Policy: D13 Dirty Protest and Decontamination of Equipment Policy (Previously D13g guidance) Version: D13/01 Ratified by: Trust Management Team Date ratified: 11 th September 2013 Title of Author: Infection Control Team/PMVA Team Title of responsible Director Director of Nursing & Patient Experience Governance Committee Patient Safety & Safeguarding Committee Date issued: 25 th September 2013 Review date: To be reviewed at TMT April 2014 (then June 2016) Target audience: All clinical staff and Managers NHSLA relevant? No Disclosure Status B B Can be disclosed to patients and the public Implementation Plan Monitoring Plan D13.xls Appended below Other Related Procedure or Documents: West London Mental Health NHS Trust Page 1 of 21
Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 21
Version Control Sheet Version Date Title of Author Status Comment D13/01 May 2013 Infection Control PMVA Team New Policy Previously a guidance document. D13g Revised as a policy and Presented to June 2013 PSS. 3 weeks consultation, ending 25 June 2013. July 2013 Presented to Sept 2013 TMT - Approved West London Mental Health NHS Trust Page 3 of 21
Content Page No. 1. Introduction 6 2. Scope 6 3. Definitions 6 4. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Duties Chief Executive Accountable Director Managers Policy Author Infection Control team The Facilities services Manager Local Policy Leads All Staff 6 6 7 7 7 7 7 8 8 5. Implementation 8 6. Immediate Action 8 7. Ongoing Actions 9 8. Care and Treatment 10 9 Conclusion of Protest 11 10 Procedure for Vacating the Seclusion Room when the Dirty Protest has Ceased 12 11 Room Decontamination 12 12 Health & Safety 13 13. Training 13 14. Monitoring 14 15. Fraud Statement (if required) 14 16. References 14 West London Mental Health NHS Trust Page 4 of 21
17. Supporting documents 14 18. Glossary of Terms/Acronyms 15 19. Appendices Appendix 1 Personal Protective Equipment Appendix 2 Method Statement Appendix 3 - Patient Restricted Items Disposal Form Appendix 4 Decontamination of Personal Protective Equipment Appendix 5 Monitoring Template 15 16 17 18 19 21 West London Mental Health NHS Trust Page 5 of 21
1. INTRODUCTION A dirty protest is where a patient has chosen to either defecate or urinate in a room without using the facilities provided; this may also include patient s using their own blood. In most cases the walls, floor or ceiling are usually affected. Some patients may choose to cover their clothing and their body with faecal waste and or blood. Although some actions may be undertaken as a protest, they may also be as a result of mental health problems. 2. SCOPE 2.1 This policy deals with the management of patients on dirty protest. The service has responsibilities under the Human Rights Act (1998) to have a justifiable and proportionate response in dealing with dirty protests. 2.2 This policy provides information on the procedure to follow when personal protective equipment is utilized when undertaking PMVA using protective equipment (see appendix 4). 2.3 There are legal duties contained within the Health and Safety at Work Act (1974) together with the requirement to undertake risk assessments under COSHH Regulations (1999). 2.4 This policy sets out the procedure to be followed in order to ensure that the health and safety of staff, other patients, and the patient protester is not compromised. It applies to anyone else who may come into contact with the patient protestor or any of the articles that have been in the patient s possession. 3. DEFINITIONS 3.1 Dirty Protest is where a patient has chosen to either defecate or urinate in a room without using the facilities provided and may also include patients using their own blood. 3.2 Seclusion is the supervised confinement of a patient in a room, which may be locked to protect others from significant harm 4. DUTIES 4.1 Chief Executive The Chief Executive has overall responsibility for ensuring that there are effective arrangements and adequate resources provided to ensure the Health and Safety of patients and staff. 4.2 Accountable Director West London Mental Health NHS Trust Page 6 of 21
