Protective Isolation Sue Dailly Infection Prevention and Control Nurse Chief Nurse and Director of Infection Prevention and Control Reviewer(s): Infection Prevention and Control Committee, Nursing and Midwifery Group Trust Reference CP075 Number: Approval body: Approval Group Status: Published Effective Date: April 2011 Review Date: April 2014 Disposal Date: 2036 Document Authorisation Control Prepared By: Sue Dailly Lead Nurse Authorised Officer Chris Gordon Acting Chief Executive Signature: Signature: Infection Prevention & Control Page 1 of 15
Protective Isolation DOCUMENT CONTROL Document Amendments Number Details By Whom Date 1.0 First Issue Infection Prevention and Control Nurse 2.0 Author Updated L. Hollister Infection Prevention Jan 2009 and Control Nurse 3.0 Author Updated Infection Prevention and Control Nurse April 2011 Review Timetable Date Reason By Whom Date Completed April 2014 Three year review cycle for policy Infection document Prevention & Control Team Distribution List Title 1 All employees via the Winchester and Eastleigh Healthcare NHS Trust Intranet 2 The public via Winchester and Eastleigh Healthcare NHS Trust Website Page 2 of 15
Protective Isolation RELATED TRUST POLICIES OP001 CP030 CP076 CP073 CP016 CPr012 CP036 CPr010 CP060 CP053 OP085 CP107 on Management of Controlled Documents Disinfection, Decontamination & Cleaning Standard Precautions (PPE) Hand Hygiene Guidelines on the Management of Neutropenia & Neutropenic Sepsis for Insertion of Intravenous Cannula for Central Venous Access Devices Urinary Catheterisation Aseptic Technique for Oral and Personal Hygiene Provision for Patients Flower Single Use and Single Patient Use Devices Page 3 of 15
Protective Isolation Contents Section Title Page 1.0 PURPOSE 5 2.0 SCOPE 5 3.0 INTRODUCTION 5 4.0 ROLES AND RESPONSIBILITIES 5 5.0 PROTECTIVE ISOLATION 7 6.0 AIMS 7 7.0 PROTECTIVE ISOLATION FACILITES 7 8.0 EQUIPMENT INSIDE THE ROOM 8 9.0 EQUIPMENT OUTSIDE THE ROOM 8 10.0 PRACTICE AND RATIONALE 8 11.0 EDUCATION AND TRAINING 11 12.0 MONITORING COMPLIANCE AND 12 EFFECTIVENESS OF POLICY 13.0 DEFINITIONS 12 14.0 REFERENCES 12 Appendix 1 Management Checklist for Nursing Patients with 14 Neutropenia & Neutropenic Sepsis Approval Proforma Appendix 2 Equality Impact Assessment Tool 15 Page 4 of 15
Protective Isolation 1.0 PURPOSE 1.1 This policy is designed to assist staff in the practice of Protective Isolation. Protective Isolation is a range of practices used in hospitals to protect immunocompromised patients from infection or further infection. 2.0 SCOPE 2.1 This policy applies to all staff employed by the Winchester and Eastleigh Healthcare NHS Trust (WEHCT), locum and agency staff. This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct 2008. 2.2 This policy has been ratified in line with OP001 on the management of controlled documents. 3.0 INTRODUCTION 3.1 Protective isolation (reverse barrier nursing) is the physical separation of a patient at high risk of infection from common organisms carried by others. 3.2 The aim of this policy is to prevent the transmission of infection to an immunocompromised patient. It does not involve the special precautions of a full protective isolation which aims to protect from commensal (endogenous) infection in patients whose neutropenia is likely to be prolonged. 3.3 Immunocompromised is a term applied to patients whose immune mechanisms are deficient. This may be due to immunologic disorders, infection, congenital immune deficiency syndrome, HIV or following immunosuppressive therapy. 3.4 Neutropenic patients are often admitted due to sepsis. See CP016 Guidelines for the Management of Neutropenia and Neutropenic Sepsis. 4.0 DUTIES, ROLES AND RESPONSIBILITIES 4.1 Chief Executive The Chief Executive Officer (CEO) has overall responsibility for the strategic and operational management of the Trust, including Infection Prevention and Control. The CEO has overall responsibility for ensuring the Trust has appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation. The CEO has a responsibility to ensure there are adequate finances and systems in place to ensure that protective clothing and education is provided for all staff. Page 5 of 15
