractors Next Review Date: February 2018 Approved & Ratified by: IP&C Group Date issued: February 2014 Author: Mary Pilgrim Infection Prevention & Control Nurse Jude Diggins Executive Director of Nursing, AHP & Quality and Director of Infection Prevention and Control Sponsor: Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 Date of meeting: 06.02.14 1 Version Control Change Record Date 15.10.13 09.01.14 Author Mary Pilgrim Mary Pilgrim Version 2 2 Page 4 2.2, 2.4 and 2.6 (added) 5 3.2, 3.3 6 3.6 1, title box 4, 2.3 5, 3.2 5, 3.3 6, 3.3 8. 9 19.1 21.01.14 Mary Pilgrim 2 7 3.7 Reason for Change Appendix numbering updated 2.6 Added for clarity of COSHH details Appendix numbering updated 3.3 grammar changes in text 3.3 reminders to staff about family not touching the body if infectious. HPA changed to PH (England) April 2013 Addition of This policy may also be read with the Trust “ Care of the service user after their Death Policy (SH CP 145) and “Care of the service user after their Death Procedure” (SH CP 146). Reference to The Health Act and policies as above. Definition of COSHH Updated text, new reference Addition of order codes References updated “Adapted from HSE 2005 and CDR 1995” added to table Added “refer to Appendix 19.1” and moved bullet point 3 to section 3.3 at top of the same page Reviewers/contributors Name IP&C Committee members IP&C Team Trudi Archer Sarah Garland Jill Angus Mark Roberts Angela Wilson Sue Adeyemo Kath Clark IP&C Committee members IP&C Team Clinical Directors & Professional Leads Bob Beeching Tracy England Steve Webb Trish Bone Jess Bundy Alan Johnstone Mandy Weldon Position Matron, ICS Matron, OPMH Area Matron, Petersfield Area Matron, Gosport & Fareham Ward Manager, Sultan, Gosport Matron, The Meadows Locality Manager, Childrens services Version Reviewed & Date Version 1 April 2012 Version 1 April 2012 Version 1 April 2012 Version 1 April 2012 Version 1 April 2012 Version 1 April 2012 Version 1 April 2012 Version 1 April 2012 Version 1 April 2012 Version 2 Jan 2014 Version 2 Jan 2014 Version 2 Jan 2014 Support Services Manager Senior Contract & Business Manager Site Manager, Parklands Site Manager, PCH FM Manager Head of Estates & Capital FM Manager Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 Version 2 Jan 2014 Version 2 Jan 2014 Version 2 Jan 2014 Version 2 Jan 2014 Version 2 Jan 2014 Version 2 Jan 2014 Version 2 Jan 2014 2 CONTENTS Page 1. Introduction 4 2. Definitions 4 3. Process • Personal care after death • Infection risk • Use of Body Bags • Vaccination of staff • Notification of Diseases • Public Health Act 5 4. Training 8 5. References 8 Appendices: • 19.1 Guidance on care of the cadaver in relation to known 9 and/or suspected infection risk • 19.2 Infection Notification Sheet 12 • 19.3 Action to be taken when a death occurs and a risk of 13 infection is known or suspected Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 3 Care of the Deceased Patient in Relation to Infection Control Procedure 1. Introduction 1.1 The care provided after a service user’s death and the support given to the family at this difficult time are an integral part of the service user’s overall care pathway and it is important to ensure that all health care professionals are able to deliver this care to the standard required. This applies to all settings in the Trust as well as the service user’s own home if attended by community staff. 1.2 There are approximately 600,000 deaths per year in the United Kingdom and about two-thirds occur in hospital, of that less than one percent is associated with a known or suspected infection. (CDR April 1995) 1.3 Opinion differs among health care workers on the management of a body associated with an infection and measures taken or advised to control the perceived hazards are often insensitively applied. For example the indiscriminate use of body bags can cause needless anxiety for the bereaved family, friends and staff. 1.4 This appendix advises staff of the actions they must take in order to prevent cross infection when caring for the deceased service user and should be read in conjunction with the policy on the care of the deceased service user including Last Offices. 1.5 Good clear communication regarding the possibility of an infection risk must be maintained between health care staff, mortuary attendants and funeral directors at all times. 2. Definitions 2.1 Cadaver – is a term used by physicians and other scientists to describe a deceased person or body 2.2 Hand hygiene – The process used to cleanse hands with soap and water, alcohol gel or a detergent based wipe, (refer to Hand Hygiene Appendix 6 Infection Prevention and Control Policy). 2.3 Last offices – This term has been used to describe the care given to the deceased person when this is focused on fulfilling religious and cultural beliefs as well as health, safety and legal requirements The Health Act 2010 (DH) also (Refer to Trust Care of the service user after their Death Policy (SH CP 145) and “Care of the service user after their Death Procedure” (SH CP 146). 