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Policy No: IC06 Version: 8.0 Name of Policy: Isolation Policy Effective From: 18/08/2015 Date Ratified Ratified Review Date Sponsor 15/07/2015 Infection Prevention & Control Committee 01/07/2017 Director of Nursing, Midwifery & Quality / Joint Director Infection Prevention & Control 14/07/2015 Expiry Date Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version. This policy supersedes all previous issues. Version Control Version Release 1.0 2.0 3.0 Feb 2002 Author/Reviewer April 2006 4.0 5.0 Sept 10 IPCT 6.0 07/12/2010 A Cobb 7.0 11/10/2012 A Cobb/ V Atkinson 8.0 18/08/2015 A Cobb IC06 Isolation Policy v8 Ratified by/Authorised by Date Infection Prevention and Control Committee 20/01/2006 Infection Prevention and Control Committee Infection Prevention and Control Committee Infection Prevention and Control Committee Infection Prevention and Control Committee 26/09/2010 Changes (Please identify page no.) 30/07/2010 27/07/2012 15/07/2015 2 Contents Section Page 1 Introduction .................................................................................................................................. 4 2. Policy scope .................................................................................................................................. 4 3. Aim of policy ................................................................................................................................. 4 4 Duties (Roles and responsibilities) ............................................................................................... 4-6 5 Definitions .................................................................................................................................... 6 6 Isolation ....................................................................................................................................... 7-13 6.1 Source of isolation ............................................................................................................. 7 6.2 Protective isolation ............................................................................................................ 7 6.3 Cohort isolation.................................................................................................................. 7 6.4 Risk assessment ................................................................................................................. 7 6.5 Accommodating the patient who requires isolation ......................................................... 7-8 6.6 The routes of transmission ................................................................................................ 8 6.7 Visitors ............................................................................................................................... 8 6.8 Indications for isolating patients........................................................................................ 9 6.9 Effective communication of infection control needs......................................................... 10 6.10 Managing patients in an isolation room ............................................................................ 10-11 6.11 Isolation precautions ......................................................................................................... 11-13 7. Training ......................................................................................................................................... 13 8. Equality and diversity ................................................................................................................... 13 9. Monitoring compliance with the policy ....................................................................................... 13 10. Consultation and review .............................................................................................................. 14 11 Implementation of policy (including raising awareness) ............................................................. 14 12 References .................................................................................................................................... 14 13 Associated documentation (policies) ........................................................................................... 14 Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Meticillin Resistant Staphylococcus Aureus (MRSA) Patient accommodation guide ........................................................................................... 15 Infection risk assessment and isolation guide .................................................................... 16-17 Universal MRSA screening cirteria...................................................................................... 18 For patients who do not meet Department of Health Universal screening cirteria ................................................................................................ 19 Alphabetical list of infections ............................................................................................. 20-24 Using an isolation room ...................................................................................................... 25 IC06 Isolation Policy v8 3 Isolation Policy 1 Introduction This policy aims to fulfil the criteria set out within The Health & Social Care Act which includes the Code of Practice for the Prevention and Control of Healthcare Associated Infections (updated 2008). This policy is underpinned with the guidance within the epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England 2014 which suggest a non-discriminatory approach to patient care with the Health & Safety Executive and Public Health England guidance. By isolating a patient in a single room or nursing patients with the same infection together the rest of the ward population can be protected from unnecessary exposure to an infection. Occasionally, patients may need to be protected from infection and in this case they are nursed in a side room to ensure that they minimize the risk of picking up infection. The Trust has a mix of facilities to care for inpatients and where there is limited availability to side rooms a risk assessment must be undertaken. See Appendix 1 and 2. 