Protective Isolation 4.2 The Trust has a duty to provide single room accommodation for patients who are found to be neutropenic. Where this is not possible a double cubicle will be provided. The mix of patients must be considered when the patient is placed in a double cubicle to minimise the risk of infection to the neutropenic patient. The neutropenic patient MUST NOT be placed in a room with another patient who has a known infection under any circumstances. Patients who are neutropenic and have an infection must be accommodated in a single room to also protect other patients from cross infection. (See CP016 Guidelines for the Management of Neutropenia & Neutropenic Sepsis) 4.3 Healthcare Staff have a duty to provide clinical care which protects a neutropenic patient as much as possible from sustaining a healthcare associated infection by ensuring that their practice follow policies and protocols. 4.4 Line Managers Line managers are responsible for ensuring adequate dissemination and implementation of this policy. They are responsible for identifying any training needs on the implementation of new or updated policies. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy. Line managers have a responsibility to ensure they allow staff time to attend infection prevention and control education sessions, also that there is adequate provision of protective equipment for all staff in the department. Managers have a responsibility to ensure the staff on their ward, whether visiting or not, follow this policy, and if not, this is followed up with education or if necessary disciplinary procedures will need to be commenced. 4.5 Trust employees All staff are responsible for ensuring their compliance to this policy to ensure the safety of all patients, staff, visitors and contracted staff to this Trust. Information regarding the failure to comply with this policy e.g. lack of training or inadequate equipment must be reported to the line manager and the incident reporting system used where appropriate. If patient or staff safety is compromised as a result of the revised policy, staff must inform their line manager and ensure that a risk assessment is completed and reported through divisional risk forums and the Trust risk co-ordinator. 4.6 Trust employees have a responsibility to attend infection prevention and control education, and to read and follow the Trust infection prevention and control policies. All Trust employees have a responsibility to follow the policy and challenge and report those who fail to follow Trust policies. Page 6 of 15
5.0 Protective Isolation Winchester and Eastleigh Healthcare NHS Trust Protective Isolation 5.1 Protective isolation is necessary for patients with a severely compromised immune system. Neutropenia refers to a neutrophil count of 0.5-1.0 9 /L (moderate neutropenia). The door to the isolation cubicle should be kept closed at all times to reduce the transmission of bacteria and viruses into the room. 6.0 AIMS Remember standard precautions must be used with all patients including those in protective isolation. 6.1 To prevent the transmission of an infection to an immunocompromised patient 6.2 To give psychological support and reassurance to the patient whilst he/she is in isolation. 6.3 To ensure that all staff (including domestic staff) are aware of the correct precautions to take. Remember that thorough hand washing before contact with these patients is extremely important (See CP073 Hand Hygiene ) 7.0 PROTECTIVE ISOLATION FACILITIES 7.1 A single side room with a wash basin and en suite toilet, if possible should be available. If an en suite is not available a commode for the sole use of this patient should be kept in the room. The commode MUST be thoroughly cleaned on all surfaces with 1,000ppm hypochlorite solution before use. See CP030 Overarching Decontamination. Where a single side room is not practical a double cubicle will be provided. The mix of patients must be considered when deciding where the patient is placed. The neutropenic patient should not be placed in a room with another patient who has an infection under any circumstances. ( See CP016 Guidelines for the Management of Neutropenia & Neutropenic Sepsis) 7.2 The room must be deep cleaned before the patient is moved into the room. 7.3 The door of the single room should be kept shut to reduce the risk of airborne infections. Page 7 of 15
