Infection Prevention and Control. Carbapenemase Producing Enterobacteriaceae (CPE)

Transcription

1 Infection Prevention and Control Carbapenemase Producing Enterobacteriaceae (CPE) IPCT CPE Policy V4 May 2018

2 Policy Title: Executive Summary: Carbapenemase Producing Enterobacteriaceae (CPE) This policy details the micro-organisms capable of producing carbapenemase, how they are identified, managed and spread within the hospital setting. Supersedes: Carbapenemase Producing Enterobacteriaceae (CPE) V2 February 2016 Description of Updated to reflect National Guidelines Amendment(s): This policy will impact on: Clinical Staff Financial Implications: Laboratory screening costs Policy Area: Infection Prevention and Control Trust Wide Document Reference: ECT Version Number: Issued By: Author: V4 Effective Date: July 2018 Infection Prevention and Control Abigail Paterson Associate Specialist Practitioner Infection Prevention and Control Review Date: May 2021 Impact Assessment Date: May 2018 APPROVAL RECORD Committees / Group Date Consultation: Infection Control Committee 19 th July 2018 Approved by Director: Director of Infection Prevention & 19th July 2018 Control / Director of Nursing and Quality Ratified by: Infection Control Committee 19 th July 2018 Received for information: Directorate SQS IPCT VRE Policy V4 July2018 Page 2

3 Table of Contents 1. Introduction 4 2. Purpose 4 3. Responsibilities 4 4. Processes and Procedures Monitoring Compliance with the Document References 12. Communication age 7. Appendices 11 Appendix 1 CPE patient information leaflet Appendix 2 Screening for Carbapenemase producing Enterobacteriaceae (CPE) Appendix 3 Carbapenemase producing Enterobacteriaceae (CPE) pathway Appendix 4 Carbapenemase-producing Enterobacteriaceae (CPE) screening flowchart Appendix 5 Carbapenemase-producing Enterobacteriaceae (CPE) contact screening flowchart Appendix 6 Mattress Integrity check 13 age IPCT VRE Policy V4 July2018 Page 3

4 1. Introduction Enterobacteriaceae such as Klebsiella spp and Escherichia coli, are a family of bacteria that live in the gut of humans and animals. They are opportunistic bacteria capable of causing a variety of infections including urinary tract, intra-abdominal and bloodstream infections (PHE, 2018). There are strains of Enterobacteriaceae that can produce Carbapenemase, an enzyme capable of destroying carbapenem antibiotics. Carbapenems are a valuable family of antibiotics normally reserved for serious infections caused by drug-resistant Gram-negative bacteria (including Enterobacteriaceae). They include meropenem, ertapenem, imipenem and doripenem. The presence of carbapenemase makes the Enterobacteriaceae resistant to multiple antimicrobials and therefore infections caused by CPE (Carbapenemase producing Enterobacteriaceae), limiting treatment options. Antibiotic resistance is a major public health concern highlighted by the Chief Medical Officers report (DH, 2011) where the incidence of CPE in the UK is discussed. Public Health England (PHE, 2013 & 2015) also issued guidance to acute Trusts & none acute settings to advise on the detection and management of CPE. This guidance has been used as an evidence base to develop this policy. Section 4.1 of this policy includes a table which identifies countries and UK regions with a high prevalence of CPE 2. Purpose This policy aims to promote awareness of CPE and enable early identification, screening and isolation of high risk patients; which are all essential steps in the control of drug resistant organisms (Damani, 2012). The guidance within promotes correct management of affected patients and aims to improve patient safety by limiting the spread of CPE locally, to contribute towards the global effort to minimise CPE transmission. 3. 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) will take the lead responsibility for the development and implementation of this policy with support of the Head of Nursing Infection Prevention and Control and the Infection Prevention and Control Doctor. In addition as the DIPC they will oversee the implementation of the policy and challenge poor practice. Providing assurance to the board that systems and process are in place to ensure compliance with agreed standards. The Infection Prevention and Control Team (IPCT) will have responsibility for: -ensuring the CPE policy is implemented and monitored across the trust IPCT VRE Policy V4 July2018 Page 4

