Infection Prevention and Control Isolation Policy

Transcription

1 Infection Prevention and Control Isolation Policy Infection Prevention & Control Jan16 Page 1

2 Policy Title: Executive Summary: Isolation Policy Standard precautions are the principal strategy for the prevention and control of Health Care Associated Infections for patients identified with either colonisation or known infections which are highly transmittable additional measures known as Isolation are required. Supersedes: Isolation Policy 2012 Description of Amendment(s): Updated to reflect National guidelines and Organisational changes and the recommendations from the Trust participation in 90 day NHSI improvement project This policy will impact on: Clinical Staff Financial Implications: Increased Screening due to identification of new cases Policy Area: Infection Prevention and Control Trust Wide Document Reference: ECT Version Number: V3 Effective Date: September 2016 Issued By: Infection Prevention Review Date: September 2018 and Control Group Authors: Anita Swaine Lead Nurse Infection Prevention and Control Impact Assessment Date: August 2016 APPROVAL RECORD Consultation: Committees / Group Infection Prevention and Control Group Date August 2016 Approved by: Date Director of Infection Prevention and Control August 2016 Infection Prevention and Control Isolation Policy Aug 16 Page 2

3 Contents Page 1 Introduction 4 2 Purpose 4 3 Roles and responsibilities 4 4 A to Z index of communicable diseases and isolation type 6 5 Side room risk matrix 15 6 Terminology 18 7 Source Isolation Procedures 20 8 Patient Transfer 23 9 Training Key Performance Indicators Monitoring compliance 23 Legislation, Guidance and References 24 Appendix 1 - Pocket Cards 25 Appendix 2 - Public Health England Notification form 26 Equality and Human Rights Policy Screening Tool 28 Infection Prevention and Control Isolation Policy Aug 16 Page 3

4 1. Introduction Standard Precautions are the principle strategy for the prevention and control of healthcare associated infection. Additional precautions are required for patients who are known or suspected to be infected (or colonised) with highly transmissible or epidemiologically/important pathogens. This is known as isolation. It is important to remember that this process of isolating the affected person is to protect others, hence minimising the risk of micro-organism transfer, and to recognise that it is the micro-organisms which are being isolated (source) rather than the patient. The infected patient as the source of the infection is segregated from unaffected patients into a side room, or within a cohort bay of similarly affected patients. The joint process of segregations, the use of personal protective equipment (PPE) and strict hand hygiene is aimed at reducing the transmission of infection to others via the airborne, droplet or contact routes. The extent of the isolation required (see specific organism s policy) is dependent on the infecting organism and the route of transmission. In addition a risk assessment may be required based on the physical and mental abilities of the patients, any variations must be clearly documented in the patients medical notes. 2. Purpose The purpose of this policy is to ensure that all East Cheshire NHS Trust staff understand how to manage patients requiring isolation based on the route of transmission, and to ensure that patients receive appropriate care in line with national guidance and best practice. In addition this policy is to ensure that other susceptible patients, staff and visitors are protected against the risk of cross infection from known infectious diseases. 3. Roles and Responsibilities 3.1 Responsibilities The Chief Executive has ultimate responsibility for the implementation and monitoring of the policies in use in the Trust. This responsibility may be delegated. The Director of Nursing, Performance and Quality, Director of Infection Prevention and Control (DIPC) has strategic responsibility for Infection Prevention and Control within the Trust and will take the lead responsibility for the development and implementation of this policy with support of the Lead Nurse - Infection Prevention and Control, and the Infection Prevention and Control Doctor. The Infection Prevention and Control Team (IPCT) has responsibility for ensuring the policy is implemented and monitored across the Trust: - Providing advice and support from 8am- 5pm Monday to Friday, (Out of hours support via the on call microbiologist). Infection Prevention and Control Isolation Policy Aug 16 Page 4

5 - Training and education to support clinical staff in implementing the policy - Implementing any changes to the Policy in light of new guidance. - Ensure compliance with the policy as part of a sustainable programme of audit. All Employees are responsible for ensuring that standards of Infection Prevention and Control are maintained in line with Trust policy and procedures. Infection Prevention and Control training and standards will be monitored via the appraisal process Infection Prevention and Control Isolation Policy Aug 16 Page 5

