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ISOLATION POLICY DOCUMENT CONTROL: Version: Ratified by: Date ratified: Name of originator/author: Name of responsible committee/individual: Date issued: Review date: Target Audience: 4 Clinical Effectiveness Committee 8 March 2012 Practice Development Modern Matron and Senior Infection Prevention and Control Nurse Specialist Infection Prevention and Control Committee 19 March 2012 March 2015 The policy applies to all staff providing care to all patients under the care of the Trust, whether in a direct or indirect patient care role. CONTENTS SECTION 1. INTRODUCTION PAGE NO 2. PURPOSE 3 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4 4.1 Chief Executive, Nurse Director, Deputy Director of Nursing 4 4.2 4.3 4.4 4.5 Infection Prevention and Control Nurse Specialists Matrons and Ward/Department Managers All staff 4 4 4 4 5. PROCEDURE/IMPLEMENTATION 4 5.1 5.2 5.3 5.4 Principles Of Isolation Guidelines For Single Room And Cohort Nursing Management Of The Isolated Patient Confidentiality 5 5 5 6 6. TRAINING IMPLICATIONS 6 7 MONITORING ARRANGEMENTS 7 8. EQUALITY IMPACT ASSESSMENT SCREENING 7 8.1 Privacy, Dignity and Respect 7 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS 7 10 REFERENCES 7 11 APPENDICES Appendix 1- Mode of Transmission Appendix 2 - ISOLATION PRECAUTIONS - PLANNING GUIDE Appendix 3- Signage for Isolation Nursing Appendix 4 - ISOLATION – CLEANING CHECK LIST Appendix 5 - Inter-healthcare transfer form 8 9 10 14 16 17 Ward/Department Managers Page 2 of 18 1. INTRODUCTION Healthcare associated infections such as Meticillin Resistant Staphylococcus aureus; Clostridium difficile infection, Extended Spectrum Beta-Lactamase, Norovirus and other multi resistant organisms may be transmitted between patients and potentially between patients, staff and visitors. Transmission of infection involves a source of infecting microorganism, a susceptible host and a mode of transmission. When a patient is suspected or known to be suffering from infection, an understanding of the source, route and mode of the transmission (Appendix 1) of infection is essential in order to institute the appropriate infection prevention and control principles, including isolation. Standard precautions must be applied to all patients without exception, inclusive of environmental cleaning, personal protective equipment and hand hygiene. The isolation of patients must be based on the infection risk, symptoms and transmission in accordance with the relevant infection prevention and control policy The Medical Practitioner is responsible for ensuring notification of communicable diseases is undertaken. In the Community Setting, isolation of patients is not usually required. However, staff caring for the susceptible or known infected patient must adhere to the principles of infection prevention and control. Advice should be sought in the first instance from the Infection Prevention and Control Team (IPCT) on the appropriateness of isolating patients. Out of hours, at weekends and bank holidays, through the Assistant Director who would if needed consult the local Microbiology service. 2. PURPOSE This policy has been developed in order to ensure the correct employment of isolation procedures to reduce and minimise the risk of cross infection to patients, visitors and healthcare workers. Minimising the inappropriate movement of patients with infections for non-clinical reasons. Ensuring the organisation complies with the requirements of the Health and Social Care Act (2008) Code of Practice for health and adult social care on the prevention and control of infections and related guidance. 3. A summarised planning guide to isolation procedures is provided (Appendix 2). The Consultant in Communicable Disease Control (CCDC) must be notified for infections marked with an asterisk (*). This is the responsibility of the medical staff and notification forms are available for this purpose. SCOPE The policy applies to all staff providing care to all patients under the care of the Trust, whether in a direct or indirect patient care role. Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum and bank staff contracted by the Trust. Page 3 of 18 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Chief Executive, Nurse Director, Deputy Director of Nursing The Chief Executive has ultimate responsibility for Infection Prevention and Control (IPC) however; the Nurse Director has designated responsibility as Director of Infection Prevention and Control (DIPC). The DIPC will provide regular updates to the Board. The Deputy Director of Nursing also has designated IPC duties in support of the DIPC, particularly with regard to the implementation of the Essence of Care Standards. 