The Director of Nursing and Patient Experience is the accountable executive director for this policy. He/she is responsible for the development of relevant policies and to ensure they comply with NHSLA standards and criteria where applicable. They must also contain all the relevant details and processes as per P3. They are also responsible for trustwide implementation and compliance with the policy. 4.3 Managers Managers are responsible for ensuring policies are communicated to their teams/staff. They are responsible for ensuring staff attend relevant training and adhere to the policy detail. They are also responsible for ensuring policies applicable to their services are implemented. 4.4 Policy Author Policy Author is responsible for the development or review of a policy as well as ensuring the implementation and monitoring is communicated effectively throughout the Trust via CSU leads and that monitoring arrangements are robust. 4.5 Infection Control Team The Director of Infection Control (DIPC) has overall accountability for the infection control team within the Trust, the implementation of infection control policies, challenging inappropriate infection control practices, undertaking the impact assessment of new and revised policies together with recommendations for change, integrating infection control together with clinical governance and patient safety teams and structures and the production of a HCAI annual report. Infection control is responsible for monitoring the effectiveness of health and safety-related processes and activities, ensuring that robust arrangements are in place in line with national policy and relevant legislation and creating an environment of continuous quality improvement and development The infection control team and the facilities department are expected to work closely to ensure that standards are being met in accordance with National guidance and that regular audits and monitoring systems are in place to ensure adherence to standards. 4.6 The Facilities Services Manager Be accountable for achieving the strategic aims and for monitoring compliance with this Policy. Provide a quarterly report to the Infection Control Committee. Attend Outbreak meetings. Work in close harmony with the Infection Control team, meeting routinely. Ensure this Policy is disseminated and implemented within the areas of responsibility. Investigate failures to comply with the Policy and ensure action is taken to prevent a recurrence. With the Infection Control team, review the frequency of audits and agree action plans to address areas of concern. West London Mental Health NHS Trust Page 7 of 21
4.7 Local Policy Leads Local policy leads are responsible for ensuring policies are communicated and implemented within their CSU / Directorate as well as co-ordinating and systematically filing monitoring reports. Areas of poor performance should be raised at the CSU / Directorate SMT meetings. 4.8 All Staff All staff are responsible for following this Policy. 5. IMPLEMENTATION 5.1 Responsibility for assessing the implications of this policy and procedure rests with the Clinical Nurse Manager/Ward Manager. They will be required to identify and carry out such preparation as necessary to confirm that staff understand the expectations on them and that they are both competent and confident to discharge these. They are also responsible for informing Facilities and Infection Prevention and Control team once a dirty protest commences. 5.2 CSUs are responsible for ensuring that all relevant staff are trained in adequate cleaning of a room 6. IMMEDIATE ACTION 6.1 As soon as staff are aware that a patient has begun a dirty protest the clinical team must be informed as soon as is practicable 6.2 Every effort should be made to ascertain the reason for the protest. Appropriate encouragement should be given to the patient to end the protest. 6.3 The Site Manager /On Call Manager/ Duty Coordinator must be informed immediately a dirty protest commences. The Security Department, Facilities and Infection Prevention and Control Team should also be alerted so that the incident can be recorded as soon as is practicable. 6.4 An incident form IR1 should be completed by the nurse in charge of the ward. This form is located on the Exchange under the heading Incident & amp; Risk Management. Use category Damage to Property. 6.5 On the authority of the Clinical Nurse Manager/ Ward Manager/Site Manager /On Call Manager, a patient on dirty protest will be moved to accommodation or other fit for purpose accommodation which will normally be a seclusion room. The patient protestor will therefore be subject to the rigors of the Trust s Seclusion Policy. 6.6 A patient on dirty protest must be informed in writing that any property within a room where there has been a dirty protest will be destroyed if the clinical team have reason to believe it has been contaminated, cannot be properly cleaned by the patient and therefore poses a risk to the health of other patients or staff. This action will be recorded in the patients clinical West London Mental Health NHS Trust Page 8 of 21