Protective Isolation 8.0 EQUIPMENT INSIDE THE ROOM: Hand soap, Hibiscrub and paper towels Patient s own wash bowl and dinamap etc. Alcohol hand gel n-clinical waste bag must be emptied frequently 8.1 Electric fans are not allowed in the room as the grills trap dust, providing a potential reservoir for micro-organisms. 9.0 EQUIPMENT OUTSIDE THE ROOM Protective isolation sign White (yellow if the patient has a communicable infection) plastic aprons & gloves Patient s charts. For Intensive Therapy Unit (ITU) and Neo-Natal Unit (NNU) where patients are nursed one-to-one and observations are recorded more frequently, it may be more appropriate to have the patient s charts in the side room. 10.0 PRACTICE AND RATIONALE 10.1 Explain to the patient the reason for isolation and give reassurance. This is to reduce anxiety and gain the patients co-operations. Leaflets of useful information for patients who are in protective isolation are available from the team and Nick Jonas ward. 10.2 Regular assessment and evaluation of the situation, in conjunction with the medical staff and/or the Team is necessary to decide if isolation of the patient remains the most appropriate form of care. 10.3 Psychological support and reassurance must be given to the patient whilst in isolation 10.4 Hand Hygiene Hands must always be washed before entering the room. Inside the room, disinfect hands with alcohol hand gel before touching the patient. Hand washing is essential to remove organisms and prevent transmission to susceptible patients. See CP073 Hand Hygiene. 10.5. Gloves Gloves should always be worn for prolonged direct contact with the patient and/or when handling body fluids. Sterile gloves should be worn for aseptic techniques or when handling an invasive device. n-sterile gloves are required when contact with blood or body fluid is anticipated. See CP076 Standard Precautions. 10.6 Aprons Page 8 of 15
Protective Isolation Put on a white plastic apron (yellow if the patient has a communicable infection) before contact with the patient. This is to prevent the transmission of organisms from the clothing of healthcare staff to the patient. See CP076 Standard Precautions. 10.7 Masks Masks are not necessary; there is little evidence to indicate that masks protect the patient from communicable respiratory infections. Masks should only be worn if the procedure or patient s infection requires it. See CP076 Standard Precautions. 10.8 Linen Nightwear and bed linen should be changed daily and when soiled. This is to prevent the transfer of organisms. 10.9 Patients personal hygiene The patient must have a high standard of personal hygiene to prevent skin colonisation or infection. Liquid soap/shower gel rather than bars of soap should be used. The wash bowl must be kept clean. Patients should receive education on good hand hygiene practices, including washing hands before eating and after toileting. Patients may use the bath provided that a high standard of cleanliness is maintained. Showers are contra-indicated where the water source is at high risk from being contaminated. Dental hygiene must be performed at least twice a day. When shaving, an electric razor should be used. This should be the patients own razor, not a communal one. See CP053 for Oral and Personal hygiene provision for Patients. 10.10 Equipment Equipment should be thoroughly cleaned with a disinfectant (Actichlor plus ) and water or disinfectant wipes before being taken into the room. Where possible have single patient use equipment. This is to prevent the transfer of organisms. See CP107 Single Use and Single Patient Use Devices and the CP030 Overarching Decontamination. Patients charts are to be left outside the room to minimize the number of staff who have to enter the room. 10.11 Cutlery and Crockery Patients use normal cutlery and crockery. This is returned to the kitchen dishwasher in the usual way. The risk of cross infection from crockery and cutlery is minimal if they have been through a dish washer. They must not be washed by hand. Page 9 of 15
Protective Isolation 10.12 Visitors Visitors must be instructed to wash hands on entering the room. Exclude those with any infection, or who have been in contact with infection. This is to prevent visitors transmitting infectious organisms to the susceptible patient. During the neutropenic phase, visitors should be advised to keep to two people. Children should be discouraged from visiting as they often have minor infections. This needs to be balanced with the psychological needs of the patient and their family. 10.13 Plants and Flowers Flowers and plants should not be inside protective isolation rooms. Although they have not been directly linked to infection in immunocompromised patients, they may, however, be a reservoir for Gram negative bacteria or fungal spores. Cut flowers also provide a reservoir for Gram negative organisms. Flowers and plants are not permitted on wards except the maternity ward where they are limited to one vase or plant per patient. See OP085 Flower. 