5 -ensuring the policy is updated to reflect any changes to the national or local guidelines -providing education and support to clinical staff -providing education and advice on the management of CPE patients within the organisation -referring to the Consultant Microbiologist / Infection Control Doctor where appropriate. All Employees are responsible for ensuring standards of Infection Prevention and Control are maintained in line with trust policies and procedures. Infection Prevention and Control training and standards will be monitored via the appraisal process Matrons / Ward Senior Sister / Departmental Managers are responsible for ensuring that all staff: -are aware of, and adhere to, this policy -are aware of their roles and responsibilities with regard to reducing healthcare associated infections (HCAIs) -are aware of patients considered high risk for CPE colonisation / infection -carry out CPE screens for high risk patients as specified in this policy -isolate all suspected / confirmed CPE patients promptly -demonstrate appropriate and effective infection control practices -alert the Infection Prevention and Control Team of suspected / confirmed CPE patients -inform the patient of their CPE status -communicate patient s status on discharge / transfer to receiving organisations (as appropriate). 4. Processes and Procedures 1. What are Carbapenemase producing Enterobacteriaceae? Enterobacteriaceae are a large family of Gram negative bacteria that usually live harmlessly in the guts of humans and animals, as per the images below. Species include: Escherichia coli Klebsiella spp Enterobacter spp Carbapenemases are enzymes made by some strains of the bacteria which allow them to destroy carbapenem antibiotics and so the bacteria are said to be resistant to these antibiotics IPCT VRE Policy V4 July2018 Page 5

6 In the UK in there has been an increase in incidence of infection and colonisation of multidrug resistant carbapenemase producing organisms. UK regions / areas where problems have been noted include: London North West- particularly Manchester Countries and regions with a high prevalence of CPE are documented in the following table. Bangladesh The Balkans China Cyprus Greece India Ireland Israel Italy Japan North Africa Malta Middle East Pakistan South East Asia South / Central America Turkey Taiwan USA 2. Which patients are at a high risk of CPE and requiring screening? All high risk / suspected CPE positive patients must be CPE screened. They must be admitted into an isolation room, preferably with en-suite facilities. Admission to augmented care ITU, CCU, Neonatal unit: A known or recently laboratory confirmed CPE case (these patients will not need rescreening but will need isolating) A direct patient transfer from any UK hospital A direct patient transfer from any hospital abroad A medical tourist from a hospital abroad A patient that has a history of hospitalisation in the last 12 months in the UK or abroad A close contact of a known CPE positive case e.g. living in the same house, sharing a sleeping place i.e. room or hospital bay Admission to general wards: A known or recently laboratory confirmed CPE case (these patients will not need rescreening but will need isolating) A direct patient transfer from any UK hospital A direct patient transfer from any hospital abroad A medical tourist from a hospital abroad A known or recently laboratory confirmed CPE case (these patients will not need rescreening but will need isolating) Patient screen required / isolation required Repeat screen not required isolation required CPE Screen Required isolation required CPE Screen Required isolation required CPE Screen Required isolation required CPE Screen Required isolation required CPE Screen Requireddiscuss with infection control isolation required 3. What is the difference between colonisation and infection? Colonisation The presence of Carbapenemase-producing Infection Carbapenemase-producing IPCT VRE Policy V4 July2018 Page 6

