Infection Prevention and Control Carbapenemase producing Enterobacteriaceae (CPE) Policy

Infection Prevention and Control Carbapenemase producing Enterobacteriaceae (CPE) Policy East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 1

Policy Title: Executive Summary: Carbapenemase producing Enterobacteriaceae (CPE) Policy This policy details the micro-organisms capable of producing Carbapenemase, how they are identified, managed and spread within the hospital setting. Supersedes: Version 1 August 2014. Description of Minor amendments to reflect updated guidance. Amendment(s): This policy will impact on: Clinical Staff, laboratory staff and clinical practices Financial Implications: Laboratory screening costs Policy Area: Infection Prevention and Control Trust Wide Document Reference: ECT002452 Version Number: V3 Effective Date: February 2016 Issued By: Infection Prevention Review Date: March 2018 and Control Group Authors: Wendy Morris Clinical Specialist Practitioner Infection Prevention and Control Impact Assessment Date: February 2016 APPROVAL RECORD Consultation: Committees / Group Infection Prevention and Control Group Date February 2016 Approved by: Director of Nursing Quality and Performance, Director of Infection Prevention and Control February 2016 East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 2

CONTENTS Title Page 1 Introduction 4 2 Purpose 4 3 Definitions 4 4 Responsibilities 5 5 Identification and screening of suspected CPE positive patients 6 6 Screening method 7 7 Measures required for managing suspected or confirmed CPE 9 patients 8 Infection Prevention and Control measures 9 9 Training 12 10 Monitoring compliance 12 Legislation, Guidance and References 13 Appendix 1: Countries and UK regions with a high prevalence of CPE 14 Appendix 2: CPE Patient Information Leaflet 15 Appendix 3: Screening for Carbapenemase-producing Enterobacteriaceae (CPE) Appendix 4: Carbapenemase Producing Entererobacteriaceae CPE Care Pathway 17 18 Appendix 5: CPE Weekly Contact Screening Flowchart 20 Appendix 6: Mattress check - Water penetration test instructions 21 Equality and Human Rights Policy Screening Tool 22 East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 3

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, 2013). 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 Carbapenamase makes the Enterobacteriaceae resistant to multiple antimicrobials and therefore infections caused by CPE (Carbapenemase producing Enterobacteraceae) 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. Appendix 1 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 (Damanii, 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. Definitions CPE Enterobacteriaceae Carbapenamases Colonisation Infection Carbapenemase producing Enterobacteriaceae a group of bacteria capable of producing cabapenamase. Gram negative bacteria which colonise the intestines of animals and humans. Enterobacter can cause a variety of conditions; eye / skin infections, meningitis, bacteraemia, pneumonia, and urinary tract infections Enzymes that cause the destruction of carbapenem antibiotics. KPC, OXA-48, NDM and VIM are all strains of carbapenamases. The presence of micro-organisms without causing signs and symptoms of infection. Invasion by and multiplication of pathogenic microorganisms in a body part or tissue, which may produce subsequent tissue injury and progress East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 4

to overt disease through a variety of cellular or toxic mechanisms. Suspected case Laboratory confirmed case Close contact CPE contact A patient who meets the high risk screening criteria. A patient with recent laboratory confirmation of CPE infection/colonisation. A person living in the same house or a patient sharing the same hospital bay. Patient who has been in contact e.g. same bay / same room with a laboratory confirmed CPE positive patient for 24 hours or greater in an healthcare setting e.g. acute / community hospital (NB: This policy should be read in conjunction with the Hand Hygiene and Standard Precautions for Infection Prevention and Control Policy). 4. Responsibilities The Chief Executive has ultimate responsibility for the implementation and monitoring of policies used in the Trust, and for ensuring sufficient resources are made available to facilitate the prevention and control of healthcare associated infections. 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 Lead Nurse Infection Prevention and Control and the Infection Prevention and Control Doctor. - Challenging poor standards and holding to account as appropriate. - 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 throughout the Trust - Ensure the policy is updated to reflect any changes to the National or local guidelines. - Provide education and support to clinical staff - Provide education and advice on the management of CPE patients within the organisation - Refer to the Consultant Microbiologist / Infection Control doctor where appropriate 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 - Are aware of patients considered high risk for CPE colonisation / infection - Carry out CPE screens on admission or thereafter as per policy East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 5

