Download Chapter 4B Isolation instruction charts 2014 V9

Infection Prevention & Control Manual
Chapter 4B
Isolation Instruction Posters
Version 9
Document Summary
This policy provides poster guidance for the appropriate actions and
responsibilities for the management of patients in isolation.
DOCUMENT NUMBER
APPROVING COMMITTEE
DATE APPROVED
DATE IMPLEMENTED
NEXT REVIEW DATE
ACCOUNTABLE DIRECTOR
POLICY AUTHOR
TARGET AUDENCE
KEY WORDS
STHK0041
Patient Safety Council
10 September 2014
1 October 2014
1 October 2017
Sue Redfern, Director of Nursing, Midwifery &
Governance
Karen Allen, Director of Infection Prevention &
Control
All clinical staff
Isolation, barrier nursing, poster, chart.
Important Note:
The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as “uncontrolled” and, as such,
may not necessarily contain the latest updates and amendments.
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
Document Version History
Date
Version
March 1986
1
December 1992
2
December 1994
3
September 2000
4
November 2003
5
1 November 2006
6
1 November 2008
7
1 October 2011
8
1 October 2014
9
1 October 2017
Review
Date
Summary of key changes
Format changed.
Contact details updated.
Posters revised.
Format changed.
Author
Designation
Service Manager
Infection Prevention
& Control
Service Manager
Infection Prevention
& Control
Service Manager
Infection Prevention
& Control
Service Manager
Infection Prevention
& Control
Service Manager
Infection Prevention
& Control
Service Manager
Infection Prevention
& Control
Service Manager
Infection Prevention
& Control
Service Manager
Infection Prevention
& Control
DIPC
Lead Nurse,
Infection Prevention
& Control
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
CONTENTS
Item No.
Subject
Page No.
1.
Scope
4
2.
Introduction
4
3.
Statement of Intent
4
4.
Definitions
4
5.
Duties, Accountabilities and Responsibilities
4
6.
6.1
6.2
6.3
6.4
Process
General Information
Isolation precautions
For further advice and guidance
Glossary
5
5
5
6
6
7.
Training
6
8.
Monitoring compliance
6
8.1.
Key Performance Indicators of the Policy
6
8.2.
Performance Management of the Policy
6
9.
References and Bibliography
7
10.
Related Policies and Procedures
7
11.
12.
Equality analysis
Appendices
Appendix 1 Contact Isolation Poster
Appendix 2 Airborne Isolation Poster
Appendix 3 MRSA and CDT Isolation Poster
Appendix 4 Protective Isolation Poster
Appendix 5 Isolation Audit Tool
7
8
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
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9
10
11
12
St Helens & Knowsley Teaching Hospitals NHS Trust
1. Scope
This policy applies to all clinical and Medirest staff within St Helens and Knowsley
Teaching Hospitals NHS Trust to ensure that appropriate actions are taken when isolation
precautions are required.
This policy assists staff in the choice of correct isolation poster, ensures correct isolation
procedures are followed according to diagnosed infections and thereby prevents spread of
the infection amongst staff and patients.
2. Introduction
When special precautions are required for patients with an infection/infectious disease an
appropriate instruction poster should be used to indicate the specific recommendations
needed to provide the patient with appropriate care whilst also promoting a safe
environment.
Instruction posters are available for placing on the outside of the isolation cubicle, to
indicate to those entering the room the special precautions to be taken.
The instruction posters can be obtained via the intranet, on the Infection Prevention and
Control website. They can be downloaded and laminated.
3. Statement of Intent
The objective of the policy is to provide information to staff on the correct choice of
isolation posters. This ensures that staff and visitors are aware of the precautions required
to prevent cross infection.
4. Definitions
An isolation poster instructs the person entering the room on what protective clothing to
wear and what precautions are required to prevent acquisition or transfer of infection.
5. Duties Accountabilities and Responsibilities
For full details of infection control responsibilities see Infection Control Policy, Chapter 28B
Infection Control Manual.
5.1. Staff
It is the responsibility of all clinical staff to:
 be aware of the current guidelines.
 put these guidelines into practice.
 bring to the attention of the Unit Manager or Infection Prevention and Control Team
any problems in applying these guidelines
Breaches of this policy may lead to disciplinary action being taken against the individual.
5.2. Unit managers (person in charge of a ward or department) must ensure that
 The policy is readily accessible to all staff.
 The required facilities and equipment are available to enable compliance with the
policies.
 All staff within their area of responsibility have received training in the appropriate
procedures with respect to infection control.
 The ADT/HEARTS/EDMS systems are checked for infection alert status when a
patient is admitted.