7 Colonisation Enterobacteriaceae (CPE) living harmlessly on the skin or within the human gastrointestinal tract and causing no signs or symptoms of infection. A carrier is colonised with Carbapenemase-producing Enterobacteriaceae (CPE). Infection Enterobacteriaceae (CPE) can cause serious infections, including urinary tract infections, intra-abdominal infections, blood stream infections (bacteremia) and hospital-acquired pneumonias. Patients with infections caused by Carbapenemase-producing Enterobacteriaceae (CPE) require treatment. 4. How is CPE transmitted? Carbapenemase-producing Enterobacteriaceae (CPE) can be spread person to person by faecal contamination of the hands, transferred from an environmental source or contaminated equipment. 5. What is the screening process for CPE? Following identification of a high risk / suspected CPE positive patient they must be CPE screened. Informed consent must be gained from the patient wherever possible. If a patient declines the screen, document this in the patients medical notes and consider taking a stool specimen. Document on the pathology form why a stool sample has to be sent CPE information must be given to the patient or relatives (see Appendix 1 ) Gloves and aprons must be worn when obtaining the CPE screen A rectal swab must be obtained using a dry transwab. The cotton tip of the transwab should be inserted just inside the rectum gently and rotated to come into contact with faeces (see Appendix 2 for screening advice). Additional swabs must be taken from any wounds (surgical wounds, ulcers, lesions) or device related sites (cannula, tracheostomy, PEG, drains or lines) Send swabs to the laboratory labelled for CPE testing include any relevant clinical details. A stool sample will be accepted if a rectal swab is deemed inappropriate e.g., patients with a stoma, paediatrics. Please label the stool sample for CPE testing and provide details of why a stool sample has been sent instead of a rectal swab. Screens must be taken on day 0 e.g. day of admission, day 2 (48 hours after the 1st screen) and day 4 (48 hours after the 2nd screen). If any of the screens return CPE positive, cease screening. See Appendix 4. Follow and complete the CPE Care Pathway using Appendix What actions do I take if the screens return negative? If all three CPE screens return as negative, the patient can be moved out of isolation (unless there is another reason for isolation) and classed as CPE negative. 7. What actions do I take if the screen returns positive? Advise the patient (and relatives if appropriate) of the positive result and provide a patient information leaflet and Public Health England CPE card, if not already done so. Establish if the patient has an infection or is colonised. Isolate in a side room (preferably ensuite) Isolation sign placed on outside of isolation room door The door to the room must be kept closed. If this is not possible, document the reason why in the patients notes. The patient must remain in isolation for IPCT VRE Policy V4 July2018 Page 7

8 the duration of their hospital stay. Hand decontamination PPE Mask / eye protection Linen Toilet facilities Equipment Hands must be decontaminated after contact with the patient, equipment and before leaving the room. Follow the WHO 5 moments for hand hygiene. Hand sanitiser or liquid soap and water can be used. Encourage patients to clean their hands before meals and after using the toilet / commode. Visitors must be advised regarding hand hygiene Aprons and gloves must be worn for clinical care and when in contact with the patients environment e.g. when changing bed linen. Yellow aprons must be worn. Decontaminate hands after removing PPE with liquid soap and water. Visitors are not required to wear PPE unless they are participating in personal care, however must comply with hand hygiene Not required unless CPE is isolated in a patient s sputum. In these circumstances a surgical facemask must be worn for aerosol generating procedures only such as: intubation, invasive suction, deep chest physiotherapy Linen must be changed daily and disposed of in a red alginate bag and then into a white linen bag. Used linen must be disposed of promptly. Linen bags must not be placed on the floor of the isolation room- this reduces the potential for further environmental contamination. Where possible admit patients with CPE into an en-suite room. If this is not possible a dedicated commode must be provided and cleaned after each use using a sporicidal agent e.g. clinell sporicidal wipes (red packet). If a patient is required to use the bathroom on the ward, try to dedicate this bathroom for their use only. If the bathroom cannot be dedicated, the bathroom requires cleaning after each use using Tristel. The bathroom must be cleaned twice daily. If possible, equipment must be dedicated for IPCT VRE Policy V4 July2018 Page 8