- Isolate all suspected / confirmed CPE patients promptly - Demonstrate appropriate & effective infection control practices - Alert the Infection Prevention & 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). 5. Identification and screening of suspected CPE positive patients All high risk/suspected CPE positive patients must be CPE screened. They must be admitted into an isolation room, preferably with en-suite facilities. High risk/suspected patients are defined as (see table 1): Admission to augmented care area, ITU, CCU, Neonatal unit: A known or recently laboratory confirmed CPE case (these patients will not need re screening but will need isolating with full Infection Control precautions) 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 acute general wards: A known or recently laboratory confirmed CPE case (these patients will not need re-screening but will need isolating with full Infection Control precautions) A direct patient transfer from any UK hospital. A direct patient transfer from any hospital abroad. A medical tourist from 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. Medium and Low risk patients: Medium and low risk patients are defined as any day case, outpatient clinic patients, or community patients. Medium and low risk patients do not require screening or isolating but standard infection control measures still apply. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 6

Table 1. High risk patients are highlighted in red Medium risk patients are highlighted in orange Low risk patients are highlighted in green PHE (2013) - Acute trust toolkit for the early detection, management and control of carbapenemase producing Enterobacteriaceae 6. Screening Method Following identification of a high risk / suspected CPE positive patient they should be CPE screened. Informed consent must be gained from the patient wherever possible. If a patient declines the screen, document this in the patient s medical notes. CPE information must be provided to the patient or relatives (Appendix 2) Gloves and aprons must be worn when obtaining the CPE screen. A rectal swab should 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 3 for screening advice). Additional swabs should be taken from any wounds (surgical wounds, ulcers, lesions) or device related sites (cannula, tracheostomy, PEG, drains or lines). East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 7

Send swabs to the laboratory labelled for CPE testing include any relevant clinical details. A stool sample can 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 should be taken on day 0 e.g. day of admission, day 2 (48 hours after the 1 st screen) and day 6 (48 hours after the 2 nd screen). If any of the screens return CPE positive, cease screening. Follow and complete the CPE Care Pathway using Appendix 4. Acting on results - Negative results If a high risk / suspected CPE patient s screening results return negative i.e. all three screens taken over 6 days are negative the patient can be removed from isolation and no further screening is required. Positive results and treatment If a patient has a laboratory confirmed CPE positive sample, establish if the patient is colonised or infected. Colonised / Infected Patients Inform the Infection Prevention and Control Team, out of hours contact the on call microbiologist. No antibiotic treatment is required for CPE colonisation. Gut decolonisation is not recommended as there is concern this may contribute to longer term resistance. Skin decolonisation is not recommended as the bacteria generally colonise the gut rather than the skin. Place an alert sticker on the patient s notes and document CPE status inside the medical notes. Patient s CPE status must be electronically tagged on CRIS Advise patient on good hand hygiene and offer hand decontamination facilities, especially after using the toilet. Provide patient / carer / family with a CPE patient information leaflet (see appendix 2) if not already done so. Place patient on a stool chart for monitoring purposes. Document bowel action a minimum of each shift as per Bristol Stool Chart. If the patient has, or develops an infection discuss treatment options must be discussed with a Consultant Microbiologist Screening contacts If a CPE positive patient has spent 24 hours or greater in a hospital bay the patient s contacts in the bay must be CPE screened. Contacts must be screened once weekly for a total of 4 weeks (Appendix 5). Contacts only need to be screened whilst they remain in hospital. Close the contact bay. When the index case has been isolated screen all contacts. The bay should remain closed until all the CPE contact screening results are available. At which time a decision will be made regarding re-opening the bay. This will be made in discussion with IPC. If possible isolate contact while awaiting screening results or cohort contacts together. The Infection Prevention and Control team will provide guidance on contact tracing and screening. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 8