4.2 4.3 Infection Prevention and Control Nurse Specialists To provide specialist advice and support to Modern Matron, Lead nurses and staff within the localities. Give advice on complex issues relating to the control of infection and report findings to the DIPC. Matrons and Ward/Department Managers It is the responsibility of Matrons and Ward/Department Managers to ensure implementation and compliance with this policy. 4.4 Ward/Department Managers It is the responsibility of ward/department managers to ensure: 4.5 All clinical staff can demonstrate compliance with the policy All relevant staff to attend mandatory annual infection prevention and control training. Infection Prevention and Control responsibilities form part of the individuals annual Personal Development Plan. All staff All staff must be aware of their personal responsibilities in preventing the spread of infection. Adherence to this policy is the responsibility of all staff. This applies to staff employed by the Trust, agency, locum, and bank staff and those contracted to the Trust. 5. PROCEDURE/IMPLEMENTATION Infection risks should be assessed (risk assessment) and managed accordingly (risk management). Advice should always be sought from a member of the infection prevention and control team. Isolation of patients is undertaken for two reasons: Source Isolation To prevent transmission of infection from the infected patient to Others Protective Isolation To prevent transmission of infection to a susceptible patient Page 4 of 18 In some cases strict source isolation is required to prevent the spread of highly transmissible infections e.g. Diphtheria and viral haemorrhagic fevers using negative pressure facilities. Current facilities for isolation within the Trust include limited single room access. These facilities are not suitable for prolonged accommodation of patients with highly infectious diseases e.g. Diphtheria and viral haemorrhagic fevers. Strict guidance must be sort from the Consultant Microbiologist and Infection Prevention and Control team. This will involve transfer of such patients to an identified infectious diseases hospital in specially equipped ambulances. Principally this policy will refer to source isolation. 5.1 PRINCIPLES OF ISOLATION 5.2 GUIDELINES FOR SINGLE ROOM AND COHORT NURSING 5.3 Ideally, the most effective form of isolation is a single room (Pratt et al 2007). Single rooms should always be the first choice for placement of an infected patient. Where this is not possible cohort nursing should be employed. Cohort nursing involves nursing patients with the same organism (or displaying similar signs and symptoms of infection) as an alternative form of isolation nursing when single room capacity is exceeded. Cohort patients should be nursed by designated staff Advice on the decision to isolate a patient and guidance on isolation management should always be sought from the Infection Control Team. Individual risk assessment should take into account infection risk; severity of illness requiring close observation, patient’s mental state being a contra-indication to single room accommodation and the availability of single room accommodation. Staff must follow standard infection prevention and control procedures at all times in line with Trust policies. Routine explanation of infection, isolation procedures and treatment must be given to affected patients and visitors. Rooms, bays and areas for isolated patients must have dedicated hand hygiene and toileting facilities for example designated commodes. Use clear signage on doors or walls to alert staff and visitors of isolation precautions (Appendix 3) Doors must be kept closed at all times. Potentially there may be a need to restrict the number of visitors / relatives visiting the affected patient. This will be discussed with the Nurse in charge and infection prevention and control team. MANAGEMENT OF THE ISOLATED PATIENT Hand Hygiene Refer to Hand Hygiene policy High standards of hand hygiene minimise the risk of cross infection Hand hygiene must be performed before and after each direct patient contact (regardless of glove use) Adequate hand hygiene facilities and hand gel must be available for use Personal Protective Equipment Refer to Standard Infection Prevention and Control Precautions policy Page 5 of 18 Disposable aprons must be worn by all staff and visitors assisting in the care of the patient or having contact with their immediate environment Disposable gloves must be worn where there is contact with bodily