2 Policy scope This policy applies to all Trust health care workers who work in the clinical setting. All health care workers have a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce the risks associated with infection. This policy incorporates advice for side room allocation for suspected or confirmed infection reasons. 3 Aim of policy This policy outlines precautions within Gateshead Health NHS Foundation Trust to minimise the risk of infection to patients, visitors and staff. The policy explains the operational implementation of risk assessment and side room prioritisation to ward teams and bed managers. 4 Duties (Roles and responsibilities) Those listed all have a duty to assist the Trust in the achievement of national standards for infection prevention and control by compliance with this and all other Infection Prevention and Control policies. All staff have a responsibility to disseminate good practice. Specific responsibilities are outlined as follows: Chief Executive Officer The Chief executive Officer has ultimate responsibility for ensuring that effective systems and processes are in place to minimise the risk of infection to patients, staff and visitors. Trust Board The Trust Board has a responsibility to ensure that the risk of infection to patients, staff and visitors is minimised to its lowest potential and therefore supports the full implementation of this policy. IC06 Isolation Policy v8 4 All Trust Staff All Trust staff have a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce risks associated with infection. All Trust Staff have a responsibility to ensure they receive annual training in Infection Prevention and Control and where appropriate are using the Infection Risk Assessment tool to screen patients and appropriately place them within their current specialty. The Director of Nursing, Midwifery & Quality, and of Director of Infection Prevention and Control The Director of Nursing, Midwifery and Quality, Director of Infection Prevention and Control has delegated responsibility for ensuring that effective systems and processes are in place to minimise the risk of infection to patients, staff and visitors. The Medical Director/Director of Infection Prevention and Control The Medical Director has a shared responsibility with the Director of Nursing, Midwifery and Quality and Infection Prevention and Control for ensuring that effective systems and processes are in place to minimise the risk of infection to patients, staff and visitors. The Director of Estates and Facilities Has the responsibility to ensure that isolation facilities are retained and where possible expanded upon to ensure availability in refurbished and new builds. Technical Ventilation Engineer Ensure scheduled testing and maintenance of ventilation systems within the Trust. Advice on the installation of isolation ventilation systems and alarm features to promote staff and patient safety. Keep records of all scheduled maintenance of ventilation systems. The Consultant Microbiologists Provide expert advice in line with Trust infection control needs and national policy to the Infection Control Team, Director of Infection Prevention and Control and service users. Assess the clinical significance of MRSA Bacteraemia with the relevant clinician and report all mandatory surveillance and other significant infections to Public Health England. Assist clinicians in the prioritisation of side room availability for Trust builds. Advise on specific infections and their epidemiology during actual or suspected outbreaks. Provide input into Trust builds from pre planning to post commissioning phases and specifically the Estates architects to provide the required complement of side rooms. The Head of Infection Prevention and Control Has a duty to provide expert infection control advice and support to the Directors of Infection Prevention and Control, the Infection Control Team and other service users. Produce an annual Forward programme for infection prevention and control which reflects the requirements of the Health and Social Welfare Act 2008 and specifically protection of staff, patients and visitors from avoidable infection. Provide input into trust builds from pre planning to post commissioning phases. Ensure that Education and Training programmes are appropriate to meet national guidelines and the local needs of service users. IC06 Isolation Policy v8 5 Infection Prevention and Control Nurses Has a duty to provide expert advice, education and training to service users. Assist in the achievement of the Forward programme. Deliver Mandatory Education and Training to service users. Participate in daily surveillance and patient management for actual and potential infection. Support staff in prioritising side room use when a new or suspected infection occurs. Modern Matrons Matrons are responsible for the reduction of Healthcare associated infection. They monitor adherence to Infection control policy via clinical presence/expertise and the Ward Quality Measure audit tools.. Ensure that Infection Prevention and Control Link staff are released to attend study sessions and perform audits for their areas which will provide the Trust with evidence of compliance in infection control. Domestic Staff Comply with requests to enhance clean side rooms and sections of wards where infection is present. Occupational Health and Safety Staff Provide support and direction to Trust staff for individual and outbreak infection control issues. Ensure implementation of the Trust Immunisation policy. Bed Managers Ensure compliance with patient placement tools for individual infections and outbreak situations within the Trust. Infection Prevention and Control Link Persons Perform Infection Prevention and Control audits as directed by the IPCT/Modern Matron. Attend Link group meetings and cascade information to the ward manager and ward teams. 