The Management of Extended Spectrum Beta Lactamase-Producing Organisms Policy Infection Prevention and Control This policy describes the key processes and protocols for patients colonised or infected with extended spectrum beta lactamase-producing organisms. It identifies the management of the patient and care delivery requirements. Keys Words: Version: Adopted by: Infection Prevention and Control Extended Spectrum Beta Lactamase 2 Quality Assurance Group Date adopted: January 2015 Main author: Mel Hutchings Infection Prevention and Control Nurse Name of responsible committee: Infection Prevention and Control Committee Quality Assurance Committee Date issued: January 2015 Review date: November 2017 Expiry date: November 2018 Target audience: Type of policy (tick appropriate box) All LPT staff Clinical Non-clinical
Contribution List Key individuals involved in developing the document Name Mel Hutchings Amanda Howell, Antonia Garfoot, Una Willis, Fiona Drew Dr Philip Monk Dr Andrew Swann Designation Infection Prevention and Control Nurse Infection Prevention and Control Team Consultant in Public Health England Consultant Microbiologist University Hospitals Leicester Circulated to the following individuals for consultation Name Designation Dr Margaret Occupational Health Physician Leverment Dr Philip Monk CCDC Consultant, Public Health England Dr Andrew Swann Consultant Microbiologist UHL Adrian Childs Chief Nurse / DiPaC Neil Hemstock Lead Nurse FYPC Di Postle Trust Lead for Professional Standards Michelle Churchard Senior Advisor, LD Claire Armitage Lead Nurse AMH Kathy Feltham Lead Nurse MHSOP Emma Wallis Lead Nurse CHS Bernadette Keaveney Health Safety and Security Manager Elizabeth Compton Ward Manager, Belvoir PICU Mark Dearden Training and Quality Assurance Lead Tracey Finnamore Practice Development Nurse, Leicester Frith Hospital Bal Johal Deputy Chief Nurse Amin Pabani Service Manager Podiatry Liz Tebbutt Performance and Quality Assurance Manager 2
Contents Definitions that apply to this policy 5 1.0 Summary 7 2.0 Introduction 7 3.0 Purpose 7 4.0 Justification for the document 7 5.0 The Management of Extended Spectrum Beta Lactamase-producing Organisms 7 5.1 Extended Spectrum Beta Lactamase-producing organisms 8 5.2 Isolation of patients within a community hospital 9-10 5.3 Care for patients within the community 10 5.4 Screening of patients 11 5.5 Movement and transport of patients 11 5.6 Deceased patients 11 6.0 Training 12 7.0 References and associated documents 13 Appendix 1 14 3
Version Control and Summary of Changes Version number Date Comment (description change and amendments) Version 1 August 2013 Version 2 September 2014 Development of a new policy to provide key processes and protocols for patients colonised or infected with extended spectrum beta lactamase-producing organisms. It identifies the management of the patient and care delivery requirements. Circulated for comments to the infection prevention and control team and key individuals within LPT and also key individuals outside the organisation that can provide an expertise review. Amendments following review of the policy and the processes and protocols required for patients colonised or infected with extended spectrum beta lactamase-producing organisms within the community For further information contact: Infection Prevention and Control Team 4
Definitions that apply to this Policy Due Regard Cohort nursing of infected patients Colonisation Extended Spectrum Beta Lactamase (ESBL) Gram negative organism HCAI - HealthCare Associated Infection Heavily exfoliating skin condition (i.e. eczema or psoriasis) Heavily exudating wound (in relation to ESBL) Having due regard for advancing equality involves: Removing or minimising disadvantages suffered by people due to their protected characteristics. Taking steps to meet the needs of people from protected groups where these are different from the needs of other people. Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Grouping of patients who are deemed to be infectious and nursing them within an area of an in-patient facility. It is often recommended as an overflow strategy when single room isolation is not available. Colonisation is the multiplication of a micro-organism after it has attached to host tissue or other surfaces, but causing no harm to the person. People who are colonised may not display signs or symptoms of infection.. ESBL producing organisms are resistant to certain types of antibiotics which would normally be used to treat such infections. An organism that stains pink in the Gram stain Healthcare associated infection is any infection acquired as the result of a course of treatment, intervention or care. A skin condition that creates a large amount of shedding skin, which then contaminates the environment. A wound that is infected with ESBL and produces a discharge or exudate which cannot be contained in a dressing Immunosuppression Suppression of the immune response, usually by disease or Infection Invasive device LPT Occupational Health Department by drugs Where an organism is present at a site and causes an inflammatory response or where the organism is present in a normally sterile site. A device that breaches the skins normal line of defence i.e. urinary catheters, intravenous devices. Leicestershire Partnership Trust Baldwin Lodge Glenfield Hospital Site Groby Road Leicester LE3 9QP TEL: 0116 225 5432 5