6 4 A- Z of Communicable diseases and Isolation type. Standard Universal precautions applies to all patients all of the time. Contact precautions should be used for patients known or suspected to be infected or colonised with micro-organisms that can be transmitted by direct contact with the patient or immediate environment Respiratory precautions large droplet spread by coughing, sneezing and small droplets which are airborne Enteric precautions relating to diarrhoea and or vomiting Protective isolation this is generally required for patients who are neutropenic A pocket card guide to the most common communicable diseases is available in clinical areas (see appendix 1) DISEASE (*=Incubation ROUTE OF Isolation Type Side Room required COMMENTS Period) TRANSMISSION AIDS/HIV (Acquired immune Deficiency syndrome / Human immunodeficiency virus (*) Can be up to 10 years vary according to the stage of infection - infectivity will be greatest when viral load is highest - Inoculation of infected blood/body fluids - unprotected sex - from infected mother to baby in utero and breast milk Routine isolation of patients is not required No Adenovirus in paediatrics Droplet Contact and Respiratory precautions Yes Main risk to healthcare staff is from contaminated sharps Contact Occupational Health immediately for sharps injuries advice Isolate for the duration of the illness. Bronchiolitis Direct contact with airborne respiratory droplets and contact with secretions Contact and Respiratory Precautions Yes May be up to three weeks even once asymptomatic Campylobacter gastroenteritis Candidiasis Candidda albicans Cellulitis e.g. Group A streptococci Faecal - oral Enteric precautions Yes Isolate until formed stool for 48hrs Hands contaminated with Standard Precautions No secretions Contact Contact precautions Yes on Orthopeadic wards Side room required until 48hrs No if on a medical ward of antibiotics completed providing covered with Infection Prevention & Control Jan16 Page 6

7 DISEASE (*=Incubation Period) Chickenpox- varicella zoster virus (*) days ROUTE OF TRANSMISSION Droplet inhalation / direct contact with vesicular fluid or respiratory secretions Isolation Type Side Room required COMMENTS Respiratory and Contact Precautions appropriate dressing. Yes If contact is a pregnant woman, seek advice from Doctor or Midwife Exclude non-immune staff and visitors Ideally should only be nursed by staff who have immunity. Cholera Faecal/oral Enteric Precautions Yes- until l 48hrs without diarrhoea Clostridium Difficile Creutzfekdt-Jakob disease (CJD) Cryptosporidiosis gastroenteritis Cytomegalovirus Diarrhoea of unknown origin suspected infectious, including: Campylobacter Dysentery EColi 0157 Cryptosporidiosis Faecal oral route following direct / indirect contact with faeces, contaminated environment, equipment Enteric Precautions - Yes- until 48 hours without diarrhoea Notifiable to Public Health England by medical teams (Appendix 2 ) Hand hygiene with liquid soap and water and increased cleaning MUST be implemented for symptomatic patients Standard Precautions No Additional precautions may be required when undertaking surgical procedures as per policy. Faecal /oral Enteric Precautions Yes Isolate for duration of illness In the saliva, urine and blood of infected person Contaminated food Contaminated water Direct/indirect faecal oral Standard Precautions No Enteric Precautions Yes Notifiable to Public Health England for food poisoning by medical teams (Appendix 2 ) Isolation required until 48hrs symptom free Infection Prevention and Control Isolation Policy Aug 16 Page 7

8 DISEASE (*=Incubation Period) Food poisoning Giardiasis Salmonella ROUTE OF TRANSMISSION Isolation Type Side Room required COMMENTS Ensure good environmental cleaning especially toilet areas Diphtheria Airborne Respiratory Precautions Yes Notifiable to Public Health England by medical teams (Appendix 2 ) Epstein-Barr virus Droplet Standard Precautions Yes infection Fungal skin Contact No Contact precautions (dermatophyte) infection Gas Gangrene Contact Contact precautions No Does not require isolation (myonecrosis) Gentamicin and extended spectrum antibiotic resistant gram negatives Glandular Fever (*) from 4-6 weeks Contact Contact precautions Yes Requires risk assessment for placement on surgical ward and ITU by Consultant Microbiologist/ IPCN Contact with saliva Can also spread by airborne droplets Standard precautions No Hand washing essential especially if hands contaminated with saliva Hand, Foot and Mouth Disease (Coxsackie virus) (*) 3-5 days Hepatitis A Contact with respiratory secretions and faeces Faecal-oral route Food contaminated by infected food handler Standard Precautions No Good personal hygiene Wash hands after handling soiled tissues Good environmental cleaning, especially of toilets. Stool Precautions Yes (while symptomatic) Notifiable to Public Health England by medical teams (Appendix 2) Hepatitis A vaccine / immunoglobulin may be given Infection Prevention and Control Isolation Policy Aug 16 Page 8

9 DISEASE (*=Incubation Period) ROUTE OF TRANSMISSION Contaminated water Isolation Type Side Room required COMMENTS to protect close family contacts Hepatitis B Blood / bodily fluid Standard Precautions No Notifiable to Public Health England by medical teams (Appendix 2 ) Hepatitis C (*) 1-6 months Herpes simplex (cold sores) (*) 2-12 days Herpes Zoster (shingles) (*) days Impetigo (*) 4-10 days Influenza/ Avian Influenza (*) 1-5 days Legionnaires disease (*) 2-10 days Blood/ Bodily fluid Standard Precautions Notifiable to Public Health England by medical teams (Appendix 2 ) Direct contact with lesions, exudate or saliva (usually during close contact such as kissing) Direct contact with lesions Until lesions have crusted (approximately 7-10 days after onset) Standard Precautions No Standard Precautions Yes Varicella immunoglobin for non- immune-compromised neonatal and pregnant contacts Direct contact with lesions Standard Precautions No I Airborne spread from respiratory droplets and can be also transmitted by direct contact on contaminated hands Not transmitted from person to person Good personal hygiene and hand washing after dealing with infected person. Respiratory Precautions Yes Contact screening and antivirals may be required as per PHE guidelines Standard Precautions No The source of the infection should be sought and rectified Usually isolation from equipment such as cooling Infection Prevention and Control Isolation Policy Aug 16 Page 9