Outbreak Management In the event of a CPE outbreak the Infection Prevention and Control team will advise and lead on actions to be taken and screening required. Refer to outbreak recognition notification and management in hospital policy. 7. Measures required for managing suspected or confirmed CPE patients Isolation High risk/suspected or laboratory confirmed CPE patients must be admitted into an isolation room with en-suite facilities if available. If en-suite facilities are not available a dedicated commode or toilet facility must be allocated to the patient. Confirmed CPE positive patients must remain isolated until discharge. If the patient is not safe to be nursed in a side room risk assess with IPC or on-call microbiologist. High risk/suspected CPE patients will require 3 negative CPE screens (spaced 48 hours apart) before they can be considered negative and removed from isolation. The isolation room door should be closed if possible following a patient safety risk assessment. The isolation room must not be used to store equipment and clutter kept to a minimum. To avoid large amounts of waste keep all stock to a minimum in a room. Encourage relatives / carers to take excess items home. Where possible, encourage the patient to remain in the isolation room but efforts should be made to reduce the psychological impact of isolation. Patients may visit in the hospital grounds, café etc if clinically appropriate, but should be advised against visiting other clinical areas / patients. 8. Infection Prevention and Control measures Hand hygiene Hands must be decontaminated with liquid soap and water in compliance with the 5 moments of hand hygiene (WHO 2006). Staff must be especially thorough after toileting the patient. CPE positive patients must perform scrupulous hand hygiene, especially after toileting. Visitors / carers must be encouraged to practice good hand hygiene using liquid soap and water prior to entering and leaving the isolation room. Personal Protective Equipment (PPE) All healthcare staff must wear single use gloves and aprons when in contact with the patient or their environment. PPE must be applied before entering the isolation room, and removed inside the isolation room followed by hand decontamination before exiting the room. Visitors do not need to wear PPE unless undertaking personal care for the patient, but must comply with hand hygiene PPE must be disposed of as per Trust waste policy. Wounds All wounds must be covered where possible. Masks Masks are not required unless CPE is isolated in a patient s sputum. In these circumstances a surgical facemask should be worn for aerosol generating procedures only such as: intubation, invasive suction, deep chest physiotherapy. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 9

Linen 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 promptly. Linen must not be placed on the floor of the isolation room to reduce the potential for further environmental contamination Waste disposal Waste to be placed into the appropriate waste stream in the isolation room as per Trust policy. Toilet facilities Where possible admit CPE positive patients into an en-suite side room. If this is not possible a dedicated commode should be provided for the patient ensuring it is cleaned after each use using a sporicidal product e.g. Tristel. If a patient needs to use a bathroom on the ward, try to dedicate this bathroom for their use only. Ask the healthcare cleaning provider to undertake an Infection Clean of the bathroom twice daily. If a bathroom cannot be cannot be dedicated for the patient then the bathroom must be cleaned after use using a sporicidal product e.g. Tristel prior to use by other patients. Non disposable equipment All equipment should be decontaminated using a sporicidal product e.g. Tristel unless the manufacturer recommends otherwise upon leaving the isolation room. Where possible allocate disposable equipment to the patient. Crockery and cutlery Patients can use crockery and cutlery from the main kitchen, no special precautions are needed. Communication Infection Control signage must be displayed on the isolation room door to ensure that all members of the MDT are aware that Infection Control precautions are required when entering the room. Patients and relatives should be given a CPE leaflet (Appendix 2). If the patient has been found to be CPE positive provide them a Public Health England CPE card available from the Infection Prevention and Control Team. CPE must be documented on patient s Electronic Discharge Notification Letter for the GP s information. Documentation Ensure all patient notes and charts are kept outside of the isolation room. Commence CPE care pathway and place in the patient s nursing notes (Appendix 4). Place an alert sticker in the patient s notes and a CPE alert on the CRIS system. Cleaning and decontamination requirements Loose stools or diarrhoea (for any reason) increase the risk of environmental spread of bacteria from the gut. Isolation room including en-suite Clinical area must contact the healthcare cleaning provider (helpdesk Ext 1999) to request a twice daily Infection Clean of the room using a chlorine based solution e.g. Tristel. Paying particular attention to frequently touched points e.g. door handles, toilet flush, taps. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 10