Personal Protective Equipment (PPE) Productive cough (in relation to ESBL) Source Isolation Standard Precautions Strike Through UHL Specialised clothing or equipment worn by employees for protection against health and safety hazards and includes: gloves, aprons, gowns, masks and eye protection. A cough that produces sputum, the sputum is infected with ESBL-producing organism Isolation for the control of infection is used to prevent infected patients from infecting others. Precautions that are used such as Personal Protective Equipment (PPE) and hand washing to prevent the spread of infection. Blood absorbed right through a dressing so as to be visible on the outside. University Hospitals of Leicester. 6
1.0 Summary This policy has been developed to give clear organisational wide guidance to staff in relation to the procedure for the management of patients with Extended Spectrum Beta-Lactamase (ESBL) as required by LPT. It describes the process for ensuring the delivery of effective infection prevention and control management of patients colonised or infected with ESBL within the community setting. 2.0 Introduction The ESBL Producing Organisms Policy applied to all staff employed by Leicestershire NHS Partnership Trust (LPT). LPT has a wide range of teams and services operating from a large number of properties making up the overall estate. LPT also delivers healthcare to people in their own homes. The provision of healthcare carries with it inherent risks to the health care worker. The purpose of this document is to ensure that all staff are aware of their responsibilities for the safe practice in relation to the management of a patient with an ESBL and take the appropriate precautionary measures to protect themselves, their co-workers and their patients. 3.0 Purpose It is the intention of this policy to provide guidance to ensure that staff are aware of the appropriate steps they need to undertake to ensure the safety of all patients within LPT, whether receiving healthcare in LPT inpatient facilities, within their own home environment or as outpatients visiting LPT on a daily basis. This includes those patients that have or suspected of having an ESBL. The purpose of this policy is to ensure that all staff employed by LPT are providing evidence based care which is in accordance with the Health & Social Care Act (2008) and the latest guidance provided by Public Health England (PHE). 4.0 Justification for Document ESBLs are a growing concern within the realms of infection prevention and control and it imperative that persons who have or are suspected of having an ESBL are care for appropriately. As a duty of care LPT must ensure that staff are given guidance as to the appropriate steps they need to undertake to ensure that they can protect the patients within their care. 5.0 The Management of Extended Spectrum Beta-Lactamase (ESBL) Producing Organisms This policy covers all healthcare settings within LPT. It identifies the management of patients with ESBL producing organisms. 7
5.1 Extended Spectrum Beta-Lactamase Producing Organisms Gram negative organisms can produce an enzyme known as an Extended-spectrum Beta lactamase (ESBL) which inhibits all antibiotics from the penicillin class from working. Any gram negative organisms can potentially produce ESBLs. These organisms are known as ESBL producing organisms and are resistant to certain types of antibiotics which would normally be used to treat such infections. This does not mean that ESBLs are untreatable, nor do they necessarily present a great risk, in terms of the number or the severity of infections caused. However, treatment of ESBLs may require the use of more broad spectrum which tend to have a higher toxicity (which may cause symptoms from the antibiotic) to the host (patient). It is the responsibility of prescribers and medical staff to follow the Leicestershire Partnership Trust Antibiotic Guidelines, thus ensuring that the right therapy is prescribed at the right time, with the right dose and via the right route to destroy the pathogens which are causing infection. ESBL-producing organisms can occur within a healthcare or a community setting. ESBL-producing organisms can also be grown from specimens from invasive device such as urethral and venous catheters. Escherichia coli (E.coli) is the most common cause of urinary tract infections (UTIs) and can also cause wound and respiratory infections. However, not all E.colis are ESBL-producing organisms. In most situations ESBLs do not cause infection but merely colonise the