5.3 Medirest
It is the responsibility of Medirest management to ensure that all domestic, catering and
portering staff adhere to the Trust Isolation Policy.
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
6. Process
6.1 GENERAL INFORMATION
Isolation Poster: What is it?
The Infection Prevention and Control Team has devised four isolation posters. These are
simple instructions to be placed on the outside of the door of a patient in a single room
who has a condition that could potentially spread infection. There is another poster, a
protective isolation poster that should be placed on the outside of the door of patients
particularly vulnerable to the acquisition of infections.
Transfers to other wards and departments
The receiving ward or department should always be informed in advance when a patient is
transferred. Staff should indicate on investigation request forms when a patient has an
infection/infectious disease. This ensures that staff handling patients with infections are
aware of the precautions required to prevent cross infection and promote a safe
environment. The infection has to be documented on the transfer form or discharge letter.
6.2 ISOLATION PRECAUTIONS
A. Contact isolation poster
Used to prevent the dissemination of infections normally spread by direct contact/or
contact with any body fluids or secretions and articles which have been in close
contact with the infected patient e.g. antibiotic resistant coliforms/pseudomonas,
Group A streptococci, gastro-intestinal infections.
B. Airborne isolation poster
Used to prevent infection with airborne pathogens: those that are transmitted by
large/small droplet nuclei and generated in the course of talking, coughing,
sneezing and during procedures involving the respiratory tract i.e. suction. e.g.
tuberculosis (TB), chickenpox, shingles.
C. Meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile
(CDI) isolation poster
Used specifically for patients with MRSA and CDI. These are compliant with
national guidelines on the prevention of spread of MRSA and CDI.
D. Blood and body fluid isolation poster (universal/standard precautions)
(No poster required)
Used to prevent infection with blood borne disease. Health Care Workers who
come into contact with blood, secretion and excreta may be exposed to pathogens
including blood borne viruses such as HIV (human immunodeficiency virus),
hepatitis B and C. As it is impossible to identify all those with infection it is
recommended that all body fluids are regarded as potentially infectious and
universal precautions are used.
E. Protective isolation
This is used to prevent both airborne infections and those spread by direct
contamination to susceptible patients (e.g. those immune-suppressed by disease or
drug therapy). Precautions are therefore to prevent contamination by direct contact
and by self infection (endogenous) from patient’s natural flora.
NB. These patients should not be nursed in the vicinity of infected patients.
Copies of isolation posters are available from the Infection Prevention and Control Nurse
Specialists. Copies of isolation posters can also be obtained from the Infection Prevention
and Control website. Do not photocopy posters. Only computer-generated posters or
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
those available from the Infection Prevention and Control Nurse Specialists are
acceptable. All posters need to be laminated. If in doubt as to which precautions to use,
check Chapter 12, Infection Control Manual.
6.3 Further advice
For further advice and guidance please contact:
Lead Nurse, Infection Prevention and Control
Ext: 1193
Clinical Nurse Specialists, Infection Prevention and Control
Ext: 2452/1384
Consultant Microbiologists
Ext: 1836/1622/1834 or duty microbiologist out of hours
6.4 Glossary
CDI: Clostridium difficile infection
MRSA: Meticillin resistant Staphylococcus aureus
7. Training
Training required to fulfil this policy will be provided in accordance with the Trust’s
Induction Mandatory and Risk Management Training Policy - Training Needs Analysis.
8. Monitoring compliance with this document
8.1 Key performance Indicators of the Policy
Describe Key Performance Frequency
Indicators (KPIs)
Review
Infection Prevention Society Audit Annual
Tool for isolation precautions
(Appendix 5)
of Lead
Lead Nurse, Infection
Prevention & Control
8.2 Performance Management of the Policy
Aspect
of Monitoring Individual
Frequency Group
/
compliance
method
responsible of
the committee
or
for
the monitoring which
will
effectiveness
monitoring activity
receive
the
being
findings
/
monitored
monitoring
report
Compliance
Ward audit
with audit tool
Appendix 5
IPCT
Annual
HIPG
Group
/
committee /
individual
responsible
for
ensuring
that
the
actions are
completed
HIPG
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
9. References/ bibliography
9.1. Department of Health 2008. The Health Act 2008. Code of Practice for the Prevention
and Control of Health Care Associated Infections.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh
_110435.pdf
10. Related trust policy/procedures
Chapter 4
Policy for the Patient in Isolation
Chapter 5
Personal Protective Equipment Policy
Chapter 12
Isolation Policy
11. Equality analysis
Please refer to the overarching document which covers all chapters of the Infection Control
Manual. http://nww.sthk.nhs.uk/MANAGE/library/documents/EqualityAnalysisforICM.pdf
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
Appendix 1: Contact Isolation Poster
CONTACT
PRECAUTIONS
(SOURCE ISOLATION)
STAFF MEMBERS
HANDS
APRONS
Wash hands or use alcohol gel
before touching the patient
Wear a yellow apron on
entering the room.