Bedpan dispose of body waste into the sluice hopper and place the bedpan in the Dekomed 190. Commode - where possible dedicate a commode for patient use. The commode must be cleaned after each use using a sporicidal product e.g. Tristel and a signed I am Clean post it note / tape placed clearly on the commode to indicate it has been cleaned. There are no extra decontamination requirements needed for endoscopes. On discharge the patient s isolation room must undergo a Post Infection Clean (see IPC Cleaning Policy on Infonet) and curtain change. Dispose of all single patient use items and all unused wrapped single use items stored in the isolation room. Visitors No restrictions are placed on visitors. However, if the patient gives consent to discuss their diagnosis with family / carers / visitors, advise immunocompromised visitors or those at extremes of age to avoid visiting if appropriate. Advise visitors with multiple hospital visits to visit the affected patient last. Visitors / carers taking part in care activities must be provided with PPE. All visitors must be advised to practice scrupulous hand hygiene with liquid soap and water prior to leaving the isolation room. Transfer of patients within the hospital/access to services Patients requiring access to services such as therapies, theatres and endoscopy will need to leave the isolation room. Treatments and procedures should not be delayed but where possible planned at the end of the day / list. The room to undergo a Post Infection Clean once the patient has left. Likewise, all multi-disciplinary team members requiring access to the patient should plan to visit high risk / suspected / confirmed CPE patients at the end of their visits, access to communal areas is acceptable unless the patient is symptomatic of infection or has diarrhoea. Portering staff are not required to wear PPE when transferring patients within the Trust. Portering staff should practice good hand hygiene. Discharge: Specialist Infection Control Clean Once a patient is identified as due for discharge the Nurse in charge of the ward, must contact the Trust s healthcare cleaning provider to request a Specialist Post Infection Clean, prior to a patient being admitted to the area. The specialist Post Infection Clean will include as a minimum steam and Tristel. All disposable equipment must be disposed of including unused dressings, ointments etc. Nursing equipment to be cleaned with a sporicidal product e.g. Tristel. All equipment including curtains must be removed from the room, cleaned or disposed of appropriately. Pillows must be disposed once the patient is discharged. The bed mattresses must be assessed as safe to use by a subsequent patient, see appendix 6. Hired specialist mattresses must be returned to the company for cleaning and decontamination. The bed management team must be informed that this area is unlikely to be available for a patient admission for the next few hours. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 11

Please note: There is no reason for non-acute settings to refuse admission or readmission of service users on the grounds that they are colonised with CPE (PHE, 2015) Patients can return to their own home without any special measures. If a patient is confirmed as CPE positive please give advice on hand hygiene. Provide patient information sheet and a patient CPE card available from the Infection Prevention and Control Team. 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. Family members if admitted to hospital should be advised to express their contact with CPE. 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 in 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 01625 661597. 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. 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. 9. Training All clinical staff must attend Trust infection control mandatory training annually. CPE toolbox training can be organised for staff by contacting the infection prevention and control team. 10 Monitoring Compliance The infection prevention and control team will review and investigate incidents reported relating to this policy and audit departments screening compliance. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 12

Legislation, Guidance and References Damani N (2012) - Manual of Infection Prevention and Control, 3 rd Edition. Oxford: Oxford University Press East Cheshire NHS Trust (2014) - Infection Prevention and Control Good Practices Policy Available on the Trust Infonet East Cheshire NHS Trust (2016) - Infection Prevention and Control Cleaning Policy Available on the Trust Infonet Chief Medical Officer (2011) - Annual Report of the Chief Medical Officer Infections and the rise of antimicrobial resistance Vol 2. DH: London. Available at: http://media.dh.gov.uk/network/357/files/2013/03/cmo-annual-report-volume-2-20111.pdf Last accessed 11.02.16 Public Health England (2013) - Acute Trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteria. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/32922 7/Acute_trust_toolkit_for_the_early_detection.pdf Last accessed 11.02.16 Public Health England (2015) - Toolkit for managing carbapenemase-producing Enterobacteria in none acute and community settings. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/43980 1/CPE-Non-AcuteToolkit_CORE.pdf Last accessed 11.02.16 WHO (2006) - 5 moments of hand hygiene Available at: http://www.who.int/gpsc/tools/five_moments/en/ accessed 11.02.16 Last East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 13