record. Legal correspondence can only be destroyed where there is obvious contamination. 6.7 A full risk assessment must be made in respect of each item in the room to determine the level of contamination and a note made in the patient s records outlining outcome. The following options must be considered: Disposal as Infectious Waste Decontamination by way of disinfection or sterilization Placed in sealed bags and stored 6.8 Any property that needs to be destroyed should be photographed by digital camera and the images stored on the patient s electronic clinical record. The patient should be notified that this has taken place (see appendix 3). 6.9 The patient on protest must be provided with clear written information about the care and treatment while on a dirty protest. 6.10 Protests of this nature are very unpleasant for staff to manage and for other patients who share the same ward area. The Trust therefore has an obligation to discourage such protests as part of its responsibilities to staff and other patients. In addition, such protests render accommodation unusable until specialist and expensive cleaning procedures have been implemented. Accordingly, the Trust s position is that it will report such protests to the Police for prosecution for Criminal Damage to Trust property and where such prosecutions are successful, it will seek through the Court compensation from the protestor for the costs of cleaning the room/s concerned, currently 1200 per room. Only if the Responsible Clinician has formed a clinical view that the patient at the time lacked legal capacity will such measures not be followed. 7.0 ON GOING ACTIONS 7.1 If the site of the dirty protest was not in a seclusion room or ICU then the room affected must be sealed until arrangements can be made for urgent cleaning. 7.2 All furniture in the affected room must be removed, bagged, sealed and marked clearly as contaminated waste. The patient s personal property will be the subject of individual risk assessment and dealt with as detailed in paragraph 6.7. 7.3 A written record will be kept of the progress of the protest; within the patients clinical record. This will include such matters as: Visits and reviews by ward multi disciplinary team, advocacy, legal advisors etc. Details of interaction with the patient. Offers to end responses and a note of encouragement to do so. Fluid and dietary intake/output. When an offer to shower is made by staff with the patient s response documented. West London Mental Health NHS Trust Page 9 of 21
7.4 The patient will be visited by a manager and member of medical staff each day. These visits will be recorded in the relevant documentation and in line with the Trust s Seclusion Policy. The visiting manager and medical staff along with the ward manager will need to make a dynamic decision around moving the patient to a different (clean) room. Patients should not be expected to remain in a room overnight in which they are carrying out a dirty protest. The decision to move the patient or not to move the patient would be made in conjunction with the managers for the area in consultation with the patients RC or deputy. If the decision is taken not to move the patient this needs to be documents with the reasons why in the patients notes. 8.0 CARE AND TREATMENT 8.1 The patient will not be permitted access to fresh air unless the patient showers/ bathes and wears clean clothing. 8.2 Visits will not be allowed unless the patient showers/bathes and wears clean clothing and visitors will be told the reason why the visit cannot take place. 8.3 In cases where a legal advisor/care Quality Commission or advocate wishes to see the patient protestor, and where the patient refuses to shower/bathe, the legal visitor should discuss and agree the arrangement under which a visit may go ahead. 8.4 In the event of a visit taking place without patient compliance due to legal or health issues the legal advisor/mental Health Act Commissioner, advocate or staff member must be advised of the conditions in which the visit will take place and provided with full protective clothing and other facilities to address personal hygiene needs in the same way as a member of staff. 8.5 Showers will be offered frequently in accordance with risk assessment to the patient who has embarked on a dirty protest and this will be recorded in the patient s clinical record. 8.6 All other access to facilities is at the discretion of the protesting patient s clinical team but the patient must shower/bathe and change into clean clothing before access to any discretionary activity is allowed. 8.7 Where a patient discontinues a dirty protest, a review of the clinical management and seclusion of the patient must be undertaken. 8.8 Patients on dirty protest will receive all incoming mail, subject to policy. However such mail may need to be destroyed after the period of dirty protest in accordance with the arrangements set out at paragraph 6.7. 8.9 Patients will be entitled to use the patient telephone provided they have showered/ bathed and wear clean clothing. West London Mental Health NHS Trust Page 10 of 21