10 DISEASE (*=Incubation Period) ROUTE OF TRANSMISSION towers associated with air conditioning and industrial processes, and in warm water systems where if the temperature is kept around 43c the bacteria can breed Isolation Type Side Room required COMMENTS Lice (body lice) Clothing or intimate body Contact Precautions No unless infected contact Lice (head lice) Direct contact Standard Precautions No Lice (pubic lice) Direct contact with public hair and less commonly axillae, beards and eyebrows Standard Precautions No Malaria (*) days but varies widely Transmission to humans by bite of infected female anopheles mosquitos. Standard Precautions No Notifiable to Public Health England by medical teams (Appendix 2 ) Cases have occurred by injection or transfusion of blood from infected person or by use of contaminated needles and syringes Infection Prevention and Control Isolation Policy Aug 16 Page 10

11 DISEASE (*=Incubation Period) Measles (*) 7-14 days ROUTE OF TRANSMISSION Airborne by respiratory droplet and direct contact with nasal and throat secretions of infected persons Isolation Type Side Room required COMMENTS Respiratory Precautions Yes Notifiable to Public Health England by medical teams (Appendix 2 ) Isolation required Combined measles, mumps and rubella (MMR) vaccine available Meningococcal Meningitis (bacterial) (*) 2-10 days Close person to person contact here respiratory secretions from the mouth and from the mouth and throat are inhaled or by direct contact (kissing) Respiratory Precautions Yes Notifiable to Public Health England by medical teams (Appendix 2 ) PHE must be notified urgently Meningitis (Viral) Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) Methicillin Resistant Staphylococcus aureus (MRSA) Faeces and respiratory secretions (kissing, coughing and sneezing) Until virus no longer present in stools Airborne Respiratory Precautions As per PHE requirements Notifiable to Public Health England by medical teams (Appendix 2 ) Contact Contact Precautions Yes A risk assessment may be undertaken based on previous negative results No Infection Prevention and Control Isolation Policy Aug 16 Page 11

12 DISEASE (*=Incubation Period) Mumps (*) days ROUTE OF TRANSMISSION Respiratory droplets and direct contact with saliva of infected person Isolation Type Side Room required COMMENTS Respiratory Precautions Yes Notifiable to public Health England MMR vaccine available Pyrexia of unknown originpatients patients with recent history of travel should be classed as high risk PVL Staphylococcus aureus Dependent on symptoms and diagnosis Standard precautions Yes Precautions will depend on symptoms Contact Contact Precautions Yes Respiratory syncytial virus Droplets Respiratory precautions Yes Ringworm on body (Tinea Corporis) (not a worm but a fungal skin infection, ring shape in appearance Direct or indirect contact with infected areas of skin. Also from infected animals and from contaminated floors and shower stalls Standard Precautions No (*) 4-10 days Rubella (German Measles) (*) days Scabies (*) 1 day 6 weeks depending on previous Direct contact with respiratory secretions or droplets Prolonged close skin to skin contact Contact Precautions Yes Notifiable to Public Health England by medical teams (Appendix 2) - MMR vaccine available - Pregnant women who have had contact and are unsure of their immunity status should speak to their Dr or Midwife immediately Standard Precautions No Avoid close contact until 24 hours following treatment Infection Prevention and Control Isolation Policy Aug 16 Page 12

13 DISEASE (*=Incubation Period) exposure Scarlet Fever (group A streptococci) (*) 1-5 days ROUTE OF TRANSMISSION Airborne droplets from coughs and sneezes Isolation Type Side Room required COMMENTS Respiratory Precautions Yes Notifiable to Public Health England by medical teams (Appendix 2 ) Shingles (Herpes zoster) Occurs in those who have previously had chickenpox and is a reactivation of the virus Streptococcus pyogenes (Group A Streptococcus) Tuberculosis (pulmonary) (*) 4-12 weeks before signs of disease found by skin testing Vancomycin Resistant Enterococcus (VRE) Worms (round worms, tape worms and thread worms) Shingles cannot be transmitted but direct contact with lesions by those who have not had chickenpox could lead to development of chickenpox Day sore throat starts until 24 hours after antibiotics commenced Contact Precautions Yes Only staff who have immunity to have patient contact. Airborne/Contact Contact Precautions Yes Inhalation of droplets containing the bacteria for example when an infected person coughs or sneezes Infectious if smear positive and remains so until 14 days after starting and adhering to treatment and clinical improvement has occurred Contact Contact Precautions Yes Faecal oral route Standard Precautions No Yes Multi Drug resistant TB will require Negative pressure room Notifiable to Public Health England by medical teams (Appendix 2 ) Viral Haemorrhagic fevers ( Ebola, Lassa fever) Blood borne Contact precautions Yes Patients will be transferred to a specialist isolation unit Notifiable to Public Health England by medical teams (Appendix2 ) Infection Prevention and Control Isolation Policy Aug 16 Page 13