5 Definitions 5.1 There are 2 main types of isolation: i ii 5.2 The Trust has 3 types of single rooms to accommodate patients for isolation: i ii ii 5.3 Source isolation for the isolation of patients to prevent the transfer of their infection to others and; Protective isolation for the patients who are highly susceptible to infection by disease or therapy. Isolation cubicles able to be switched to positive pressure for protective isolation or negative pressure for source isolation. This type of facility has an antechamber or gowning lobby. Single on suite rooms with no antechamber Single rooms with no en suite or antechamber facilities. Multi Drug Resistant Tuberculosis This can occur when a patient has a co infection with a virus such as HIV or has not completed a full course of treatment and develops resistance to several antibiotics. IC06 Isolation Policy v8 6 6 Isolation 6.1 Source Isolation Source isolation can be further divided into the following categories: i) Standard Isolation for most communicable diseases and also for patients who have infections caused by multi-resistant organisms. ii) Strict Isolation for highly transmissible disease e.g. Multi drug resistant tuberculosis (MDRTB), viral haemorrhagic fever (VHF) or pulmonary anthrax. These patients would need to be transferred to the Infectious Diseases Unit at Royal Victoria Infirmary, Newcastle. When suspected, urgently contact in person the Microbiologist and if necessary the Infection Prevention and Control Nurse. If inpatient treatment is being considered for suspected or known multi drug resistant tuberculosis (MDRTB) suitable accommodation is not currently available in this Trust and transfer to the Infectious Diseases unit at RVI Newcastle should be considered. In the interim the patient should be nursed in a negative pressure cubicle with the doors closed. iii) 6.2 Respiratory for diseases where the main pathway of transmission is airborne i.e. pulmonary tuberculosis or pandemic flu. Most childhood illnesses would also be in this category. Protective Isolation For patients who are highly susceptible to infection by disease or therapy. Where positive pressure isolation facilities are available they should be used for nursing this patient group. 6.3 Cohort Isolation In the event of respiratory epidemics, clusters of MRSA or other multi-resistant organism (MRO) infections or diarrhoeal outbreaks it may be preferable to temporarily designate a ward area to accommodate similar infected/colonised patients. Cohort nursing will require one team of nurses to look after these patients where possible. 6.4 Risk Assessment Whenever a situation arises where there are not enough single rooms available for the isolation of patients then a risk assessment of each patient requiring a side room needs to be undertaken. Staff responsible for care of the patients will assess who may be at an increased risk of cross infection. The Infection Prevention & Control Team will assist in this process. Refer to Patient Accommodation Guide – appendix 1 and Risk Assessment Tool appendix 2. Whenever a patient cannot be isolated appropriately a Datix report should be completed by the healthcare worker looking after them at that time. 6.5 Accommodating the Patient who requires isolation All patients admitted to this trust should have an infection risk assessment completed on admission. Please refer to trust risk assessment tool appendix 2. This will assist in deciding if the patient requires accommodation in an isolation room. IC06 Isolation Policy v8 7 All adult patients admitted to this Trust should be screened for MRSA if they fulfil the universal screening criteria (appendix 3), otherwise screen if the patient has identified infection risk factors on completion of the risk assessment tool. This should be done either on admission to the ward if an emergency admission or in Pre-assessment Clinic if they are a waiting list admission. Please refer to appendix 2 for details of the Risk Assessment tool. Bed Managers in conjunction with the senior nurse with site responsibility and the ward staff have responsibility for finding suitable accommodation for patients. When suitable accommodation is NOT available for a patient who is either infected or potentially infected the Infection Prevention and Control Team are available for advice. A Consultant Microbiologist is available on a 24-hour basis via QE switchboard. Where necessary refer to other policies in the Infection Prevention and Control Trust Intranet. Further information and advice is available on the Infection Prevention and Control Team Trust Intranet page. Specific information relating to infectious diseases and their management can be obtained by contacting: 6.6 6.7 • Consultant Microbiologists (QEH Tel: 0191 4820000 or via the Duty Bleep 2092) • Infection Prevention & Control Nurse (QEH Tel: 0191 4820000 Ext 3161, Bleep 2057) • Consultant in Communicable Disease Control, Public Health England: Tel: 03003038596 (contact via QEH switch board out of hours) The Routes of Transmission i. Airborne – droplets from a cough or sneeze, skin/dust floating in the air from bed making etc. ii. Enteric excretions - faecal oral route. iii. Direct contact – hands, clothing, and equipment. iv. Blood borne disease e.g. Hepatitis B, & C and Human Immunodeficiency Virus (HIV) infection – any contact with body fluids or secretions which may contain blood. Visitors All visitors should routinely report to ward staff before visiting patients who are in a side room. Visitors should be made aware that they should NOT visit if they have an infection, an infected wound or symptoms of flu or diarrhoea and/or vomiting. Any visitors or staff with infections or a potentially infective lesion or skin condition should be excluded from the clinical areas. For staff, a referral to Occupational Health will need to be made in this instance. IC06 Isolation Policy v8 8 6.8 Indications for isolating patients The following categories of patient should be admitted to isolation beds in the first instance: 1. Patients symptomatic of Clostridium difficile infective diarrhoea or GDH positive (see IC Policy 26 Clostridium difficile and Infective Diarrhoeal Illness Policy). The time interval to isolate the patient into an isolation bed will be investigated by the Modern Matron and Infection Prevention and Control Team during the roost cause analysis process as prompt isolation is essential to prevent cross infection. 