fluids and when handling contaminated items Fans must not be used to control patient’s temperature Medical notes and charts must be kept outside the room/bay/area Personal protective clothing worn in the isolation room should be disposed of in the room unless dealing with body fluids that require disposal in the sluice Cleaning and Decontamination Refer to the Decontamination policy Isolation room/bay/area should be clean and uncluttered with only necessary equipment used Where possible single patient use equipment should be used e.g. commodes and medical equipment Multiple patient use equipment must be decontaminated in accordance with the Decontamination Policy Protective covers should be used on both disposable and non-disposable bedpans/urinals. When used bedpan holders, bedpans and urinals must be emptied and placed immediately into washer disinfector at a temperature of 80 degrees Celsius Treat all linen as infected (Refer to Laundry policy) Waste must be categorised as hazardous waste (Refer to Waste policy) Cleaning procedures must be rigorously applied (Refer to Decontamination policy) Enhanced cleaning must be performed twice daily and documented accordingly (Appendix 4) All staff must be aware of individual responsibilities for undertaking regular cleaning (Refer to Decontamination policy) All staff including domestic staff must be aware of which rooms require terminal cleaning and when these have been completed. Movement Transfer and movement of patients must be kept to a minimum to reduce the risk of cross infection Transfer and movement of patients must only be undertaken for clinical reasons If transfer is necessary 5.4 Inform the Infection Prevention and Control team Receiving area must be informed of infection status to ensure implementation of infection control measures. Ensure the inter health care transfer form is fully completed (appendix 5) Hand hygiene and personal protective equipment procedures must be strictly maintained Equipment used for transfer of patient must be decontaminated after use CONFIDENTIALITY All patients have a right to dignity, privacy and respect. It is essential to maintain confidentiality, regarding the patient's illness. Certain infections or outbreaks of infection arouse interest and speculation by the media and staff must not divulge such information within or outside the hospital. 6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but all staff will need to be aware of its contents. Staff will be made aware through: Line manager Page 6 of 18 7. Team Brief Team meetings One to one meetings/supervision Trust Policy web site MONITORING ARRANGEMENTS Area for How monitoring Breaches policy When Isolate 8. Who by of IR1 Modern Matrons and IP&CT Incorporated in IP&CT to IP&C audit tool Reported to Frequency IP&C Committee As there occur Audit results to Annually Modern Matron and Ward Managers EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. Indicate how this will be met No issues have been identified in relation to this policy. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 9. LINKS TO OTHER PROCEDURAL DOCUMENTS This policy should be read in conjunction with other Trust Infection Prevention and Control Policies, particularly: 10. Standard Precautions Hand Hygiene Laundry Waste Management Decontamination REFERENCES 1. Hospital Infection Society (2001) - Review of Hospital Isolation and Infection Control Related Precautions - Report of the Joint Working Group. Page 7 of 18 2. Wilson, J. (2001) - Infection Control in Clinical Practice. London: Bailliere Tindall. 3. Department of Health (2008). The Health and Social Act: Code of Practice for health and adult social care on the prevention and control of infections and related guidance. London. Crown Copyright. 4. Department of Health (2009) Clostridium difficile infection : How to deal with the problem 5. Department of Health (2007a) Saving Lives: Reducing Infection, Delivering Clean and Safe Care. www.dh.gov.uk 6. Department of Health (2007b) High Impact Intervention No 7. Care Bundle to Reduce the Risk from Clostridium Difficile. www.dh.gov.uk 7. Department of Health (2007c). A Simple Guide to Clostridium Difficile. www.dh.gov.uk 8. Department of Health (2006). Essential Steps to Safe, Clean Care. London. Crown Copyright. 9. Department of Health (2006). A Health Technical Memorandum: Safe Management of Healthcare Waste. London. Crown Copyright. 10. Department of Health (2006). Saving Lives Programme. Isolating patients with healthcare associated infection. A summary of best practice. London. Crown Copyright. 