14 DISEASE (*=Incubation ROUTE OF Isolation Type Side Room required COMMENTS Period) TRANSMISSION Precautions Respiratory Contact Enteric Standard Side Room YES Assess Risk Yes Rarely Aprons Yes Yes Yes Yes Gloves Yes Yes Yes Yes Masks Risk Assess see TB Policy Standard Precautions MERS PHE Guidelines Influenza No No No *Public Health England notification form (Appendix 2) is available on the Trust infonet, Infection Prevention and Control Page. Infection Prevention and Control Isolation Policy Aug 16 Page 14

15 HIGH RISK MUST BE ADMITTED TO A SIDE ROOM 5 Side Room Isolation Risk Matrix - This matrix is to aid clinical staff in identifying risk factors for patients requiring isolation, it details when patients can be moved out of isolation. Priority for Isolation Condition or Organism Factors to consider when moving patients out of isolation Type of clean Acute Hepatitis A Patients are usually infectious until 7 days after the onset of jaundice, but children may Routine excrete for longer. IPCT to risk assess before moving patient out of isolation. Blood Borne virus (BBV) with active DO NOT remove from isolation until active bleeding has stopped. (Patients with a blood Infection bleeding borne viruses and no active bleeding do not need isolating unless receiving renal dialysis). Clostridium Difficile associated diarrhoea Isolate patient until 48 hours clear of Type 5-7 stools. Infection Confirmed CPE (Carbapenemase DO NOT remove from isolation unless approved by IPCT Infection producing enterobacteriacae) CPE - transfer from other hospitals pending CPE screening If the patient meets CPE screening criteria they will require 3 negative screens over 6 days before they can be removed from isolation. Ask transferring institution if they are willing to undertake first screen, this will speed up removal from isolation. In exceptional circumstances e.g. bed crisis, providing the patient has no history of CPE they may be nursed in a bay (preferably beside a sink) whilst CPE screens are being undertaken. The patient must be isolated if any screen returns positive. Ensure standard precautions and strict hand hygiene practices are maintained in line with the good practices policy. Isolate until 48 hours clear of type 5-7 stools, or a non-infectious cause identified. Routine / Infection depending on screening result Diarrhoea and/or vomiting of suspected Infection infectious origin German measles (Rubella) Isolate adults for 4 days after onset of rash. Children may excrete for longer. IPCT to risk Routine assess before moving patient out of isolation. Influenza DO NOT remove from isolation until symptom free (minimum of 3 days from onset) Infection Invasive Group A Streptococcal Infection DO NOT remove from isolation until 48 hours of appropriate antibiotic therapy. Consult with Infection IPCT Measles Isolate for 4 days after onset of rash Routine Meningitis/Meningococcal septicaemia Can be removed from isolation following 24 hours of appropriate antibiotic therapy. Please Routine discuss with IPCT prior to removal from isolation. MRSA / MSSA (PVL Positive) DO NOT remove from isolation - discuss with IPCT Infection MRSA sputum positive with cough DO NOT remove from isolation unless discussed with IPCT Infection Infection Prevention and Control Isolation Policy Aug 16 Page 15

16 MEDIUM RISK A side room is preferred Priority for Isolation Condition or Organism Factors to consider when moving patients out of isolation Type of clean MRSA with exfoliating skin condition See medium risk for MRSA colonisation MRSA transfer from another hospital pending MRSA screen DO NOT remove from isolation unless discussed with IPCT If patient is screened as MRSA negative and has no previous MRSA history, patient can be removed from isolation In exceptional circumstances e.g. bed crisis, providing the patient has no history of MRSA they may be nursed in a bay (preferably beside a sink) whilst MRSA screens are being undertaken. The patient must be isolated if any screen returns positive. Ensure standard precautions and strict hand hygiene practices are maintained in line with the good practices policy. Infection Routine / Infection depending on screening result Mumps Isolate for 5 days after onset of symptoms. Routine Pyrexia of unknown origin Isolate until an infective cause if excluded Routine Pulmonary tuberculosis (TB) including DO NOT remove from isolation unless approved by IPCT/ TB Nurse specialist. Suspected / Routine Multi-Drug Resistant TB confirmed Pulmonary TB patients MUST be cared for on ward 4 in negative pressure room. Severely immunocompromised patients DO NOT remove from isolation until patient s white cell count is normal, consult medical Routine team. Viral haemorrhagic fever DO NOT remove from isolation. These patients MUST be moved to an infectious diseases Consult IPCT unit. VRE colonisation/infection DO NOT remove from isolation unless approved by IPCT Deep Clean Whooping cough DO NOT remove from isolation until patient has had 5 days of appropriate antibiotics Routine Extended spectrum beta lactamase (ESBL) colonisation Can be removed from isolation if isolation is required for a higher priority patient. Ensure standard precautions and good hand hygiene practices are maintained in line with the good practices policy. Infection MRSA colonisation (Other than the above) Patient s whose ESBL has been identified from a catheter urine specimen and have a urinary catheter in place should be isolated unless a higher priority patient presents. ESBL s identified from mid-stream urines from patient without a urinary catheter insitu do not need isolating. Can be removed from isolation if isolation is required for a higher priority patient. Ensure standard precautions and good hand hygiene practices are maintained in line with the good practices policy. Patients who have 3 consecutive negative MRSA screens (as per MRSA policy) can be removed from isolation. Infection until removed from isolation Infection Prevention and Control Isolation Policy Aug 16 Page 16