2. Patients with diarrhoea of suspected infectious or unknown cause. In addition the Infection Prevention and Control Team should be informed in the event of two or more patients and/or staff members on a ward having diarrhoea or vomiting (See IC Policy 24 Outbreak Management Policy). 3. Patients with wounds that are known to be colonised/infected with resistant organisms e.g. Meticillin Resistant Staphylococcus Aureus (MRSA) or multi-resistant organisms (MRO). 4. Suspected meningitis. 5. Neutropenic patients and those undergoing chemotherapy. 6. Patients in whom pulmonary TB is known or suspected always inform Infection Prevention & Control Team and place into a negative pressure isolation room whenever possible. 7. Patients with severe infected dermatitis or large open wounds, should always be accommodated in a single room. Patients admitted with abscesses or other open wounds, including pressure sores, should also be in a single room until the results of microbiological culture are known. 8. Pyrexia of unknown origin (PUO) where there is a clinical indication or the patient has made recent travel abroad. 9. Patients in whom clinical AIDS is known or suspected to protect the very vulnerable individual (inform pathology dept. when submitting specimens). 10. Respiratory infection during respiratory disease epidemics (especially children). Occasions may arise when cohorting of patients is more appropriate. See also Major Incident Plan, appendix 5 – Pandemic Plan. 11. Neonatal transfers are routinely isolated until results of screening available. 12. It is best practice to isolate patients transferred from other hospitals whenever there are problems with hospital-acquired infections e.g. MRSA or when an infectious illness such as TB has been diagnosed elsewhere. See Appendix 4 for alphabetical list of infections and the level of isolation required. IC06 Isolation Policy v8 9 6.9 Effective Communication of infection control needs Good written and verbal communication is essential between the various disciplines of staff involved in the patient’s care and treatment. Cubicle signage notices asking visitors and visiting members of staff to seek advice from a member of staff before entering the cubicle are essential. See below: It is the responsibility of each visiting member of staff to ask the ward nursing staff for information and advice about any infection risks or specific precautions required before they enter a side room. Always document in the patient’s plan of care, the reasons for isolation and the rationale for not isolating patients when isolation is recommended. Note the position of the patient within the ward prior to isolation. STOP! Please report to a member of the nursing staff before entering 6.10 Managing Patients in an Isolation room Please refer to appendix 5 – Using an Isolation Room guide. The door should normally be kept closed unless patient’s safety and wellbeing would be compromised. Following the assessment of the patients safety, if the door is required to be open the rational for this should be clearly documented in the nursing evaluation. All unnecessary furniture or equipment must be removed and the room equipped to suit the patient’s needs/requirements. Pillows and mattress must always have intact waterproof covers. Dedicated equipment to monitor the patient is preferable A patient being isolated should be nursed in a single room preferably with an ante chamber and extract ventilation. Extract ventilation may operate under either: Positive pressure when the aim is to protect the patient being nursed in isolation e.g. neutropenic patients. Negative pressure when the aim is to protect other patients as well as the patient being isolated e.g. open pulmonary tuberculosis (TB), MRSA. Patient compliance to remaining in a side room with the doors closed may be variable and additional advice may be obtained from the Infection Prevention and Control Team. Leaflets to support cooperation are available for common infective conditions. IC06 Isolation Policy v8 10 The domestic response team should be contacted when a patient vacates their room and a terminal enhance clean is required - stating which organism/infection it is for, i.e. TB, MRSA (infection not colonisation) or C. difficile etc. See Cleaning and Disinfection Policy Negative Pressure Positive Pressure The negative pressure setting should be used when: The positive pressure setting should be used when: The patient has an infection or is suspected of an infection The patient is particularly vulnerable to infection i.e. neutropenic Negative pressure air flow ensures that air from the patient’s room does not enter the main corridor. Positive pressure air flow ensures that air from corridor does not enter the patient’s room. 6.11 Isolation Precautions This applies to Standard, Strict, Respiratory and Protective isolation unless otherwise stated. Hand Hygiene: Hand hygiene before and after any patient contact is the single most effective way to prevent the spread of infection. Hands and forearms should be thoroughly washed using the correct technique with soap and water or an alcohol foam should be applied, on entering and leaving the patient’s room and before/after removing personal protective equipment (PPE) e.g. aprons, masks and gloves. NB. DO NOT USE ALCOHOL HAND FOAM FOR DIARRHOEAL PATIENTS Please refer to Infection Control Policy No. 4 Hand Hygiene Personal Protective Equipment: Aprons/Gowns: All staff with direct patient contact, their secretions or dirty linen must wear disposable plastic aprons. They are single use only and should be discarded after use as per policy - See IC No 9 - Waste Disposal and Recycling Policy (Paediatrics/maternity only - disposable plastic apron with