9 Waste Disposal Crockery and cutlery Documentation the patient. If this is not possible, any shared equipment must be decontaminated after use using a sporicidal product e.g. Tristel before leaving the isolation room. Clinical waste to be placed into an orange bag. Patients can use crockery and cutlery from the main kitchen, no special precautions required. An alert must be placed electronically on Extramed by ward staff or IPCT An alert sticker must be placed on the patient s notes and the alert card at the front of the notes completed. Monitor patient bowel habit on a stool chart. Ensure patient has an information leaflet and Public Health England CPE card. The ward is responsible for informing the patients GP of their CPE status. Gut decolonisation is not recommended as there is a concern this may contribute to longer term resistance. Skin decolonisation is not recommended as the bacteria generally colonise the gut rather than the skin. No antibiotic treatment is required for CPE colonisation. If a patient is to be transferred to another hospital or care home, the receiving organisation must be notified of the patient s CPE status prior to transfer by the transferring clinical area / department. 8. Do contacts require screening? If a patient returns positive for CPE and has spent 24 hours or more in a main hospital bay, the patients contacts in the bay must be CPE screened. Contacts must be screened weekly for a total for 4 weeks (whilst an inpatient). See appendix 5. Contacts only need to be screened whilst they remain an inpatient. Only begin contact screening once the positive index case has been isolated / left the bay. Cohort the contact patients together and close the bay to admissions. The contact bay must remain closed until all CPE screen results have returned or until the contact patients have been isolated. The decision to reopen the bay must be discussed with IPCT / out of hours Consultant Microbiologist. The IPCT can provide guidance on contact tracing and screening. The above precautions must be followed for contact patients. Screening of household contacts and healthcare staff is NOT required. IPCT VRE Policy V4 July2018 Page 9

10 9. Are there any restrictions on visitors? There are no restrictions placed on visitors. However, if the patient gives consent to discuss their diagnosis with family / carers / visitors, advise immunocompromised patients to avoid visiting if appropriate. All visitors must be advised to practice scrupulous hand hygiene with liquid soap and water prior to leaving the room. Advise visitors undertaking multiple hospital visits to visit the affected patient last. Visitors / care takers taking part in care activities must be provided with PPE, shown how to apply and remove it and the correct waste streams to dispose PPE into. 10. What actions must be taken for the transfer of patients within the hospital/ access to services? Transfer to a different ward within the trust Access to services e.g. therapy, theatre, radiology Multi-disciplinary team members requiring access to a patient with confirmed / suspected / contact of CPE Hospital porters Patients with CPE must only be moved to a different ward if there is a clinical need for a different speciality. This may be reviewed by the bed management team and IPCT if the trust is experiencing organisational pressures and ward moves are required to facilitate patient flow through the organisation. Treatments and procedures must not be delayed however, where possible, planned at the end of the day / list (without compromising clinical treatment). MDT members should visit patients last on their list wherever possible. Access to communal areas is acceptable unless the patient is symptomatic of infection or has diarrhoea. Porters are not required to wear PPE when transferring patients within the trust. Portering staff must practice good hand hygiene after transferring a patient. 11. What actions should be taken on discharge? Type of clean Disposable equipment Clinical equipment Mattress and pillows Post Infection Clean Steam and Tristel Curtain change Including dedicated bathroom if appropriate All disposable equipment to be disposed of including unused dressings, ointments, tapes, wipes etc. To be cleaned with sporicidal agent e.g. Tristel by clinical staff. Pillows must be disposed of The mattress must be assessed as safe to re-use (see appendix 6) Hired mattresses must be returned to the company for cleaning and decontamination IPCT VRE Policy V4 July2018 Page 10

11 Please note: There is no reason for non-acute settings to refuse admission or readmission of service users on the grounds they are colonised with CPE (PHE, 2015). Patients can return to their own home without any special measures. If a patient is being discharged to another healthcare facility / community services the clinical area caring for the patient is responsible for informing the receiving organisation of the patient s CPE status prior to transfer, to allow them time to organise appropriate facilities. Ambulance staff must be informed of the patient s CPE status to enable them to make appropriate preparations. CPE positive patients should undergo a risk assessment in order to determine the requirement for a separate ambulance. 12. What actions are required for community care? While the level of risk for infected or colonised individuals is lower than that in acute settings, if the levels of hygiene in the care setting are inadequate, resistant bacteria may spread amongst individuals who congregate together e.g. in a care home. This may increase the risk of the spread of infection within the care setting (PHE, 2015). Healthcare staff must maintain strict IPC standard precautions e.g. hand hygiene to prevent spread within the persons home or to other clientele on their case list. Where possible CPE positive patients should be seen at the end of the list / day. Patients should not be prevented from attending communal rehabilitation sessions. If a patient is diagnosed CPE positive during an inpatient stay at a healthcare organisation other than East Cheshire NHS Trust, please inform the IPC team on This will enable alerts to be placed in the patient s medical records and preparations to occur to facilitate their potential admission at a point in the future. 13. What actions are required on the patient s death? Precautions taken when performing last offices for the deceased person are the same as in life. This use of Danger of infection stickers and body bags are unnecessary. Mortuary and undertaking staff should abide to standard infection control precautions as appropriate for their role. 5. Monitoring Compliance with the Document The infection prevention and control team will review and investigate incidents reported relating to this policy. IPCT VRE Policy V4 July2018 Page 11