10.14 Inter-hospital Visits Ideally, investigations should be performed in the isolation room. Other departments should be notified in advance that the patient is susceptible to infection. This is to ensure the time out of the single room is kept to a minimum and contact with other patients is avoided. Neutropenic patients must not be placed in communal waiting areas and should never be placed in the same room adjacent to people (staff or patients) with a known infection. 10.15 Staff with infections (coughs, colds, sore throats or cold sores ) must be excluded from nursing these patients. Preferably staff who are nursing patients with infections should not nurse patients in protective isolation during the same shift. This is to minimize the risk of transferring infection to susceptible patients on the hands/clothing of staff. 10.16 Cleaning Cleaning must be carried out prior to the admission of the patient. A high standard of cleanliness by damp dusting must be maintained for the duration of the protective isolation. Dust may harbour pathogenic organisms. Frequent cleaning will remove them. Rubbish bags must be emptied frequently. Explain to the domestic staff that if they have a cold or other infection they should not enter the room. 10.17 Food advice and food restrictions Good personal hygiene when handling food, in particular hand washing and the use of a clean blue plastic apron. Food must be served from the distribution trolley without delay. Meals must not be retained for later Page 10 of 15
Winchester and Eastleigh Healthcare NHS Trust Protective Isolation consumption. Relatives should be discouraged from preparing meals for the patient. Food brought in by relatives may not have been prepared using a high standard of hygiene. Storage facilities for food must not be offered. Food to be avoided: Take-Away food Salads Pepper Soft boiled eggs Soft ripened cheese (Brie, Camembert, Blue Vein) Soft cheeses and ready to eat meals may contain Listeria Fruit should be washed or peeled Fresh pasteurised milk is permissible. Further information on food to avoid can be found on leaflets produced by the Dietetics Department. Neutropenic patients are more susceptible to disease from pathogenic bacteria in food. Micro-organisms will multiply in food unless stored above 65 C or below 5 C. Listeria will multiply at fridge temperatures (4 C). 10.18 Drinking Water Water should be from a tap with an identified filter. Where there is no filtered tap within the ward, sterile water should be used, obtained from pharmacy. Commercially produced bottled water is not permissible. 10.19Aseptic techniques and invasive devices. Staff must use a strict aseptic technique when performing any necessary invasive procedures. See CP060 Aseptic Technique. If an IV cannula is necessary the site must be checked at least twice daily and documented on the VIP score sheet. The cannula must not be left in situ longer than 72 hours and must be removed sooner if not required or possibly infected. See CPr012 Intravenous Cannulation Avoid inserting a urinary catheter where possible, as the risk of infection from this is increased in neutropenic patients. If it is necessary to insert a urinary catheter, this must be undertaken with strict aseptic technique. There must be full documentation of insertion, monitoring and removal using the Urinary Catheter Assessment and Monitoring (UCAM) form. See CPr010 Urinary Catheterisation policy. Appendix 1 is a Management Checklist for Nursing Patients with Neutropenia & Neutropenic Sepsis 11.0 Education and Training Specific education and training about neutropenia is not provided for staff at the time of writing this policy. Nick Jonas Ward staff and the Cancer Care Team are available for advice. 11.1 All clinical staff are required to attend mandatory Infection Prevention and Page 11 of 15
Protective Isolation Control induction days, annual updates and departmental updates. Line managers have a duty of care to ensure that all staff annually receive Updates. The line manager keeps a record of staff attendance on the training matrix. Each member of clinical staff keeps their own records of attendance at study sessions within their portfolio. It is the responsibility of individuals and their line managers to ensure attendance at training. The Training Department give feedback on non attendance to line managers and it is their responsibility to follow up non attendees and ensure their subsequent attendance. 11.2 If staff do not attend training, this will be reviewed at their appraisal and prompt training arranged. 