11. Healthcare Commission and the Health Protection Agency (2005). Management, prevention and surveillance of Clostridium Difficile: Interim findings from a national survey of NHS acute trusts in England. December 2005. 12. Healthcare Commission (2007) Investigation in to outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust. London. October (2007). 13. Hospital Infection Society (2001) - Review of Hospital Isolation and Infection Control Related Precautions - Report of the Joint Working Group. 14. Wilson, J. (2001) - Infection Control in Clinical Practice. London: Bailliere Tindall. 15. Department of Health (2008). The Health and Social Act: Code of Practice for health and adult social care on the prevention and control of infections and related guidance. London. Crown Copyright. 16. Department of Health (2009) Clostridium difficile infection : How to deal with the problem 17. Department of Health (2007a) Saving Lives: Reducing Infection, Delivering Clean and Safe Care. www.dh.gov.uk 18. Department of Health (2007b) High Impact Intervention No 7. Care Bundle to Reduce the Risk from Clostridium Difficile. www.dh.gov.uk 19. Department of Health (2007c). A Simple Guide to Clostridium Difficile. www.dh.gov.uk 20. Department of Health (2006). Essential Steps to Safe, Clean Care. London. Crown Copyright. 21. Department of Health (2006). A Health Technical Memorandum: Safe Management of Healthcare Waste. London. Crown Copyright. 22. Department of Health (2006). Saving Lives Programme. Isolating patients with healthcare associated infection. A summary of best practice. London. Crown Copyright. 23. Healthcare Commission and the Health Protection Agency (2005). Management, prevention and surveillance of Clostridium Difficile: Interim findings from a national survey of NHS acute trusts in England. December 2005. 24. Healthcare Commission (2007) Investigation in to outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust. London. October (2007). 25. National Institute of Clinical Excellence. (2003) Infection Control: Preventing Healthcare Associated Infection in primary and community care. NICE Publications. 26. National Institute of Clinical Excellence. (2003) Infection Control: Preventing Healthcare Associated Infection in primary and community care. NICE Publications. 11. APPENDICES Page 8 of 18 APPENDIX 1 Mode of Transmission Airborne Microorganisms transmitted directly, to susceptible patients, in dust and skin cells carried by the air during procedures. The microorganism is dispersed widely and over long distances Human Skin scales, droplets wound dressings, bedding and respiratory Aerosolised fluid Nebulisers, humidifiers, showers and cooling towers Dust Building work, sweeping and bed making Droplet Contact Microorganisms transmitted in respiratory droplet nuclei sneezing, coughing and talking. The microorganism is dispersed over short distances only Direct Microorganisms transmitted from person to person and by the hands of healthcare workers Skin, mucous membrane, blood and body fluid Indirect Microorganisms transmitted to susceptible people via contaminated objects (faecal oral route) Blood borne Equipment, environment and food Blood borne Exposure to blood/body fluid infected with microorganisms Including exposure to needle stick and sharps injuries contaminated intravenous infusion fluids Page 9 of 18 and APPENDIX 2 ISOLATION PRECAUTIONS - PLANNING GUIDE This guide outlines measures to prevent cross-infection within the hospital environment. Notifiable to CCDC Disease Acquired Immune Disease Route of Spread What is infected Blood and body fluids Campylobacter* Faeces Chicken Pox Respiratory secretions Discharge from vesicle fluid CJD and CJDv Brain, eye, nerves and lymphoid tissue Personal Protective Equipment Linen Period of precaution Comments No unless bleeding profusely Yes For contact with blood or body fluids Infected If contaminated with blood or body fluids On going throughout admission Yes Yes contact with diarrhoea If soiled treat as infected Until symptom free for 48 hrs Direct contact with vesicle Droplet/airborne Indirect contact with freshly soiled clothing/linen Yes With door closed Yes For direct patient contact Infected Until lesions are crusted and dry Non immune and pregnant staff to avoid contact with affected patient Direct and Indirect contact Not usually Yes For contact with blood or body fluids Gloves For direct patient contact If soiled treat as infected On going throughout admission Special care with surgical instruments Blood or infected tissue Sexual exposure Vertical transmission Breast milk Occupational exposure e.g. sharps injury Faecal oral Ingestion of organism Single room Page 10 of 