12 6. References Legislation, Guidance and References Damani N (2012) - Manual of Infection Prevention and Control, 3 rd Edition. Oxford: Oxford University Press Chief Medical Officer (2011) - Annual Report of the Chief Medical Officer Infections and the rise of antimicrobial resistance Vol 2. DH: London. Available at: Last accessed Public Health England (2013) - Acute Trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteria. Available at: _trust_toolkit_for_the_early_detection.pdf. Last accessed Public Health England (2015) - Toolkit for managing carbapenemase-producing Enterobacteria in none acute and community settings. Available at: Non-AcuteToolkit_CORE.pdf Last accessed IPCT VRE Policy V4 July2018 Page 12

13 Appendix 1 CPE Patient Information Leaflet What are Carbapenemase-producing Enterobacteriaceae? Enterobacteriaceae are bacteria that usually live harmlessly in the gut of humans. This is called colonisation (a person is said to be a carrier ). However, if the bacteria get into the wrong place, such as the bladder or bloodstream they can cause infection. Carbapenems are one of the most powerful types of antibiotics. Carbapenemases are enzymes (chemicals), made by some strains of these bacteria, which allow them to destroy carbapenem antibiotics and so the bacteria are said to be resistant to the antibiotics. Why does carbapenem resistance matter? Carbapenem antibiotics can only be given in hospital directly into the bloodstream. Until now, doctors have relied on them to successfully treat certain difficult infections when other antibiotics have failed to do so. In a hospital, where there are many vulnerable patients, spread of resistant bacteria can cause problems. Does carriage of carbapenemase-producing Enterobacteriaceae need to be treated? If a person is a carrier of carbapenemase-producing Enterobacteriaceae (sometimes called CPE), they do not need to be treated. However, if the bacteria have caused an infection then antibiotics will be required. How do people pick up carbapenemase-producing Enterobacteriaceae? Do ask your doctor or nurse to explain this to you in more detail. As mentioned above, sometimes this bacteria can be found, living harmlessly, in the gut of humans and so it can be difficult to say when or where it is picked up. However, there is an increased chance of picking up these bacteria if you have been a patient in a hospital abroad or in a UK hospital that has had patients carrying the bacteria, or if you have been in contact with a carrier elsewhere. How will I be cared for whilst in hospital if I am found to be positive? You will be accommodated in a single room with toilet facilities whilst in hospital. You may be asked to provide a number of samples, depending on your length of stay, to check if you are still carrying the bacteria. These will probably be taken on a weekly basis. The samples might include a number of swabs from certain areas, such as where the tube for your drip (if you have one) enters the skin, a rectal swab i.e. a sample taken by inserting a swab briefly just inside your rectum (bottom), and / or a faecal sample. You will normally be informed of the results within two to three days. How can the spread of carbapenemase-producing Enterobacteriaceae be prevented? By accommodating people in a single room this helps to prevent the spread of the bacteria. Healthcare workers will wash their hands regularly. They will use gloves and aprons when caring for you. The most important measure for people to take is to wash hands well with soap and water, especially after going to the toilet. Avoid touching medical devices (if you have any) such as a urinary catheter tube and intravenous drip, particularly at the point where it is inserted into the body or skin. Visitors will be asked to wash their hands on entering and leaving the room and may be asked to wear an apron. What about when I go home? Whilst there is a chance that you may still be a carrier when you go home quite often this will go away with time. No special measures or treatment are required; any infection will have been treated prior to your discharge. You should carry on as normal, maintaining good hand hygiene. If you have any concerns you may wish to contact your GP for advice. IPCT VRE Policy V4 July2018 Page 13