11.3 E-Learning for is an acceptable alternative on alternate years once face to face induction is completed. E-Learning is accompanied by certification which can be used in evidence at appraisal. 12.0 MONITORING OF COMPLIANCE AND EFFECTIVENESS OF THE POLICY There is a regular programme of audits, led by the Director of Infection Prevention and Control (DIPC) and co-ordinated by the Infection Prevention and Control Team, which are reported to the Infection Prevention and Control Committee (IPCC) e.g. Hand Hygiene, use of Isolation facilities, infection control policy compliance, High Impact Interventions including aseptic technique. Serious Incidents Requiring Investigation (Infection) are discussed at the IPCC and reported to the Risk Management and Governance Committee, Health Protection Agency and NHS Hampshire Training and education attendance is monitored by the Education Centre and reported to individual managers and collectively to Risk Management and Governance Committee Monthly reports on infection prevention and control and surveillance are taken by the to the Trust Board as part of the performance report. Training attendance reports are presented to the Risk Management and Governance Committee 13 DEFINITIONS NMC Nursing and Midwifery Council CEO Chief Executive Officer NVQ National Vocational Qualification Page 12 of 15
Protective Isolation DIPC IPCC Committee 14.0 REFERENCES 1. Department of Health (1999) Health Service Circular HSC 1999/179 Controls Assurance in Infection Control: Decontamination of Medical Devices. London:Department of Health 2. Department of Health (1999) Health Service Circular 1999/178 v CJD: Measuring the risk of transmission.london: Department of Health 3. Medical Devices Agency (2000) Single-Use Medical Devices: Implications and Consequences of Reuse MDA DB2000 (04). London: Medical Devices Agency 4. Department of Health (2000) HSC 2000/32 Decontamination of MedicalDevices.London: Department of Health 5. Nursing and Midwifery Council (2008) Standards of conduct, performance and ethics for nurses and midwives. London: Nursing and Midwifery Council Page 13 of 15
Protective Isolation Appendix 1: MANAGEMENT CHECKLIST FOR NURSING PATIENTS WITH NEUTROPENIA & NEUTROPENIC SEPSIS Deep clean room prior to admission of patient. Provide single room with en-suite toilet/ commode. If a single room is not practicable, a double bedded-bay may be shared with another patient with NO known infection. If the neutropenic patient has a communicable infection they must be isolated on their own. Protective Isolation sign should be displayed outside the room. Keep door shut. Provide Information Leaflet for Patients and Relatives on Neutropenia. Explain reasons for isolation and provide plenty of reassurance and psychological support. Prepare equipment inside: Alcohol hand gel Hibiscrub and paper towel BP machine/ Dinamap Wash bowl for patient s own use Prepare equipment outside: White plastic apron & gloves Patient s chart Yellow clinical waste bin For drinking water, use sterile water, obtainable from pharmacy. Bottled water is not permissible. Advice on Food and Diet can be found on the Information Leaflet available on the Trust intranet. Use disinfectant wipes to clean equipment before being taken into patient s room. Wear white apron prior to contact with patient. Use gloves for prolonged contact; sterile gloves for aseptic and invasive procedures; non-sterile gloves for blood and body fluid contact. If the patient has IV cannula, check the site twice daily and document on VIP score sheet. Keep cannula for maximum of 72 hours or remove sooner if not required or possibly infected. Change all linen & night wear daily and when soiled. Keep to a maximum of 2 visitors at a time. Children must be discouraged from visiting due to minor infections. plants/ flowers. electric fans. For further information please refer to: CP016 for the Management of Neutropenia and CP 075 Neutropenic Sepsis Protective Isolation Page 14 of 15
Winchester & Eastleigh Healthcare NHS Trust for Central Venous Access Devices Appendix 2 - Equality Impact Assessment Tool To be completed and attached to any controlled document when submitted to the appropriate committee for consideration and approval. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? If you have identified a potential discriminatory impact of this procedural document, please refer it to the Board Secretary, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Compliance and Governance Manager: Telephone Number: 01962 825376 Infection Control Director of Infection Prevention and Control Reference: CP075 Page 15 of 15