8.10 Patients will be entitled to communicate with their legal advisors/care Quality Commission on the patient telephone provided they have showered/bathed and wear clean clothing. 8.11 Protesting patients will be provided with food according to their cultural, ethnic and religious beliefs. A record of their intake and output will be maintained. 8.12 Food and drinks will be served using disposable plates, cups and cutlery. These items will be used once only and disposed of in orange infectious waste bags. 8.13 Where possible, meals and drinks will be offered through a door hatch otherwise appropriate Personal Protective Equipment (PPE) worn and taken into the patient. 8.14 Patient protestors will be encouraged to wash their hands prior to receiving food and drink. 8.15 Refused food and drink must be disposed of immediately in orange infectious waste bags and a record of the food and drink items refused will be recorded. 8.16 All staff involved in intervention of any form with the protesting patient must wear protective clothing. The clothing must be disposed of after each intervention. 8.17 Patients must be encouraged to end the protest and will be asked at least twice a day to do so. A record of this, including the name of the person engaged in this dialogue with the patient will be included in the patient s clinical record. 9.0 ON CONCLUSION OF PROTEST 9.1 The patient will wear disposable protective overshoes when outside seclusion. 9.2 Protective clothing and equipment for staff and where necessary other visitors will be made available and the means to dispose of it will be provided. The clothing must comprise of: Disposable overalls capable of preventing contamination by particles or splashes Disposable gloves Overshoes Face mask Eye protection (appendix 1) 9.3 Immediately after use clothing must be sealed in red alginate bags or orange infectious waste bags depending after risk assessment whether the clothing is going to be washed or disposed of. West London Mental Health NHS Trust Page 11 of 21
9.4 Staff and visitors who have been in close proximity to the protesting patient should have the opportunity to shower and appropriate washing materials should be available from the ward. 10.0 PROCEDURE FOR VACATING THE SECLUSION ROOM WHEN THE DIRTY PROTEST HAS CEASED 10.1 The patient must wear overshoes as described above. 10.2 Staff in protective clothing will terminate the seclusion and conduct a rubdown search and escort the patient to the shower or bath. 10.3 At the bathing / shower area the patient s clothing and overshoes must be sealed in red alginate bags or orange infectious waste bags depending after risk assessment whether the clothing is going to be washed or disposed of and clean clothes provided. 10.4 The patient is then escorted back to the ward environment 10.5 The seclusion room is to be sealed after the patient has left and been relocated. Arrangements to be made to have the affected seclusion room cleaned by the specialist cleaning team once the ward staff have carried out the initial clean. 11.0 ROOM DECONTAMINATION 11.1 Nursing staff must wear appropriate personal protective equipment as described in 9.2. 11.2 All cleaning equipment to be obtained before entering the room and to comply with the National Colour Code Bucket of hot water with neutral detergent Mop Wipes/cloths Infectious waste bags Red alginate bags 11.3 Nursing staff are responsible for the initial clean of the room, ensuring that all body fluids and any other waste is removed following method statement Appendix 2. The specialist cleaning team will then undertake a terminal clean of the room. It is important that the specialist cleaning team supports nursing teams in undertaking cleaning as soon as possible. 11.4 Specialist cleaning team must wear appropriate personal protective equipment 11.5 Specialist cleaning team will then deep clean/steam clean the area 12.0 HEALTH AND SAFETY 12.1 A safe system of work must be in place to manage the disposal of items from the area where the protest took place. The systems will cover arrangements for: West London Mental Health NHS Trust Page 12 of 21