14 Before you leave hospital, ask the doctor or nurse to give you a letter or card advising that you have had an infection or been / are colonised with carbapenemase-producing Enterobacteriaceae. This will be useful for the future and it is important that you make health care staff aware of it. Should you or a member of your household be admitted to hospital, you should let the hospital staff know that you are, or have been a carrier and show them the letter / card. Where can I find more information? If you would like any further information please speak to a member of your care staff, who may also contact the Infection Prevention and Control Team for you. Websites are another source of information: Public Health England NHS Choices Useful contact: East Cheshire NHS Trust Infection Prevention and Control team IPCT VRE Policy V4 July2018 Page 14

15 Appendix 2 Screening for Carbapenemase-producing Enterobacteriaceae (CPE) Rectal specimens to be taken on day 0, 2 & 4 (3 swabs over 5 days), additional swabs to include wounds or devices. If any screens return CPE positive, cease swabbing Specimen type: Rectal screen (preferred sample type) Stool sample (if patient declines or is unable to provide a rectal screen). Document on pathology card reason for stool specimen. TRANSWAB charcoal swab Performing a rectal screen: Explain the procedure to the patient to gain their consent. Ensure the patient s privacy & dignity while performing the procedure Decontaminate hands using liquid soap and water. Confirm patient details on the pathology request card with the patient, or against patient s ID band. Put on non-sterile examination gloves and plastic apron to collect specimen. Insert the dry charcoal swab into the rectum approximately 2.5 cm (for adults) beyond the anal sphincter and very gently rotate to obtain faecal flora. Ensure that the tip of the swab is well covered in faecal material. Remove apron and gloves. Decontaminate hands using liquid soap and water. Dispose of PPE / equipment into appropriate waste stream Label specimens correctly and organise transport to laboratory. Rectum Complete pathology request form: A minimum of 3 patient identifiers must be evident on the pathology form e.g. patient s name, Hosp. No, NHS No, DOB etc. Document rationale for CPE request e.g. CPE screen, CPE contact screen IPCT VRE Policy V4 July2018 Page 15

16 Appendix 3 Carbapenemase Producing Enterobacteriaceae CPE Care Pathway If a patient admitted to any augmented care area or meets any of the below criteria please isolate and screen the patient for CPE. Criteria Tick Date Is the patient a known or recently laboratory confirmed CPE case (these patients will not need re screening but will need isolating with full Infection Control precautions) Is the patient a direct transfer from a UK hospital? Is the patient a direct transfer from a hospital abroad? Has the patient been a medical tourist abroad in the last 12 months? Does the patient have a history of hospitalisation in any care setting in a UK hospital in the last 12 months? Does the patient have a history of an augmented care admission in the last 12 months abroad? Has the patient been identified as a contact of a CPE positive case? Infection Control Precaution Checklist during screening Initial Date Has the patient / relative / carer been given a CPE leaflet? Has the patient been isolated with the door closed if safe to do so? Have dedicated toilet facilities been arranged for the patient if applicable? Has the patient been placed on a stool chart? Has advice been given to patient /carer / visitors regarding hand hygiene? Is PPE accessible outside the isolation room? Is the isolation room clutter free? Are the patient s notes and charts being kept outside of the isolation room? Infection Control Precaution Checklist following positive result Initial Date Has the patient / relative / carer been given a CPE card? Has Infection Control signage been placed on the isolation room door? Has a twice daily Infection Clean of the room been requested from the Trust cleaning provider (Ext 1999) Is the nursing equipment being cleaned twice daily by ward staff using a sporicidal agent e.g. Tristel / chlorine releasing agent? Has an alert sticker been placed on the medical notes and annotated CPE Has an electronic alert been placed on CRIS Please complete screening flowchart on the following page IPCT VRE Policy V4 July2018 Page 16