17 LOW RISK Priority for Isolation Condition or Organism Factors to consider when moving patients out of isolation Type of clean Shingles Isolation is required until vesicles are dry and have scabbed Routine Viral meningitis Isolation is preferred until symptoms have resolved Routine Respiratory infection of unknown origin Discuss symptoms with medical team and IPCT Routine Chronic diarrhoea of non-infectious origin Patients do not need to be isolated. Ensure standard precautions and good hand hygiene Routine practices are maintained in line with the good practices policy. Scabies Do not need isolation but this may be more comfortable for the patient while undergoing Routine treatment. Head lice Patients do not need to be isolated. Ensure standard precautions and good hand hygiene Routine practices are maintained in line with the good practices policy. Legionella Patients do not need to be isolated. Ensure standard precautions and good hand hygiene Routine practices are maintained in line with the good practices policy. Malaria Patients do not need to be isolated. Ensure standard precautions and good hand hygiene Routine practices are maintained in line with the good practices policy. Pseudomonas Patients do not need to be isolated. Ensure standard precautions and good hand hygiene practices are maintained in line with the good practices policy. Routine Cleaning requirements (As per Trust Cleaning Policy), contact ISS helpdesk to request cleans - Ext 1999 Routine clean Once daily clean and routine cleaning on discharge. Infection clean - Two daily cleans with sporicidal and a post infection clean with curtain change on discharge. Evening clean will include high contact areas e.g. door handles / plates, taps, toilet handles etc. Post infection clean clean with a sporicidal and curtain change (Steam and Tristal). Deep Clean IPCT (triple clean)- These occur as part of a planned programme of work, following a specific micro-organism and or following an outbreak. Requests for a deep clean will be made by the IPCT/Clinical Matron. Out of hours this will be via the site manager. Further Infection Prevention and Control advice and support during normal working hours Monday to Friday on ext1597 Out of hours contact the on call Consultant Microbiologist via hospital switchboard. Infection Prevention and Control Isolation Policy Aug 16 Page 17

18 6. What are the Isolation requirements, terminology and modes of transmission. 6.1 Who should be isolated? All patients with known or suspected infection or colonisation with a multidrug resistant organism must be isolated as detailed in the A-Z Guide (see section 4) Patients admitted with a history of foreign travel and pyrexia of unknown origin All patients with suspected infective cause or loose stools, type 5-7 (after 3 episodes) on the Bristol stool Chart (with all other medical causes excluded) Patients who are vomiting (with all other medical causes excluded). All inpatients with suspected or confirmed neutropenia Staff must ensure that the reasons for the patients being isolated are clearly explained to the patient and their carers/family, if required an interpreter should be used. Clinical staff/ Healthcare Cleaning Staff who require access to the area should clearly understand the precautions they need to implement to prevent transmission to others. 6.2 Isolation Priority Category A, for example known or suspected EBOLA patients, MUST be isolated immediately and notified to the IPCT and or Consultant Microbiologist as arrangements will need to be made to move this patient to a specialist infectious disease unit. Out of hours this must be the Consultant Microbiologist on Call Patients identified as requiring isolation MUST be isolated as soon as practically possible within 4 hours When a side room is unavailable, or it is not possible to comply with this time frame a review must be undertaken of other patients using the side room isolation risk matrix (Section 5). The delay MUST be clearly documented in the patients medical notes. A review should be undertaken of side room availability on other wards, input should be sought from the clinical team responsible for the patient. Complete a DATIX for any patients who require isolation and cannot be isolated due to side room availability. Until the patient is isolated source isolation precautions must be applied wherever the patient is currently situated. Neighbouring patients must be reviewed to establish their risk factors in remaining next to a patient with an identified infection. Further advice is available from the Infection Prevention and Control Team and or Consultant Microbiologist. Out of hours this should be discussed with the Consultant Microbiologist on Call. In the event of an outbreak or the presence of several patients on a ward with the same infection, cohorting of these patients may be considered. The decision to cohort patients MUST be made in collaboration with the IPCT and the Consultant Microbiologist (out of hours this must be discussed with the on call microbiologist). This will be based on the clinical risk of other patients and may result in ward closures as per the Outbreak policy. 6.3 Explanation of terminology Source Isolation Used for patients suffering from a communicable disease or carriers of a communicable/ infectious disease. Use of source isolation prevents the spread of infection to others (section 5) Protective Isolation Used to protect immunological compromised patients from the risk of infection from other patients, visitors and staff Infection Prevention & Control Jan16 Page 18

