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Transcript
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) Page 1 of 13 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) Page 2 of 13 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) Page 3 of 13 Issue Date: 1st October 2014 Policy Reference number: STHK0041 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) Page 4 of 13 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) Page 5 of 13 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) Page 6 of 13 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) Page 7 of 13 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 Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical) Page 8 of 13 Issue Date: 1st October 2014 Policy Reference number: STHK0041 St Helens & Knowsley Teaching Hospitals NHS Trust 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 Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical) Page 9 of 13 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) Page 10 of 13 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 Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical) Page 11 of 13 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 Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical) Page 12 of 13 Issue Date: 1st October 2014 Policy Reference number: STHK0041 St Helens & Knowsley Teaching Hospitals NHS Trust 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: Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical) Page 13 of 13 Issue Date: 1st October 2014 Policy Reference number: STHK0041