individual. However, when infections do occur they can range from mild urinary tract infections to severe life threatening blood stream infections (septicaemia). Klebsiella species are also a common organism that can develop into an ESBLproducing organism, but again not all Klebsiella species will develop into an ESBLproducing organism. The most common infection is Urinary Tract Infections. ESBL s can, however, be detected in other Enterobacteriaceae, Pseudomonas aeruginosa,burholderia cepacia, and Capnocytaphaga ochracea. Risk Factors There are many factors which contribute to the patient becoming infected or colonised with an ESBL-producing organism which can include: Prolonged hospital stay Prior anti-microbial therapy The strain of the organism The site at which the organism has been identified Immunosuppression The presence of invasive devices or wounds Severe underlying medical conditions 8
Increasing age Premature neonates ESBL Prevention and Control Strategies To develop a strategy for the prevention and control of ESBL-producing organisms several factors must be considered which include: The risk to the individual patient The risk of spread to other patients The risk to staff members The impact of control measures on the individual s other therapeutic and care needs The risk presented to patients in other care environments that are linked by patient and staff movement The degree to which ESBL-producing organisms have become endemic within an area Sometimes patients who are colonised with an ESBL-producing organism can naturally eliminate such bacteria from their system. However, in those with severe underlying illness, some ESBL-producing strains may be present for months or even years. Prevention and Control Effective hand hygiene before and after each patient contact and contact with their environment is of paramount importance in reducing spread. Antibiotics must be prescribed according to the Trust policy. Personal protective equipment must be worn where there is a risk of exposure to blood or body fluids Cleaning and decontamination of equipment must be undertaken as per the Trust policy 5.2 Isolation of patients within a Community Hospital or inpatient facility Any patient with a positive result for ESBL must be assessed for the presence of ESBL risk factors. This should be done immediately on admission to the area or when ESBL is first diagnosed. There should be continued observation throughout a patient s stay for the development of these risk factors if not present on the first assessment. If risk factors develop then the process for patients with risk factors must be followed. The risk factors for transmission are: A urinary catheter in situ Urinary incontinence Faecal incontinence A heavily exudating wound A productive cough 9
Exfoliating skin condition Intravenous lines in situ If a patient is admitted with, or develops one or more of the risk factors during their hospital stay source isolation precautions are required regardless of where the ESBL has been identified. Patients requiring source isolation should be admitted or transferred to a single room. If a single room is not available the clinician caring for the patient must carry out a risk assessment. The outcome of the risk assessment must be documented and filed in the patient s notes. The Infection Prevention and Control Nurse must be informed of the outcome of the risk assessment as soon as possible. The risk assessment will ensure, wherever possible, that only patients presenting the least cross infection risk to others will be cared for in the main ward area using source isolation procedures and precautions. If it is necessary to nurse patients with ESBL and requiring source isolation precautions in the main ward area it may also be necessary to consider spatial isolation within the bay. This is where consideration is given to avoid nursing those patients who are known to require source isolation in the same bay as patients who are considered to be at a higher risk of contracting an infection, for example patients who are immune compromised or who have a urinary catheter in situ. A source isolation form should be displayed on the single room door or at the patient s bedside as a communication tool to all staff (See appendix 1). For heavily exudating wounds a super absorbent dressing may be needed; please see the wound management formulary available on the intranet. All infected wounds must have their dressing changed on strike through if not due before. This must be documented in the patient s records. If a patient has a positive result for ESBL but does not have any of the above risk factors for transmission they do not require source isolation precautions but should be nursed in the area with standard precautions. There should be continued observation throughout a patient s stay for the development of these risk factors and if any risk factors develop then the process for patients with risk factors must be followed. 5.3 Care for patients within their own homes There is not a need for patients to have source isolation precautions implemented when they are nursed in their own homes. Standard precautions must, however, be in place at all times, as with any patient cared for by LPT staff. Waste does not require to be segregated and special waste collections do not require to be set up purely because a patient has an ESBL. Waste should be treated as usual with regards to segregation. 10