a non-slip absorbent front) Strict isolation precautions: Staff are required to wear long sleeved disposable gown rather than a disposable apron on entering room. Please refer to IC No 2 Personal Protective Clothing in Clinical Practice Policy. IC06 Isolation Policy v8 11 Masks & eye: Necessary for all procedures likely to cause splashing or aerosol spray Protection to the face or mucous membranes e.g. suctioning patients, chest physiotherapy or a procedure that induces coughing. Masks are single use only; remove by the strap rather than touching the mask itself; dispose of as clinical waste and wash hands after disposal. Eye protection is required when there is a risk of spray into the eyes. Protective isolation precautions: Masks should be worn when staff member has a cough or cold or a lesion such as a cold sore. (Please refer to Personal Protective Clothing in Clinical Practice Policy No. 2). Gloves: Disposable gloves should be worn when contact with any body fluid is anticipated, for handling infected sites or wounds and contaminated materials such as bed linen, incontinence pads. Single use only and dispose of after use as per policy IC No 9 Waste Disposal and Recycling Policy. Linen: Return to laundry in red alginate bag. Dispose into red bag immediately at the bedside. Clinical Waste: All waste from isolation rooms must be classed as clinical waste and disposed of into orange clinical waste bags and immediately removed to sluice facility. Please refer to Waste Disposal Policy – Infection Control Policy Number 9. See also Infection Control Policy No.22 for suspected or known cases of CJD. Respiratory precautions: Infective Secretions Sputum, sputum cartons, used paper tissues are disposed as clinical waste. Always wear personal protective clothing - aprons and gloves Advise patients and visitors to wash their hands after a cough or sneeze or after using a tissue. Excreta Dispose of immediately wearing personal protective clothing, either in the en-suite facility or in the sluice room. Equipment Autoclavable equipment must be returned to CSSD in the bags provided. Where possible allocate equipment to single patient use or disposable items otherwise ensure the correct decontamination of equipment before re-use. Refer to Cleaning and Disinfection Policy No.15 for information on the cleaning of all other equipment. The Medical Device library holds a stock of BP monitoring machines and tympanic thermometers. Respiratory precautions: Disposable items such as oxygen masks, humidifiers, nebulisers, suction canisters and tubing should be used and disposed of as clinical waste. Always wipe clean after each use. Crockery & cutlery IC06 Isolation Policy v8 Return to central dishwashing area main kitchen or dishwashers available in most ward kitchens. Hot water and detergent wash in ward kitchen areas. 12 Waste water Water used to wash the patient must not be disposed of into the clinical washbasin. This would present a risk of potential contamination to the tap, basin and splash back. Sharps Always dispose of sharps IMMEDIATELY in sharps box at the point of care. Always wear PPE - apron and gloves, facial protection if risk of splash into the face when using a sharp. It may be reasonable and practicable in some instances to leave the sharps boxes in the patient’s room or in the air lock room but only after an individual risk assessment. Needlestick or sharps injuries must be reported to Occupational Health Department immediately or go to A+E if out of hours and Datix report submitted. See IC - Blood Borne Virus Policy no. 7 – Sharps Policy. 7 Training All staff with clinical input or potential contact with body fluid will receive advice at local induction and via mandatory training Local induction to the staff area must include use of any isolation facilities available. 8 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy has been appropriately assessed. Care should be planned on an individual basis taking into account the needs of the patient, including their mental health and well-being. Where isolation would endanger the mental health and safety of an individual, their situation must be urgently discussed with a microbiologist or the IPCT. 9 Monitoring compliance with the policy Standard/process/issue Monitoring of isolation for suspected infective diarrhoea patients. Monthly ward DAMP compliance report sent to individual ward managers/Matrons for actioning aspects of non-compliance sharing good practice. Trust monthly DAMP compliance report sent to the DIPC, associate directors, service line managers, Matrons and ward managers for action. Ongoing surveillance follow up with new results across the Trust Suspected Cross infection investigation IC06 Isolation Policy v8 Monitoring and audit Method By IPCN for surveillance reviews all inTrust staff patient diarrhoea IPCN patients when a stool sample has been submitted. IPCN for surveillance advises to DATIX exception/delay As above with serious investigation (SI) where indicated Trust staff SI panel and/or Hospital coordinating Group and IPCT Committee Frequency Ongoing Monthly reports Local IPCC to Trust IPCC by clinical membership Trust IPCC Part 2 paper for Trust Board if indicated from investigation Ongoing Exceptions Ongoing Exceptions 13 10 Consultation and review Infection Prevention & Control Team – Head of Infection Prevention & Control, Consultant Microbiologists and Infection Prevention & Control Nurses. The policy has been circulated electronically to members of the Infection Prevention and Control Committee (IPCC) prior and agreed by the committee 11 Implementation of policy (including raising awareness) On ratification of this policy at the Infection Prevention & Control committee, a trust e mail will be sent via OD & Training to alert Trust personnel of the updated policy. 