19 Cohort Nursing Negative Pressure Room (Ward 4 side room 5& 6). Category A infections Refers to the nursing of a group of patients with the same infection within a confined area such as a bay or a ward A side room with a negative pressure ventilation system, used for patients who are isolated because they are a risk of infection to other patients. As the door of the room is opened because of the negative pressure inside, air is sucked into the room. Air from the room is released to the outside via a filter away from inlets to other ward or department areas Infectious substances or pathogens that present a severe risk of infection to humans e.g. EBOLA, MERS (these patients would be transferred out to a specialist infectious disease unit for example Liverpool 6.4 Modes of Transmission Route of Transmission Contact Transmission Droplet Transmission Airborne Transmission The method by which infection is transmitted from one person to another, understanding the route of transmission is essential to apply appropriate isolation precautions and the correct use of PPE This is the most frequent mode of transmission of nosocomial infections. This may be direct contact for example touching, biting and kissing. It also includes indirect contact via equipment (including sharp objects e.g. needles scalpels) as well as via the faecal oral route. Large droplets are generated from the source person predominantly during coughing, sneezing, or via cough inducing procedures such as suctioning or bronchoscopy. Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance (approximately 1 metre) and deposited into the hosts mouth, nasal mucosa or conjunctivae. This route of transmission can be divided into two types, droplet nuclei and dust. Droplet nuclei are small respiratory droplets which rapidly evaporate into small particule residues that may contain micro-organisms. Droplet nuclei remain suspended in the air for long periods of time and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient. Dust is skin squames which are shed from the skin surface are at a rate of approximately 300 million a day and are a main component of dust. Small dust particles may remain airborne for several hours and can be inhaled or settle in wounds. Infection Prevention and Control Isolation Policy Aug 16 Page 19

20 7 Source Isolation Procedures 7.1 Communication to patients, staff and visitors Explain the rationale for isolation to the patient/relatives; including the potential duration of the isolation. Provide written information about the infectious disease in the format of leaflets available from NHS Choices, PHE website (discuss with IPCT). Staff should recognise the patient anxiety caused by the need to isolate and ensure they are supported; this may include the use of radios, TV s, computers and additional support from the family. Patients with Dementia may not fully understand the rationale for Isolation, staff must ensure that strategies are introduced to minimise the risk of transmission to the patient and to others, this may require additional support from the relatives/carers, 1-1 nursing, and diversion using TV s. Games, twiddle muffs. Explain the need for strict hand hygiene to any visitors and the need to use PPE if required for example if giving direct care. Place the Infection Prevention and Control restriction signs on the side room/ bay door Record in the patient s notes that isolation has commenced and the reason why, include this information in the ward hand over sheets Liaise with the Infection Prevention and Control team to ensure all measures are in place and that the patient is in isolation If the patient has a notifiable disease then the Medical team responsible for the patients care must complete and submit the appropriate notification form to Public Health England (see appendix 2) If full isolation procedures cannot be maintained due to the patients physical or mental condition any variances must be clearly documented in the patents notes. Contact healthcare cleaning service and request Isolation cleaning for that area in line with the Trust Cleaning Policy. Most discharges will require a post infection clean using steam and Tristal however, for some organisms a Deep Clean will be required which will be a triple clean of Steam, tristal and Steam this will only be requested by the IPCT or Clinical Matron. Patients may be required to attend other departments for treatment/investigations; these should not be delayed unless clinically the Consultant responsible for the patient feels it would not be in their best interest, the receiving area must be informed of the patient s infection status and any controls they need to implement. Transfer to other care settings (Nursing Homes) can occur as required however they must be fully informed of the patient s infection status and controls they require further support can be obtained from the IPCT. Patients who are medically fit can be discharged to their own home; advice should be given if any precautions are required in relation to their infection. 7.2 Accommodation Identify appropriate isolation facilities e.g. Side room or cohort bay. The Negative pressure side room (Ward 4) may be required for specific organisms for example Multi Drug resistant TB. This will require patients from side room 5 and 6 moved to other side rooms/ bays. As far as reasonably practicable the door must be kept closed when isolation restrictions are in place, if the patient requires closer observation for example high risk of falls this must be discussed with the ICT and variations recorded in the patients notes and on the handover sheet. Risk assess and implement additional precautions, further advice can be obtained from the IPCT/ Consultant Microbiologist. Infection Prevention and Control Isolation Policy Aug 16 Page 20