17 Patient Identifier Label Appendix 4 CPE SCREENING FLOWCHART Date of 1 st CPE screen Sites screened Results If any of the screening results return positive the patient will need to be isolated throughout their entire admission. Please discuss results with medics to determine whether the patient is colonised or has an infection. If an infection is suspected please discuss treatment with Consultant Microbiologist If the 1 st CPE screen is negative please repeat the screen 48 hours after the first: Date of 2 nd CPE screen Sites screened Results If any of the screening results return positive the patient will need to be isolated throughout their entire admission. Please discuss results with medics to determine whether the patient is colonised or has an infection. If an infection is suspected please discuss treatment with Consultant Microbiologist If the 2 nd CPE screen is negative please repeat the screen 48 hours after the first: Date of 3 rd CPE screen Sites screened Results If any of the screening results return positive the patient will need to be isolated throughout their entire admission. Please discuss results with medics to determine whether the patient is colonised or has an infection. If an infection is suspected please discuss treatment with Consultant Microbiologist If all 3 CPE screens are negative patient can be classed as CPE Negative and removed from isolation IPCT VRE Policy V4 July2018 Page 17

18 Patient Identifier label Appendix 5 Carbapenemase-producing Enterobacteriaceae (CPE) Contact Screening flowchart Date of 1 st CPE screen Sites screened Results If any of the screen results positive the patient will need to be isolated throughout their entire admission. Please discuss results with medics to determine whether the patient is colonised or has an infection. If an infection is suspected please discuss treatment with Consultant Microbiologist If the 1 st CPE screen is negative please repeat the screen 1 week after the first Date of 2 nd CPE screen Sites screened Results If any of the screen results positive the patient will need to be isolated throughout their entire admission. Please discuss results with medics to determine whether the patient is colonised or has an infection. If an infection is suspected please discuss treatment with Consultant Microbiologist If the 2 nd CPE screen is negative please repeat the screen 1 week after the second Date of 3 rd CPE screen Sites screened Results If any of the screen results positive the patient will need to be isolated throughout their entire admission. Please discuss results with medics to determine whether the patient is colonised or has an infection. If an infection is suspected please discuss treatment with Consultant Microbiologist If the 3 rd CPE screen is negative please repeat the screen 1 week after the third Date of 4 th CPE screen Sites screened Results If any of the screen results positive the patient will need to be isolated throughout their entire admission. Please discuss results with medics to determine whether the patient is colonised or has an infection. If an infection is suspected please discuss treatment with Consultant Microbiologist If the 4 th CPE screen is negative patient can be classed as CPE negative and requires no further screening IPCT VRE Policy V4 July2018 Page 18

19 Appendix 6 Mattress integrity check - Water penetration test instructions 1. Wear appropriate PPE (gloves and aprons) 2. Inspect the mattress for any visible signs of damage to mattress integrity, if noted inform the nurse in charge as a replacement mattress must be sought and the damaged mattress disposed of. 3. Unzip the mattress and inspect inner mattress for signs of soiling. If there are any stains / decolouration to the underside of the cover remove the mattress from circulation and inform nurse in charge so that a replacement mattress can be sought and the damaged mattress disposed of. 4. If soiling not evident, proceed with water leak test: Place a sheet of absorbent tissue between the top surface of the mattress and the cover in the area where the patients bottom would normally be. Re-Zip the mattress cover Using the fist, indent the mattress over the area where the tissue is located to form a shallow well and pour approximately 30 mls of tap water into the well. Agitate the area with the fist for one to two minutes Mop up the water with disposable paper towels and discard as domestic waste. Undo zip and inspect tissue for water spots. If the absorbent tissue is wet, then the integrity of the mattress has been breached and the mattress must be replaced. If no water is evident the mattress can be used by further patients The mattress should be removed from use and the mattress cover replaced if it is found to fail the above test or if it is visibly damaged. IPCT VRE Policy V4 July2018 Page 19