18 Full face visor if risk of splashes or sprays * - Disease What is infected Route of Spread Single room Personal Protective Equipment Linen Period of precaution Comments Clostridium Difficile Faeces Faecal oral Ingestion of organism Yes Yes contact with diarrhoea If soiled treat as infected Until symptom free for 48 hrs Diarrhoea +/Vomiting, known or suspected food poisoning * E Coli 0157 Faeces and vomit Faecal oral Ingestion of organism from faeces or vomit Yes Yes contact with diarrhoea If soiled treat as infected Until symptom free for 48 hrs Review antibiotic use Stringent environmental cleaning Refer to outbreak policy if more patients affected Faeces Faecal oral Ingestion of organism Yes Yes contact with diarrhoea If soiled treat as infected Until symptom free for 48 hrs Group A Streptococcus Saliva Wound exudates Respiratory secretions Fluid from lesions Yes Yes For direct patient contact Infected Hepatitis A * Faeces Yes Yes contact with diarrhoea Hepatitis B * Blood and body fluids No unless bleeding profusely Yes For contact with blood or body fluids If soiled treat as infected Infected If contaminated with blood or body fluids Hepatitis C * Blood and body fluids Faecal oral Ingestion of organism Blood or infected tissue Sexual exposure Vertical transmission Breast milk Occupational exposure e.g. sharps injury Blood or infected tissue Sexual exposure Vertical transmission Breast milk Occupational exposure e.g. sharps injury Until 48 hrs of appropriate antibiotics or advised by IPCT Until symptom free for 48 hrs On going throughout admission No unless bleeding profusely Yes For contact with blood or body fluids Page 11 of 18 Infected If contaminated with blood or body fluids On going throughout admission Can cause haemolytic uraemic syndrome Staff developing a sore throat refer to Occupational health Disease Route of Spread What is infected Influenza Respiratory secretions Respiratory airborne Legionnaire Lung tissue Airborne Water Measles Respiratory secretions Droplet spread Indirect contact Meningococcal Meningitis (bacterial) Respiratory secretions Droplet spread Direct contact – mucous membrane Pneumococcal Meningitis Respiratory secretions MRSA Dependent on site of colonisation / infection Respiratory secretions Mumps Rotavirus Faeces, vomit and Respiratory secretions Single room Personal Protective Equipment Linen Yes for direct contact Treat as non infected No Treat as non infected Yes With door closed Yes Yes For contact with respiratory secretions Yes For contact with respiratory secretions Treat as non infected Droplet spread Direct contact – mucous membrane Yes Yes For contact with respiratory secretions Treat as non infected Direct contact Yes Yes for direct contact Treat as infected Yes Yes For contact with respiratory secretions Treat as non infected Yes Yes For contact with diarrhoea and respiratory secretions Infected Droplet spread Direct contact – mucous membrane Droplet spread Faecal oral Yes With door closed No Page 12 of 18 Treat as non infected Period of precaution Comments Duration of illness Masks must be worn Refer to HPA pandemic flu guidance Not thought to be transmissible person to person For 4 days after the rash has appeared Until patient has received 24 hrs of appropriate antibiotic therapy Until patient has received 24 hrs of appropriate antibiotic therapy Until advised by Infection prevention and control For 9 days after onset of swollen glands Non immune staff to avoid contact with affected patient Prophylaxis indicated for close family contacts - discuss with Microbiologist Until symptom free for 48 hrs Refer to outbreak policy if many babies affected Refer MRSA screening Policy MRSA policy Non immune staff to avoid contact with affected patient Respiratory Syncytial virus Respiratory secretions Rubella * Respiratory secretions Salmonella * Faeces Scabies Skin SARS * Respiratory secretions Shingles Vesicle fluid Pulmonary TB Whopping cough (pertussis) Sputum Respiratory secretions Droplet spread Direct contact with respiratory secretions Droplet spread Direct contact with respiratory secretions Faecal oral Yes Yes For contact with respiratory secretions Infected Until free Yes Yes For contact with respiratory secretions Treat as non infected For 7 days after onset of rash Yes Yes For contact with diarrhoea Infected soiled if Until 48 hrs symptom free Scabies mite Direct skin to skin contact Droplet spread Direct contact with respiratory secretions Airborne Direct contact with vesicle fluid Indirect contact with soiled linen Airborne Direct contact with respiratory secretions No Yes For direct patient contact Treat as non