21 If a patient has suspected infectious diarrhoea and or vomiting it is preferable to use an en-suite side room. This may require a risk assessment and the movement of another patient in isolation (refer to the Infection Control Side Room Isolation Risk Matrix) Keep all furniture and equipment to a minimum ensuring that the following is available: - Hand hygiene facilities (Alcohol gel may need to be removed dependent on the organism for example CDI). - Gloves and Aprons to be stored outside the room - Clinical waste bin within the patient s room - Sphygmomanometer/stethoscope and thermometer stored outside the room unless these are wall mounted and integral to the isolation room. - Dedicated toilet facilities if not an en suite - Nursing notes/ charts should be kept outside the room 7.3 Isolation Procedure in ICU If a patient is assessed as requiring isolation, the type of isolation and reasons for isolation must be documented in the patient s records, and explained to the patient/relatives, ideally this should be in the designated side room. If the side room is occupied a risk assessment will be undertaken by the ICU staff and the IPCT/Consultant Microbiologist. If the patient is nursed in the side room the correct isolation precautions sign must be clearly displayed, and PPE must be available outside the room. PPE must be removed and disposed of as clinical waste immediately after the care activity, and hands decontaminated with liquid soap and water. If the patient is nursed in a bed space as far as reasonably practicable this should be in the bed space nearest the side room, the need for strict isolation procedures must be communicated to all staff (included on staff SBAR). Single use consumables must be kept to a minimum with a small supply in the patient s bed area. Any reusable equipment must be decontaminated as per manufacturer s instructions/ Trust cleaning policy. Once the patient is identified as clinically fit for moving out of the unit, the receiving area must be notified of the need for isolation (this may mean the patient must be moved into a side room). Further advice and support can be obtained from the IPCT/ Consultant Microbiologist. Following the patient s discharge from the unit and or the cessation of isolation a Post infection/deep Clean will be required as per the Cleaning Policy. Please notify ISS on x1999, and upon completion of the clean inform the bed managers when the area is ready for use. 7.4 Hand Hygiene Hands must be decontaminated on entering the isolation area with liquid soap Hands must be cleaned with liquid soap prior to leaving the isolation room; in addition hand hygiene must occur between different patient care activities as per the Five moments of hand hygiene. This action is evidence based as a significant factor in reducing the risk of transmission not only to the patient but also to others within the clinical environment. Infection Prevention and Control Isolation Policy Aug 16 Page 21

22 Visitors must be advised to wash their hands with liquid soap on entering and leaving the side room/bay (Isolation area) and advised not to visit other clinical areas after visiting a patient in isolation. 7.5 Personal Protective Equipment (PPE) It is unnecessary for all people entering the isolation area to wear PPE If contact with blood and bodily fluid and or direct patient contact is anticipated then PPE (e.g. gloves and aprons) should be worn. These precautions would also apply when stripping beds or assisting with toileting. PPE must be removed immediately prior to leaving the room and disposed of as clinical waste in the room, except when leaving the room to dispose of used bedpans etc; on these occasions it should be removed in the sluice after placing the bed pan in the bed pan washer. For some specific infections visitors may be required to wear PPE this is usually gloves and aprons the IPCT will advise if this is required. Occasionally additional PPE is appropriate, including masks (Multi Drug Resistant (MDR) TB and gowns. However please note in the use of masks surgical face masks have limited benefit and the use of FFP3 masks must only occur if staff has undergone the relevant training (Cascade trainers are available in clinical areas to provide training/refresher training, this is supported by the IPCT). 7.6 Linen Patient s bed linen must be changed on a daily basis. Relatives should be asked to provide clean night attire and towels as part of this daily change. Used linen to be placed in a red alginate bag and then into a white outer bag. Used linen to be removed from the isolation room and disposed of as quickly as possible. Patients, relatives, carers should be advised that own clothing can be washed as normal on the hottest temperature for the fabric. This should be placed in the patient s locker in a property bag and relatives asked to take home as soon as practicable. 7.7 Waste disposal Waste should continue to be segregated as per the Trust waste policy: Black bags (for papers, tissues, wrappers) Clinical waste bins must be placed in all side rooms or bays used for isolating patients for the disposal of PPE, aprons, gloves. 7.8 Environmental Cleaning Once a patient is moved into isolation ISS must be informed via the hotline number x1999 that infection cleaning is required. All horizontal, vertical surfaces including frequent touch point areas for examples bedside tables, door handles must be cleaned twice daily using a sporicidal product e.g. Tristal. During an outbreak this frequency may be increased at the request of the Outbreak Control group. Dedicated equipment must be used for patients requiring isolation, however this will not always be practicable (e.g. hoists); on these occasions the equipment must be cleaned immediately after use (It may be necessary to refer to the manufacturer s instructions for any specialist equipment to ensure correct decontamination occurs). For the majority of items such as commodes, chairs, Tristal or sporicidal wipes will be appropriate. As far as practicable keep items to a minimum, this includes patient s personal items, it may be appropriate to request extra items are sent home Infection Prevention and Control Isolation Policy Aug 16 Page 22