12 References Epic 3 (2014) http://www.epic.tvu.ac.uk/ DoH Health & Social Care Act 2008 http://www.dh.gov.uk http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/Publications PolicyAndGuidanceArticle/fs/en?CONTENT_ID=4139336&chk=6oAPfi 13 Associated documentation The following policies have been highlighted within this policy and will provide additional support towards the implementation of this policy. IC 2 IC 3 IC 4 IC 7 IC 9 IC 15 IC 24 Personal Protective Clothing in Clinical Practice Policy Standard Precautions Policy Hand Hygiene Policy Sharps Policy Waste Disposal and Recycling Policy Cleaning and Disinfection Policy Outbreak Management Policy Influenza Pandemic Plan – appendix within the Major Incident Plan (available via the Trust intranet homepage) IC06 Isolation Policy v8 14 Appendix 1 Meticillin Resistant Staphylococcus Aureus (MRSA) Patient Accommodation Guide (Range 1 = Preferred accommodation – 4 = Only accommodation available) *Always risk assess the patients physical and mental suitability for sideroom accommodation Colonised with MRSA* (Colonised patients have MRSA but are not at present symptomatic of clinical signs/symptoms of infection) Infected with MRSA* • 1. Sideroom with gowning lobby 2. Sideroom 3. Bay with like patients 4. Bay with patients with no wounds, devices, skin conditions, planned surgery or immunocompromising condition. 1. 2. 3. Sideroom with gowning lobby Sideroom Bay with like patients If unable to accommodate patient using flow chart, contact the infection control team on bleep 2057 or out of hours a Microbiologist via QEH switchboard. IC06 Isolation Policy v8 15 Appendix 2 Infection Risk Assessment and Isolation Guide • • • • • Risk factors for infection should be identified at initial admission assessment and managed appropriately within the patient’s plan of care. Repeated thereafter weekly or as condition changes or on transfer to another ward. All patients should be offered daily Octenisan body wash & shampoo to minimise cross infection. The KIC (Known Infection Colonisation) Record placed at the front of the medical notes is completed for any previously known MRSA, Clostridium difficile/ GDH, TB, Blood borne viruses, e coli & MSSA bloodstream or any significant infection or multi-resistant organism cases and will assist with your patient management and bed allocation. All adult patients, Critical Care Department patients including SCBU, require MRSA screening of nose and throat plus any other wounds, sputum if expectorating and indwelling devices on admission to hospital, transfer to another ward or if condition changes. Any elective surgical or medical admissions should be checked for their pre-assessment screening results and if they have had no pre-operative screen completed it should be taken on admission to hospital. Infection Risk factors: (please tick and date all that apply) Current or previous MRSA infection/ colonisation Dry Skin condition Wounds/ leg ulcers/pressure damage *Take a swab as part of admission or transfer MRSA screen Devices in situ, including urinary catheter, central venous access device, peg tube, drain, tracheostomy *Take a specimen as appropriate as part of admission or transfer MRSA screen Immunosuppression Frequent hospital or healthcare admissions/interventions Nursing/Residential /Institution resident eg. prison or armed forces Transfer from another hospital Healthcare worker Recent foreign travel Unexplained diarrhoea – ensure that a Stool chart is completed, laxatives are discontinued and a stool specimen is obtained No risks identified IC06 Isolation Policy v8 Date Date Date Date Date Date Date 16 All healthcare workers should follow infection prevention & control practices in adherence with Trust policies and procedures at all times. Infection Prevention & Control Policies and Care Standards are available for reference on Trust Intranet. Condition / key High Risk – priority isolation Must be in a cubicle TEC = terminal enhance clean including curtain change MRSA or MSSA (for further info refer to MRSA policy) If infected or colonised (a carrier of MRSA/MSSA bacteria but no active infection) with open wounds, pressure damage and/or devices (cannula, catheter etc). To start decolonisation treatment. TEC required Patient with confirmed or suspected infectious diarrhoea. (Clostridium Difficle, GDH +ve, salmonella, campylobacter or norovirus) (for further info refer to C.diff and Outbreak polices) Scabies (classical or Norwegian) (for further info refer to Scabies policy) Head Lice Once treatment given patient is not infectious. A cubicle may be preferred for privacy & dignity. Meningitis (for further info refer to Meningitis policy) Clostridium difficile toxin positive or GDH positive, with type 5-7 stools. Patient with diarrhoea and/or vomiting . Stools 5-7 on Bristol stool chart. TEC required when 72 hours clear of type 5-7 stools Moderate Risk – isolation necessary, consider at earliest opportunity Could be moved in to main ward, only if essential but maintain standard precautions Once decolonisation treatment has commenced. If patient does not have open wounds or skin conditions and is not coughing or having aerosol generated treatment. Must not be placed next to/adjacent to patients with open wounds, SRC or skin conditions. Nursing Home, Residential Home or other institution resident or transfer from another hospital. Routine clean with Chlorclean Minimal Risk – may remain in main ward area May be moved out of cubicle on to main ward area Negative swabs post decolonisation obtained, from all potential sites including pressure damage and CSU. When room vacated, TEC required if patient had expectorating cough or active wound infection. Otherwise routine clean with Chlorclean. Clostridium difficile - 72 hours clear of symptoms and patient well. Norovirus - if 48 hours clear of symptoms. TEC required if patients once 48 hours clear of symptoms. Routine clean with Chlorclean For both classical and Norwegian, post treatment and with clear skin. Routine clean with Chlorclean If patient suspected of having scabies, whilst undergoing treatment. Consider MRSA status TEC required for Norwegian scabies. After 2 treatments, 1 week apart. Norwegian scabies may need longer as 2 treatments may not be enough. Establish MRSA status. Routine clean with Chlorclean Patient with suspected