5.4 Screening of Patients Samples should not be sent for clearance of ESBL from patients who are asymptomatic with no signs of local or systemic infection. Stool samples are not required and should only be sent if the patient is experiencing diarrhoea and an infection is being considered. Samples should only be sent if there is a clinical need. 5.5 Movement and Transport of Patients Patients who are colonised or infected with ESBL-producing organisms can visit other departments within the hospital and other hospitals or care environments for treatment or investigations following consultation with the head of the receiving department or their deputy. Patients with risk factors for transmission should ideally be booked at the end of the session to allow time for cleaning and disinfection of patient contact areas by the relevant staff members. Staff in the receiving department who are having direct contact with patients that are infected with ESBL-producing organisms and have risk factors (for transmission) must wear a disposable apron and disposable nitrile gloves. Personal protective equipment should be disposed of in a clinical waste bag and hands decontaminated using soap and water followed by alcohol sanitiser following removal. All equipment including the wheelchair or trolley used by the patient must be cleaned with Chlor- Clean. If patients are transferred to care environments other than those within LPT the information related to infection status must be forwarded in advance to the receiving area, so that symptomatic patients can be isolated as per the receiving areas policies and guidelines. Ambulance Transportation The ambulance service must be informed at the time of booking if a patient with a known ESBL producing organism needs to use the ambulance service so that transportation with other patients who are susceptible to infection can be avoided. Ambulance staff must be advised if source isolation precautions are required during the transfer process in order for the appropriate cleaning and decontamination to be carried out. 5.6 Deceased Patients Standard precautions must be in place during the care of a deceased patient. There is no specific ESBL risk from the body to relatives, mortuary staff or undertakers. Plastic body (cadaver) bags are not necessary. Any lesions that leak should be covered with impermeable dressings. 11
6.0 Training There is no training requirement identified within this policy There is a need for training identified within this policy. In accordance with the classification of training outlined in the Trust Human Resources & Organisational Development Strategy this training has been identified as mandatory and role development training. The course directory e source link below will identify: who the training applies to, delivery method, the update frequency, learning outcomes and a list of available dates to access the training.http://www.leicspart.nhs.uk/library/academycoursedirectory.pdf A record of the event will be recorded on Ulearn as appropriate.the governance group responsible for monitoring the training is the Infection Prevention and Control Committee and Quality Assurance Committee. 12
7.0 References and Associated Documents Centre for Disease Control and Prevention: Guidance for Control of Carbapenemresistant Enterobacteriaceae (CRE) 2012 CRE Toolkit Centre for Disease Control and Prevention: Management of Multidrug-Resistant organisms in Healthcare Settings 2006 NHS Ayrshire & Arran: Extended Spectrum Beta-Lactamase (ESBL) Producing Organisms Infection Control Guidance (2010) NHS North Yorkshire and York Community and Mental Health Services: North Yorkshire Community Infection Prevention and Control Policies and Guidance. Multi- Resistant Gram-Negative Bacteria including ESBL s (Extended Spectrum Beta Lactamase) (2008) NHS York Teaching Hospital NHS Foundation Trust: Infection Prevention Policy Control and Prevention of Extended Spectrum Beta lactamase (ESBL) (2011) University Hospitals of Leicester NHS Trust: Multi resistant gram negative organisms policy and procedures LPT policies via intranet. The website can be accessed at http://www.leicspart.nhs.uk/ 13
APPENDIX 1 SOURCE ISOLATION PRECAUTIONS FOR IN-PATIENT FACILITIES Visitors: Before entering the room please speak to the nurse looking after the patient All Staff: Before entering the room and having contact with the patient or any items in the room you MUST Wear disposable gloves Wear a disposable plastic apron All visitors and staff please wash your hands before leaving the room 14