23 ISS must be notified via x1999 when the patient is due for discharge and given a time to commence cleaning based on the time of discharge. There are two levels of cleaning following discharge dependent on the organism Post infection requirements is Tristal and steam - this will take a minimum of an hour A deep clean/ triple clean (Steam, Tristal and Steam) will take up to 4 hours (though may be longer if a full bay/ward requires cleaning). This clean must be signed off by the ISS supervisor and the Matron/ infection Prevention and Control nurse. If occurring out of hours this signoff should be undertaken by the Site Manager/Night sister and ISS Supervisor. The Bed management team must be informed of an estimated time for completion of the clean. 8 Patient Transfer Patients identified with a known infection or in the process of being screened for an infection must not be moved onto another ward unless for clinical reasons. On occasions when patients are transferred owing to clinical need, they must be transferred into a side room and the receiving area must be informed of their infection. 9 Training All clinical staff must undertake annual Trust infection control mandatory training. Specific Infection Prevention and Control training to support clinical practice will be delivered by the Infection Prevention and Control Team. 10 Key Performance indicators Isolation of patients with known infections will be monitored based on time to isolate patients monitored via Post infection reviews and 6 monthly audit via CRIS bed management system. 11. Monitoring compliance The infection prevention and control team will review and investigate incidents reported relating to this policy and audit departments compliance with Isolation requirements. Failure to follow the guidance in this policy will be reviewed as part of the Post Infection Review process and consideration given if this constitutes a Lapse in Care contributing to the development of an infection. Non-compliance with the policy will be managed via the staff disciplinary route; this will be supported by the Director of Nursing, Quality, Performance, DIPC, and the Medical Director. This policy should be read in conjunction with all other Infection Prevention and Control policies in particular but not exclusively: Standard Precautions Outbreak Policy Specific Micro-organisms Cleaning Policy Infection Prevention and Control Isolation Policy Aug 16 Page 23

24 Legislation, Guidance and References Advisory Committee on Dangerous Pathogens. (2003). Infection at Work: Controlling the Risks. A guide for employers and the self-employed on identifying, assessing and controlling the risk of infection in the work place Chin, J. (2000) Control of Communicable disease manual: American Public Health Association. Department of Health (2007). Isolating patients with HCAI. Summary of best practice. /03 /Document_Isolation_Best_Practice_FINAL_ pdf Department of Health (2013). Infection Control in the built environment HBN , Department of Health (2013) Environment and Sustainability Health Technical Memorandum - Safe Management of Health Care Waste, Department of Health (2015) The Health and Social Care Act 2008, Code of Practice on the prevention and control of infection and related guidance Available at: Loveday H.P, Wilson J.A, Pratt R.J, Golsorkhi M, Tingle A, Bak, A, Browne J, Prieto, J, Wilcox. M. (2013) epic 3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infections 86S1(2014) S1-S70 NICE guidelines: Clinical diagnosis and Management of Tuberculosis and Measures for Prevention and Control, Royal College of Physicians March NICE (2014) Infection Prevention and Control Nice Quality standard. Hospital Infection Society Working Party Review of Hospital Isolation and Infection Control Related Precautions. WHO (2006) Your 5 moments of hand hygiene [pdf] Available at: Infection Prevention and Control Isolation Policy Aug 16 Page 24

25 Appendix 1 - Pocket Cards INFECTIONS REQUIRING ISOLATION Does my patient need isolating? If your patient has one of the following infections please consider the need for isolation. 1,2 & 3 should be considered as priority however a full risk assessment must always be completed. 1.CPE Post Infection Clean Steam & Tristel A patient with CPE must ALWAYS be isolated. Repatriated patients must be isolated and screened for CPE (3 x swabs 48 hours apart to obtain a total of 3 swabs) 2.VRE Deep clean Steam, Tristel, steam A patient with VRE must ALWAYS be isolated 3.Clostridium Difficile Post Infection clean Steam & Tristel A patient with C.diff both Toxin +ve & Toxin -ve with active diarrhoea PTO V0.5 IPCT bleep: 3034 / 3449 Bed / Site Managers bleep: 3011 / 7203 Does my patient need isolating? 4.D&V Post Infection Clean Steam & Tristel A patient with suspected infectious diarrhoea and vomiting. Consider patients with bowel conditions/ laxatives / encephalitis may not need isolation seek senior advice. 5.Influenza Post Infection Clean Tristel A patient with suspected or confirmed Flu must be isolated. 6.MRSA Post Infection clean- Post Infection Clean Tristel A patient with MRSA / previous and no negative screens (check labcentre) For suspected TB and Shingles please check the Rapid assessment tool for single room isolation. Please refer to the Isolation Policy for the assessment tool which contains a full list of infections. For information relating to cleaning of equipment, please see the Cleaning Policy via Infonet. Infection Prevention and Control Isolation Policy Aug 16 Page 25

26 Appendix 2 - Public Health England Notification form Infection Prevention and Control Isolation Policy Aug 16 Page 26

27 Infection Prevention and Control Isolation Policy Aug 16 Page 27

28 Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Isolation Policy Details of person responsible for completing the assessment: Name: Anita Swaine Position: Lead Nurse Infection Prevention and Control Team/service: Infection Prevention and Control State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) Standard Precautions are the principle strategy for the prevention and control of healthcare associated infection. Additional precautions are required for patients who are known or suspected to be infected (or colonised) with highly transmissible or epidemiologically/ important pathogens this is known as isolation. It is important to remember that this process of isolating the affected person is to protect others hence minimising the risk of micro-organism transfer and recognise that it is the micro-organisms which are being isolated (source) rather than the patient. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Infection Prevention and Control Isolation Policy Aug 16 Page 28

29 Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Infection Prevention and Control Isolation Policy Aug 16 Page 29