meningitis. Routine clean with Chlorclean If meningitis confirmed as bacterial to stay in cubicle. If viral may move out of cubicle if patient well. Routine clean with Chlorclean May come out of cubicle when asymptomatic and course of antibiotics complete. Routine clean with Chlorclean Suspected or known respiratory tuberculosis (for further info refer to TB policy) Any patient who has suspected or known tuberculosis. TEC with 5,000ppm HAZ tabs May move out of cubicle, after 2 weeks of antibiotic treatment and with the clinician’s agreement. Cubicle must be TEC with 5,000ppm HAZ tabs Routine clean with Chlorclean Non respiratory TB cases do not require isolation Suspected or known shingles (for further info pleases refer to antimicrobial guidelines for shingles) Any patient who has suspected or known shingles. Consider MRSA status. Routine clean with Chlorclean Pandemic flu Measles, mumps Routine clean with Chlorclean Other infective conditions May move out of cubicle after 5 days of treatment and rash has dried up. Routine clean with Chlorclean. Recent foreign travel with signs of May move out of cubicle infection. when free of symptoms or Pyrexia of unknown origin. Unknown cause established cause. When of jaundice with other infection markers. room vacated routine clean Routine clean with Chlorclean with Chlorclean References: Epic3 (2014) National evidence based guidelines for preventing healthcare associated infection; Health Act (DoH 2008) IC06 Isolation Policy v8 17 Appendix 3 Universal MRSA Screening Criteria Following the introduction of MRSA screening for all elective patients by the end of March 2009, there is a commitment in the 2010/2011 Operating Framework to introduce screening of relevant emergency admissions for MRSA by December 2010. All elective admissions should be routinely MRSA screened on admission or pre-admission with the following exceptions: Day case Ophthalmology Day case Dental Day case Endoscopy Minor dermatology procedures e.g. warts or other liquid nitrogen applications Minor procedures such as arthroscopies, joint injections, minor hand surgery such as carpel tunnel decompression Lumbar puncture procedures and attendances for clinical immunology Radiological patients Children/paediatrics unless in a high risk group (identify using infection risk assessment tool) Maternity/obstetrics except for elective caesareans and any high risk cases, ie. high risk of complications in the mother and/or potential complications in the baby (likely to need SCBU, NICU because of size or known complications or risk factors) or infection risks identified on infection risk assessment tool. Admissions for respite care or pain management therapy Mental Health patients unless known infection risks eg. IV drug users, self harm, chronic wounds, indwelling devices All emergency admissions should be MRSA screened on admission regardless of the route of admission with the following exceptions: Attendances at A&E departments Children/paediatric emergency admissions should be risk assessed and MRSA screened if fulfil risk factor criteria Mental Health emergency admissions unless known infection risks eg. IV drug users, self harm, chronic wounds, indwelling devices Maternity/obstetrics unless high risk of complications in the mother and/or potential complications in the baby (likely to need SCBU, NICU because of size or known complications or risk factors) or infection risks identified on infection risk assessment tool. References: MRSA screening – Operational Guidance 3 DH gateway ref no. 13482 March 2010 MRSA screening – Operational Guidance DH gateway ref no. 10324 July 2008 IC06 Isolation Policy v8 18 Appendix 4 FOR PATIENTS WHO DO NOT MEET DEPARTMENT OF HEALTH UNIVERSAL SCREENING CRITERIA Admission and Pre-assessment Infection Risk Assessment Patient name Date of Birth Unit number Clinician Ward/Dept Date Please file the top section of this form in the patient’s notes. The information below helps to: • Identify patients who are, or who may be, colonised with MRSA (i.e. unknowingly carrying MRSA) • Place the patient in the most appropriate accommodation • Reduce the risk of infection for vulnerable patient groups Has the patient: Yes No Unsure 1. Had MRSA in the past? _ _ _ 2. In contact with a known or suspected case of MRSA? _ _ _ _ _ _ _ _ _ 5. A regular visitor to this or other hospital or healthcare setting? _ _ _ 6. Has the patient recently developed a productive cough? _ _ _ _ _ _ _ _ _ 3. Transferred from another department/ward/ hospital or healthcare settings? 4. Recent (within previous 6 months) patient in this or another hospital/ Healthcare setting? 7. Does the patient have an open wound; recurrent/non-healing skin condition or medical device in situ? (Excluding an intravenous cannula inserted within 72hrs and a Visual Infusion Phlebitis Score of 0 - 1) 8. Is the patient a health care worker? If YES to any of the above questions, take swabs* from the following sites and send to pathology using ICE request system to request each swan separately. 1) 2) 3) 4) 5) Nose (Anterior nares; Use one swab for both nostrils) Throat Only include Perineum for procedures affecting groin, hip or perineum eg. Obs & Gynae/Gynae oncology, vascular, colorectal, femoral/inguinal hernia repair, varicose veins* Swab from wound/skin lesion or medical device - State wound site and give clinical details Sputum if coughing and expectorating Date, Designation, Print and Sign Name on completion of form and file in patient notes: IC06 Isolation Policy v8 19 Appendix 5 DISEASE CATEGORY OF ISOLATION PERIOD OF ISOLATION TRANSMISSION ROUTE COMMENTS • ANTHRAX (Respiratory) Strict Length of illness Airborne Standard Length of illness Direct contact ) ) ) ) ) ) AUTOIMMUNE DEFICIENCY DISEASE (HIV) Standard Duration of illness Blood borne BRONCHIOLITIS (infants) Standard Clinical recovery Airborne BURNS/SCALDS Protective Clinical recovery Direct contact Airborne See Personal Protective Clothing in Clinical Practice Policy IC No 2 CHICKEN POX or Standard 7 days from start of eruption Airborne Direct contact Staff who have