Appendix 1 - Countries and UK regions with a high prevalence of CPE Bangladesh The Balkans China Cyprus Greece India Ireland Israel Italy Japan North Africa Malta Middle East (All) Pakistan South East Asia South/Central America Turkey Taiwan USA This is not an exhaustive list; admissions to ANY hospital abroad should be considered when making a risk assessment. Lack of data from a country not included in this list may reflect lack of reporting / detection rather than lack of a Carbapenemase problem (which may additionally contribute to an under-estimation of its prevalence). UK regions / areas where problems have been noted in SOME hospitals: North West especially Manchester London IMPORTANT Healthcare providers have a Duty of Care to proactively communicate any problems they are experiencing with Carbapenemase producing Enterobacteraceae, not only with colleagues in healthcare settings which are coterminus but with any organisation they detail with on the patient pathway, either routinely or sporadically (see Card A,B) PHE (2013) - Acute trust toolkit for the early detection, management and control of Carbapenemase producing Enterobacteriaceae East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 14

Appendix 2 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 ie 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 East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 15

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. 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 carbapenemaseproducing 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 http://www.hpa.org.uk/topics/infectiousdiseases/infectionsaz/carbapenemresistan ce/ NHS Choices http://www.nhs.uk/news/2014/03march/pages/antibiotic-resistance-toolkitlaunched.aspx Useful contact: East Cheshire NHS Trust Infection Prevention and Control team 01625 661597 East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 16

Appendix 3 Screening for Carbapenemase-producing Enterobacteriaceae (CPE) Rectal specimens to be taken on day 0, 2 & 4 (3 swabs over 6 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 Rectum 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. 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 East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 17

Patient Identifier Label Appendix 4 Carbapenemase Producing Entererobacteriaceae 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 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 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 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 Tick Initial Initial Please complete screening flowchart on the following page East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 18

Patient Identifier Label 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 East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 19

Patient Identifier Label Appendix 5 CPE WEEKLY CONTACT 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 1 week 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 1 week after the second 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 the 3 rd CPE screen is negative please repeat the screen 1 week after the third 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 the 4 th CPE screen is negative patient can be classed as CPE negative and requires no further screening East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 20

Appendix 6 Mattress 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. 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. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 21

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? Carbapenemase Producing Entererobacteriaceae (CPE) Details of person responsible for completing the assessment: Name: Wendy Morris Position: Clinical Specialist Practitioner 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) 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 (Damanii, 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 to the global effort to minimise CPE transmission 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). 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). East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 22

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 2011. 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%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 23

Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) None 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? None 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No Explain your response: For any patient whose forst language is not English, as information needs to be provided and understood, staff will follow the trust interpretation policy. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No Explain your response: No impacts identified. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 24

DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes No Explain your response: Clinical staff will need to implement support for patients in isolation as this is a mandatory requirement of this policy. Staff should follow the trust interpretation policy for people who are Deaf and involve the health facilitators for people with learning disabilities. AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes No Explain your response: Visitors at the extremes of the age range should be discouraged from visiting as they may be more susceptible, LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No Explain your response: No impacts identified. RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes No Explain your response: No impacts identified. CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes No Explain your response: May need to be involved in the support of the patient post discharge. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes No Explain your response: No other impacts identified. East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 25

4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children. This policy applies the same as for adult patients. If any concerns are noted with any child these would be escalated via the appropriate channels. 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? This policy has been ratified by the ICG which includes a member of the public. As with the majority of IC policies it is acknowledged that staff need to support individuals who require Isolation, any variance to this must be clearly documented in the patients notes as part of their clinical care 6. Date completed: 15.2.16Review Date:5/2.18 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Approval : At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: 16.2.16 East Cheshire NHS Trust Infection Prevention and Control CPE V3 March 2016 26