infected Yes Infected Until successfully treated Duration of illness Dermatology referral is recommended for in patient areas. Masks must be worn. Seek urgent advise from infection control If soiled treat as infected Until lesions are crusted and dry Non immune staff to avoid contact with affected patient Yes With closed Yes For contact with respiratory secretions Infected door Until 2 weeks after effective compliant treatment Airborne Direct contact with nasal and throat secretions Yes With closed door Yes For contact with respiratory secretions Treat as non infected Until 5 days appropriate antibiotic therapy Staff should wear special filter masks when exposed to respiratory droplets Only immune staff to attend patient Restrict contact with infants and young children until pt has received at least 5 days treatment Yes With closed door Yes Yes For direct vesicle fluid Page 13 of 18 contact with symptom APPENDIX 3 Signage for Isolation Nursing STOP AND THINK! Isolation Nursing All Visitors: All Staff Please wash and dry your hands before entering and on exiting the room Please ask the nurse before entering so that she/he can explain any precautions you need to take Please close the door behind you Please ask the nurse/matron or member of the infection control team to explain anything you are unsure of Page 14 of 18 Please adhere to standard infection control precautions at all times Please check care plan/ward guidance if you are unsure about any infection control procedure All Visitors: All Staff Please wash and dry your hands before Entering and on exiting the room Please ask the nurse before entering so that she/he can explain any precautions you need to take Please close the door behind you Please ask the nurse/matron or member of the infection control team to explain anything you are unsure of Page 15 of 18 Please adhere to standard infection control precautions at all times Please check care plan/ward guidance if you are unsure about any infection control procedure APPENDIX 4 ISOLATION – CLEANING CHECK LIST Domestic Services provided by_____________________________________ Room/Bay: Ward: Date Isolation Cleaning Commenced: Domestic/Service/Ward Assistants should wear a yellow plastic apron and yellow gloves to carry out the cleaning Chlor-Clean (Chlor- clean or alternative antimicrobial detergent) must be used as per manufacture instructions Patient Environment - 2 x Daily Clean On discharge full terminal clean performed Responsibility –Domestic services Date Time Signature Day 1 Frequency 1 Frequency 2 Day 2 Frequency 1 Frequency 2 Day 3 Frequency 1 Frequency 2 Day 4 Frequency 1 Frequency 2 Day 5 Frequency 1 Frequency 2 Day 6 Frequency 1 Frequency 2 Day 7 Frequency 1 Frequency 2 Page 16 of 18 Print Name Appendix 5 Inter-healthcare transfer form Patient/client details: (insert label if available) Name: Address: NHS number: Date of birth: Consultant: GP: Current patient/client location: Transferring facility – hospital, ward, care home, other: Contact no: Is the Infection Prevention and Control team aware of transfer? Yes/No Receiving facility – hospital, ward, Care Home, Community Contact no: Who is aware of the transfer Is this patient/client an infection risk? Please tick most appropriate box and give confirmed or suspected organism Confirmed risk Organism: Discussed with: ……………………………………………………… Confirmed risk Organism: Date / Time …………………………………………………………… Suspected risk Organism: Completed by ………………………………………………………… No known risk Patient/client exposed to others with infection e.g. D&V Yes/No Designation …………………………………………………………… Is the patient/client aware of their diagnosis/risk of infection? Yes/No Date completed ………………………………………………………. If patient/client has diarrhoeal illness, please indicate bowel history for last week: (based on Bristol stool form scale, see previous page) 1. Separate hard lumps, like nuts (hard to pass) 4. Like a sausage or snake, smooth and soft 5. 2 Sausage-shaped but lumpy Soft blobs with clear-cut edges (passed easily) 3. Like a sausage but with cracks on its surface 6. Fluffy pieces with ragged edges, a mushy stool 7. Watery, not solid pieces ENTIRELY LIQUID Day Number episodes of Is the diarrhoea thought to be of an Does the patient/client require isolation? Yes/No Should the patient/client require isolation, please phone the receiving unit in advance infectious nature? Yes/No Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page 17 of 18 Relevant specimen results (including admission screens – MRSA, C. Difficile, other multi-resistant organisms) and treatnt information, including antimicrobial therapy: Other information Page 18 of 18