not had disease should be excluded. CLOSTRIDIUM DIFFICILE OR ACTIVE GDH POSITIVE Standard For a minimum of 72 hour post symptoms Direct contact Faecal oral route (Enteric) See policy IC 26 Blue gown and gloves with soap and water hand hygiene for environmental and patient contact CJD Standard For length of stay Unknown See also IC Policy No 22 Transmissible Spongiform Encephalopathies agents: Safe working and the prevention of infection. DIARRHOEAL DISEASE OF UNKOWN ORIGIN Standard Duration of illness/ 72 hours from last episode Enteric With toilet facilities. Inform ICN if two or more cases of unexplained diarrhoea. (Cutaneous) HERPES ZOSTER IC06 Isolation Policy v8 Laboratory to be notified when sending specimens. ICN to be informed ) See also ) Sharps Policy ) IC No 7 20 DISEASE CATEGORY OF ISOLATION PERIOD OF ISOLATION TRANSMISSION ROUTE • DIPHTHERIA Strict Negative cultures Airborne • BACILLARY DYSENTRY (Shigella) Standard Until 3 negative specimens after acute phase Enteric • CAMPYLOBACTER E COLI 0157 Standard Clinical recovery/ 72 hours from last episode Enteric • CHOLERA Standard Length of illness Enteric • CLOSTRIDIUM DIFFICILE Standard 72 hours symptom free Enteric • SALMONELLA (Food poisoning and Enteric fever) Standard Discuss with ICN/ Microbiologist Enteric • ROTAVIRUS Standard 72 hours symptom free Enteric • NOROVIRUS (SRSV) Standard 72 hours symptom free Enteric HERPES SIMPLEX Standard Length of illness Direct contact • HEPATITIS A Standard Length of illness Enteric • HEPATITIS B/C Standard Length of illness Blood borne • VIRAL HAEMORRHAGIC FEVERS e.g. LASSA FEVER, EBOLA, MARBURG Strict COMMENTS GASTROINTESTINAL INFECTIONS IC06 Isolation Policy v8 ) ) ) ) ) ) ) ) ) ) With toilet ) facilities. IPCNs ) to be informed. ) ) ) ) ) ) ) ) ) ) ) ) ) Staff should wear gloves when in contact with infected lesions. Assess each individual isolate if risk of haemorrhage or patient jaundiced. These patients should be admitted to the Regional Centre – NEWCASTLE GENERAL HOSPITAL 21 DISEASE CATEGORY OF ISOLATION PERIOD OF ISOLATION TRANSMISSION ROUTE COMMENTS INFLUENZA Standard Clinical recovery Airborne Direct contact Isolate only if admitted with influenza IMMUNOSUPRRESSION/NE UTROPENIA Protective Clinician in charge will decide Airborne Direct contact Positive pressure isolation room • LEGIONNAIRES DISEASE None necessary LEPROSY (Smear positive) Standard Clinical recovery Airborne Not infectious following adequate treatment • MEASLES Respiratory 7 days from onset of rash Airborne MENINGITIS Respiratory Clinical recovery Airborne/ Enteric • Meningococcal/H . Influenza is notifiable. Includes acute encephalitis • MRSA Standard Negative culture Direct contact Airborne See IC Policy No 18 MRSA Policy • MUMPS Standard 9 days after onset of parotid swelling Airborne NECROTISING FASCITIS Standard Clinical recovery Direct contact • OPHTHALMIA NEONATORUM Standard 24 hour antibiotics Direct contact • PLAGUE Strict Negative culture Airborne • POLIOMYELITIS Standard Until discharged Enteric • PSITTACOSIS (Parrot disease) Standard Clinical recovery Airborne PUERPERAL SEPSIS Standard Until bacteriologically negative (72 hours or longer) During/ following childbirth IC06 Isolation Policy v8 22 DISEASE CATEGORY OF ISOLATION PERIOD OF ISOLATION PYREXIA OF UNKNOWN ORIGIN Standard ? Until diagnosis is confirmed. Where likely to be infectious when in doubt isolate. • RABIES Standard Length of illness Airborne • RUBELLA Standard 7 days from onset of rash Airborne • SCABIES Standard 72 hours treatment Direct contact • SARS Strict Respiratory Until symptom free Airborne Direct contact • SCARLET FEVER Standard 24 hours antibiotics Airborne STAPHYLOCOCCAL INFECTION Standard Until lesion is negative following treatment Airborne Direct contact • TETANUS No special source isolation precaution. Patient should be in side room for medical reasons not for isolation reasons. TONSILITIS (Group A streptococcus) Standard 24 hours treatment Airborne • TUBERCULOSIS (open/pulmonary) Standard 2 weeks following commencement of treatment Airborne • TYPHOID (Paratyphoid and carriers) Standard For duration of stay Enteric IC06 Isolation Policy v8 TRANSMISSION ROUTE COMMENTS Exclude young pregnant women unless immune. Requires specialist isolation facilities at Ward 25 Newcastle General Hospital See also IC 18 MRSA Policy TB masks/PFR P2 to be worn in procedures involving close contact, e.g. chest physiotherapy. 23 DISEASE CATEGORY OF ISOLATION PERIOD OF ISOLATION TRANSMISSION ROUTE GENERALISED VACCINIA (smallpox vaccine) Strict Length of stay Airborne/Direct contact • WHOOPING COUGH Standard Clinical recovery Airborne PATIENTS ADMITTED WITH WOUNDS/ INFECTED OPEN LESIONS UNTIL RESULTS OF CULTURE ARE KNOWN Standard Variable Airborne/Direct contact COMMENTS • INDICATES ILLNESSES THAT SHOULD BE NOTIFIED EITHER OFFICIALLY OR LOCALLY TO HPA. • Death Certification – please inform Consultant Microbiologist and Dr Beaumont Medical Director if considering completing death certificate part 1 IC06 Isolation Policy v8 24 Appendix 6 USING AN ISOLATION ROOM 1. Keep doors closed. 2. Only open immediate door to corridor when absolutely necessary. 3. When possible, allocate equipment to single patient use otherwise ensure correct decontamination of equipment before re-use. 4. Enter gowning lobby door via corridor and close door immediately. 5. Wash your hands. 6. Put on relevant personal protective equipment i.e. apron and gloves. Wear a mask if splash/spray is anticipated. 7. Open door from gowning lobby into patient room and close door immediately. 8. Following patient care, open door from patient room into gowning lobby and close door immediately. 9. Discard personal protective equipment into an orange bin within the room or if available into the antechamber/gowning lobby. 10. Wash your hands. 11. Exit gowning lobby into corridor and close door immediately. NB: The door from the main corridor into the gowning lobby and the door from the gowning lobby into the patient room should never be opened at the same time or remain open. IC06 Isolation Policy v8 25