GLOVES
Wear gloves if you are to have
direct or indirect contact with
the patient, bed linen,
secretions, etc
DOOR
Please keep the door
CLOSED
BEFORE
LEAVING
Decontaminate equipment
when it leaves the room.
Discard gloves and apron
and wash hands before you
leave the room.
VISITORS/PORTERS/DOMESTICS
REPORT TO THE NURSE-IN-CHARGE OR
SEEK ADVICE FROM THE NURSING STAFF
BEFORE ENTERING THIS ROOM
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ISSUE DATE: JUNE 2007
REVIEW DATE: DECEMBER 2014
Appendix 2: Airborne Isolation Poster
AIRBORNE
PRECAUTIONS
STAFF MEMBERS
HANDS
APRONS
GLOVES
MASKS
DOOR
Wash hands or use alcohol gel
before touching the patient
Put on a yellow apron and
gloves on entering the room.
Put on mask only if directed by
Infection Prevention and
Control.
Please keep the door
CLOSED
Decontaminate equipment
when it leaves the room.
BEFORE
LEAVING
Discard gloves and apron and
wash hands before you leave
the room.
VISITORS/PORTERS/DOMESTICS
REPORT TO THE NURSE-IN-CHARGE OR
SEEK ADVICE FROM THE NURSING STAFF
BEFORE ENTERING THIS ROOM
ISSUE DATE: JUNE 2007
NEXT REVIEW DATE: DECEMBER 2014
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
Appendix 3: MRSA and CDT Isolation Poster
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical)
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
Appendix 4: Protective Isolation Poster
PROTECTIVE
ISOLATION
PRECAUTIONS
STAFF MEMBERS
HANDS
APRONS
Wash hands or use alcohol gel
before touching the patient
Put on a yellow apron and
gloves on entering the room.
GLOVES
DOOR
Please keep the door
CLOSED
Decontaminate equipment
when it enters
& leaves the room.
BEFORE
LEAVING
Discard gloves and apron
and wash hands before you
leave the room.
VISITORS/PORTERS/DOMESTICS
REPORT TO THE NURSE-IN-CHARGE OR
SEEK ADVICE FROM THE NURSING STAFF
BEFORE ENTERING THIS ROOM
ISSUE DATE: JAN 2011
REVIEW DATE: JAN 2014
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Issue Date: 1st October 2014
Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
Appendix 5: Infection Control audit tool: clinical practices- isolation precautions
Standard: Clinical practices are based on best practice and reflect infection control
guidance to reduce the risk of cross infection to patients whilst providing appropriate
protection to staff
N.B. This audit should be undertaken over a period of time to allow for the observation of
as many practice elements as possible
Date ………………………. Ward …………………………………..
Auditor……………………………………….
Yes No
1
2
3
4
5
6
7
8
9
10
11
12
N/A
Comments
Isolation facilities are available in
inpatient areas
Patients requiring isolation facilities due
to infection have access to them
Where a patient is being isolated for
infection control reasons, the
precautions are appropriate and
according to local policy
Protective clothing is readily available
upon entering the isolation room
Hand hygiene facilities are available,
accessible and clean within the room
No inappropriate or unnecessary items
are stored in the isolation room (no
clutter)
Where a patient is being isolated for
infection control reasons, the patient is
aware of the need or rationale for this
Clear instructions for staff and visitors
are in place when a patient is in
isolation (e.g. confidential notice on the
door)
Appropriate information leaflets are
available to patients for common
infections e.g. MRSA, Clostridium
difficile infection (CDI)
Visitors are advised that they do not
routinely need to wear protective
clothing
Reusable equipment which may
become readily contaminated is
dedicated for the patients use only (e.g.
Commode, hoist, sling) are they clean?
Used linen, waste and crockery have
been removed from the room in a timely
manner
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13
14
15
16
17
18
19
20
Continued
Housekeeping staff are aware of the
local policy and procedures for cleaning
isolation rooms
Separate colour coded cleaning
equipment is in use for isolation
facilities
Isolation precautions are discontinued
when no longer necessary
Nursing documentation is outside the
side room
Are staff following infection control
policy? i.e. wearing PPE,
decontaminating hands.
Are MRSA/CDI care plans evident in
nursing documentation?
Have CDI patients had referral to
dietetics?
Are fluid balance/stool posters evident
in CDI patient’s documentation?
Yes No
N/A
Comments
Comments:
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