2.4 PPE – Personal protective equipment should be available to all staff undertaking service user care (refer to Standard Precautions Appendix). 2.5 Body Bag – refer to 3.3 2.6 COSHH – (Control of substances hazardous to health) – Provides information on the control of substances hazardous to health, using chemicals or other hazardous substances at work that can put people’s health at risk. Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 4 3. Process. 3.1 Personal care of the service user after death (formally known as last offices) should honour the spiritual or cultural wishes of the deceased person. However if the service user has been in contact or has been diagnosed as an infection risk certain standard precautions are required to safeguard the health care worker, mortuary attendant and funeral director. It is essential that the management of deceased service users be handled with extreme sensitivity and a sensible approach. An individualized approach assists with the relationship between the families and carers at a time of probable distress. 3.2 Organisms in a dead body are unlikely to infect healthy people with intact skin, but there are other ways they may be spread. • Needle stick injuries from a contaminated instrument or sharp fragment of bone (refer to Sharps and Inoculation Management Appendix10 Infection and Prevention Policy). • Intestinal pathogens from anal and oral orifices • Through abrasions, wounds and sores on the skin • Contaminated aerosols from body openings or wounds e.g. tubercule bacilli when condensation could possibly be forced out of the mouth. • Splashes and/or aerosols onto the eyes The risks of infection are not high (and no more than in life) and are usually prevented by the use of standard precautions and the observation of COSHH regulations. The latter includes an assessment of risks of any micro organism which creates a hazard to health of any person. These standard precautions should be adhered to at all times and include: • Hand Hygiene • Appropriate use of protective clothing i.e. water repellent aprons and gloves • Appropriate cleaning of the environment. • Body Fluid Spillage management. • Waste disposal as per Trust Waste Management Policy • Sharps & Inoculation Management 3.3 Body bags should only be reserved for cases where a risk assessment makes it necessary. Plastic body bags are used for cadavers thought to be infective to handlers, or likely to leak in transit, or otherwise offensive bodies. The bags are in many cases used inappropriately for bodies, are of minimal or no risk and this causes problems to the staff of funeral parlours and unnecessary distress to relatives. Bodies cool more slowly inside a body bag, facilitating decomposition and making hygienic (last offices) preparation more difficult. It may only be possible to only display the head for viewing and this may cause additional distress to the bereaved. (Essex Health Protection Unit, 2012 Infection Control guidelines for Funeral Directors). Key Actions: • Most deceased service users with a known or suspected infection would be classed in categories, either A-D or 1-4 depending on the process adopted locally. Categories 1 (D) or 2 (C) are low risk and DO NOT require a body bag. Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 5 • There may still be occasions when a body bag is required because the service user is leaking body fluids or exudates. If a body is likely to leak then it must be placed in a body bag regardless of their infectivity status. These bags are available from NHS Supplies; there are many types of body bags available. But it is recommended that those made of polyvinyl chloride should not be used if the body is to be cremated because of the risk of dangerous emissions of dioxins (alternatives are available see table below); Order no VMS002 Manufacturers product code SL42 Description Body bag PEVA Adult size 220 x 107cm white with 3 sided zip capacity 140kg=22stone Price Qty Price 1+ 7.71 VMS011 Manufacturers product code SL57 Body bag PEVA Grab handled body bag with three sided zip size 228cm x 109cm white capacity 178kg = 28stone Qty Price 1+ 12.10 VMS015 Manufacturers product code SL90 Body bag PEVA Economy adult body bag with three sided zip 213cm x 101cm white capacity 120kg = 19 stone Qty Price 1+ 6.34 VMS021 Manufacturers product code SL75 Body bag PEVA Bariatric body bag with three sided zip size 250cm x 132cm white capacity 280kg = 43stone Qty Price 1+ 30.55 • If the deceased person had a known infectious disease that falls into Category 3 (B) or 4 (A) they must be placed in a heavy duty body bag. A reminder should be given that family, friends and staff must refrain from handling the body. • If the person had a known Category A or B (sometimes recorded numerically as 3 or 4) disease you must inform anyone else coming into contact with that service user e.g. Funeral Directors. (See appendix 19.1 of this document) • In some areas e.g. Lymington Hospital, all deceased service users are placed in a lightweight (white) body bag prior to removal from the ward. • Infection Notification sheet (Appendix 19.2) should be completed and attached to all bodies prior to their removal from the ward. This must be “outside” and visible for mortuary staff. Those who directly handle the body should wear appropriate protective clothing of disposable aprons and gloves. Mortuary staff should follow their own policies and procedures regarding the use of protective clothing. Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 6 3.4 All staff providing clinical care should have been appropriately immunised against Hepatitis B per current Occupational Health Guidance. (HPA March 2009) and SHFT Staff Immunisation Policy. Although vaccines can give good protection against Polio Virus, Diphtheria, Tuberculosis and Hepatitis B, the protection is not 100% effective and there are other infections against which there are no vaccines available e.g. HIV/AIDS and Hepatitis C. The use of standard precautions is therefore crucial in preventing cross infection. 3.5 Under the Health and Safety at Work Act (1974) (section 6.1.1) all employers have a responsibility for the safety of their employees. Those employees also have a duty of care to inform others of potential risks. Care of a deceased person who had a potentially infectious disease fall into this category (refer to Appendices 19.1 of this document) for guidance on the care of a cadaver in relation to known and/or suspected infection risk. 3.6 Notification Process for Infectious Diseases. The Health Protection Agency (HPA) is responsible for protection the community (or any part of the community) against infectious diseases and contamination. In relation to the notification process it has two main roles:• Receiving and responding to notifications • Surveillance reports and epidemiological studies 3.7 Public Health (Control of Diseases) Act 1984 & Regulations of 1988 – Section 10 of the Act defines those diseases to which sections 43-45 of the Act applies (see below and also refer to Appendix 19) when dealing with dead bodies. • Section 43 of the Act empowers a registered medical practitioner not to allow a body having suffered from AIDS, anthrax, rabies or viral haemorrhagic fever to be removed from hospital except for the purpose of being taken direct to a mortuary or being forthwith buried or cremated. • Section 44 of the Act places a responsibility on the person in control of a premises where a deceased person who has died from a Notifiable disease is held to prevent any other persons coming unnecessarily into contact with, or proximity to, the deceased person. - Section 44 thus places a specific responsibility on hospital authorities, nursing and residential homes and funeral directors. Section 44 requires appropriate steps to be taken to physically separate and control access to such a dead person. The law nevertheless recognizes that the separation can never be total. • Religious customs may dictate certain rites to be performed and relatives and friends to touch and kiss the face to complete the grieving process; there is no reason to discourage this in normal circumstances. • Section 45 of the Act considers it unlawful to hold a wake over such a body. The law therefore requires us to balance the necessary with the unnecessary. Public Health (England) can advise further. (Bakhshi SS 2001). Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 7 4. Training Refer to TNA in IP&C Policy 5. References: Bakhshi SS 2001: Code of Practice for funeral workers: managing infection risk and body bagging. Communicable Disease and Public Health vol 4 no 4 Department of Health2010: Health Protection Legislation (England) Guidance 2010 Healing TD, Hoffman PN, Young SEJ, (1995), Communicable Disease Report, CDR Report, The Infection Hazards of Human Cadavers, vol 5, R62-R68. Health and Safety at work Act 1974 Health Protection Agency, (March 2009, Revised 2012) Essex Health Protection Unit, Infection Control Guidelines for Funeral Directors Health and Safety Executive (HSE 2005) Controlling the risks of infection at work from human remains a guide for those involved in funeral services (including Embalmers) and those involved in exhumation. HSE 06/2005 Public Health (Control of Diseases) Act 1984: Section 10 Sally Bestwick, (2008) Policy for the Management of the Cadaver. Western Cheshire NHS Primary Care Trust. The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (DH 2010). Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 8 Appendix 19.1: Guidance on care of the cadaver in relation to known and/or suspected infection risk - Adapted from HSE 2005 and CDR 1995 Infection Embalming Hygiene Precautions (Last Offices) No No* Bereaved permitted to touch and spend time with body Yes Yes Yes Yes Yes Yes A (4) C (2) D (1) C (2) Yes No* No No** No Yes Yes Yes No Yes Yes Yes Cryptosporidiosis Dermatophtosis Diphtheria (N) Dysentery (Amoebic or Bacillary) Food Poisoning (or suspected) (N) HIV/AIDS Influenza Lassa Fever Legionellosis (N) Leprosy (N) Leptospirosis Lyme Disease Malaria (N) D (1) D (1) C (2) C (2) No** No No* No** Yes Yes Yes Yes No Yes Yes Yes with special care Yes Yes Yes Yes C (2) No** Yes Yes Yes B (3) D (1) A (4) D (1) D (1) C (2) D (1) C (2) No** No Yes No No No No No Yes Yes No Yes Yes Yes Yes Yes Yes** Yes No Yes Yes Yes Yes Yes Measles (N) D (1) No Yes Not advised Yes No Yes Yes Yes Yes Yes with special care Yes Meningitis (N) (non-meningococcal) Meningococcal Disease (N) D (1) No Yes Yes Yes C (2) No* Yes Yes Yes Mumps (N) D (1) No Yes Yes Yes MRSA Ophthalmia Neonatorum Orf virus disease Paratyphoid Fever (N) Plague (N) D (1) D (1) No No Yes Yes Yes Yes Yes Yes D (1) C (2) No No** Yes Yes Yes Yes Yes Yes A (4) Yes No No No Acute Encephalitis (N) Acute Poliomyelitis (N) Anthrax (N) Brucellosis (N) Chickenpox/Shingles Cholera (N) Degree of Risk e.g. 4=A = high D (1) C (2) Heavy Duty Body Bag Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 Yes Yes Yes Yes Yes 9 Infection Degree of Risk e.g. 4=A = high D (1) D (1) D (1) A (4) C (2) Heavy Duty Body Bag Bereaved permitted to touch and spend time with body Yes Yes Yes No Yes Embalming Hygiene Precautions (Last Offices) Yes Yes Yes No Yes Yes Yes Yes No Yes D (1) A (4) No Yes Yes No Yes No No** Yes No –but current WHO guidance states that relatives may view the body if they wear appropriate PPE Yes Salmonellosis C (2) Yes Yes Scarlet Fever C (2) No* Yes Yes Yes Smallpox (N) A (4) Yes No No No Invasive Group A Streptococcal Infection Tetanus (N) Tuberculosis Typhoid Fever Typhus Viral Haemorrhagic Fever (N) Transmissible Spongiform Encephalopathies e.g. Creutzfeldt – Jakob Disease Tuberculosis (N) Viral Hepatitis A Viral Hepatitis B, C & Non A, non B Hepatitis Whooping Cough(N) Yellow Fever (N) A (4) Yes No No No D (1) C (2) C (2) B (3) A (4) No No* No** Yes Yes Yes Yes Yes No No Yes Yes Yes No No Yes Yes Yes No No B (3) Yes Yes No Yes C (2) C (2) B (3) No* No* No** Yes Yes Yes Yes Yes Not advised Yes Yes Yes*** D (1) A (1) No Yes Yes No Yes No Yes No Pneumonia/Bronchitis Psittacosis Q Fever Rabies (N) Relapsing Fever Rubella (N) SARS (N) No No No Yes No* Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 10 Key to Table (N) = Notifiable Diseases = Diseases requiring notification (to Local Authority Proper Officers) under the Health Protection (Notification) Regulations 2010. No* The degree of (A, B, C &D) are absolute and, in most cases, are not specified in law. The advice given in a specific case may be varied if the Clinician-inCharge/Hospital Infection Control Doctor or Consultant in Health Protection has deemed it appropriate after assessing the risks. No** Means no unless there is leakage of body fluids Yes*** Means Last offices can be performed unless there is leakage of body fluids. Standard precautions are always required and supervision of relatives. Levels of Risk used in table above maybe referred to numerically or alphabetically by different agencies e.g. A = 4 = very high risk, as below:A (4) – Very High B (3) – High C (2) – Medium D (1) - Low *Adapted from HSE 2005 and CDR 1995 Other conditions requiring a body bag a. Known intravenous drug user b. Severe secondary infection c. Gangrenous limbs and infected amputation sites d. Large pressure sores e. Body fluid or exudate leakage (as above). f. Death in a Dialysis Unit g. Following a Post Mortem examination h. Incipient decomposition Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 11 Appendix 19.2: Infection Notification Sheet Please place in an envelope marked for the attention of the undertaker to accompany the deceased. Name of the deceased Address DOB GP & Surgery Date and time of death Hospital & ward The deceased’s remains are a potential source of infection: YES / NO / UNKNOWN (SEE NOTE 1 BELOW) If YES (see note 2 below) the remains present a potential infectious hazard of transmission by: (ring as appropriate) Inoculation Aerosol Ingestion Instructions for handling remains (if YES, tick as appropriate): Can relatives view the body ( ) Body bag required ( ) Embalming ( ) Signed: Print name: NOTES: Note 1: Not all service users display typical symptoms, therefore some infections may not have been identified at the time of death. Note 2: In accordance with the Health and Safety law and the information provided in Health Services Advisory Committee Guidance Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 12 Appendix 19.3 Action to be taken when a death occurs and a risk of infection is known or suspected In hospital/community At home/community Death Risk of infection to others Assess by Clinician Assess by GP May consult Infection Control Doctor (at local Acute Trust) May consult Consultant in Public Health Agree risk of infection refer to Appendix re: risk section 3.7 Infection control sheet to accompany body Mortuary staff and Funeral Directors Care of the Deceased Patient in Relation to Infection Control Procedure Infection Prevention and Control Nurse Version 2 February 2014 13