The provision and use of protective clothing and a dirty and clean zone to enable the safe removal and destruction of the clothing. Screening the area into dirty and clean zones around the protest area. Access to shower facilities for staff. The collection and destruction of infectious waste, which must be bagged, security sealed and marked as such. These bags should be stored in a dirty utility area awaiting removal following the Trust s Waste Policy. Staff will undertake continuous risk assessments to identify the health and safety issues and develop strategies to reduce risk to staff, other patients and persons who come into contact with the patient protestor. 12.2 The patient must be offered materials to clean the area every day with staff supervision and a record of this made in the patient s continuous record. 12.3 A patient on dirty protest will be permitted to keep the following: Pyjamas/strong night attire. Mattress Bedding/strong bedding Reading materials 12.4 Subject to risk assessment the patient will be issued with toiletries, on a supervised basis: Soap Shampoo Flannel Towel Toothbrush and toothpaste Shaving equipment 13.0 TRAINING 13.1 Facilities Department are responsible for ensuring that the specialist cleaning team are adequately trained for the required tasks 13.2 CSUs with assistance from Facilities and the Infection Prevention and Control Team will offer additional training for staff as required. 13.3 Infection Prevention and Control team will offer any additional training for staff in the use of personal protective equipment etc 13.4 Clinical managers to offer training to staff around this issue as required 14.0 MONITORING Please refer to the Monitoring spreadsheet at Appendix 5. 15.0 FRAUD STATEMENT No fraud statement is required for this policy. West London Mental Health NHS Trust Page 13 of 21
16.0 REFERENCES (EXTERNAL DOCUMENTS) This policy should be read in conjunction with the following: The Human Rights Act 1998 Health and Safety at work Act 1974 COSHH Regulations 1999 Health and Safety Guidance Dirty Protest 2004 Prison service guidelines National Colour Code 2004 National Patient Safety Agency The Revised Healthcare Cleaning Manual 2009 National Patient Safety Agency 17.0 SUPPORTING DOCUMENTS (TRUST DOCUMENTS) ICP1 Infection Prevention and Control Policy and Guidelines ICP14 Cleaning and Decontamination Policy ICP10 Waste Policy S2 Seclusion Policy S28 Safeguarding Vulnerable Adults Policy and Reporting Procedure 18.0 GLOSSARY OF TERMS / ACRONYMS PPE ADDITIONAL PPE HSS ONLY (SEE APPENDIX 4) NHSLA PMVA SMT IR1 CSU RC ICU COSHH Personal Protective Equipment Personal Protective Equipment: Equipment used in addition to general PPE to manage high risk incidents. National Health Service Litigation Authority Prevention and Management of Violence and Senior Management Team Incident Reporting Clinical Service Unit Responsible Consultant Intensive Care Unit Control of Substances Hazardous to Health West London Mental Health NHS Trust Page 14 of 21
19.0 APPENDICES. Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Personal Protective Equipment Method Statement Patient Restricted Items Disposal Form Decontamination of Personal Protective Equipment Monitoring Form West London Mental Health NHS Trust Page 15 of 21
Appendix 1 PERSONAL PROTECTIVE EQUIPMENT To be available for up to 3 people Microgard 2500 suit Microgard 2500 Anti slip over boot Essentials Eye Protection Mask Gloves West London Mental Health NHS Trust Page 16 of 21
Appendix 2 Method Statement Task Seclusion room cleaning following dirty protest Equipment Yellow gloves Waterproof suit Overshoes Goggles & Facemask Yellow bucket Yellow cloths Yellow mop bucket Yellow mop handle and mop head Paper towels Cleaning chemical (neutral detergent) Infectious waste bags Wet floor signs Method 1. Ensure area is clear 2. Display wet floor signs 3. Wash hands and put on gloves, coverall, overshoes, facemask and eye protection 4. Prepare cleaning solution in bucket according to manufacturers instructions 5. Prepare cleaning solution in mop bucket according to manufacturers instructions 6. Open infectious waste bag and ensure it is close to spillage area 7. Clear spillage with paper hand towels and place directly in to infectious waste bag 8. Dampen the cloth in the solution and clean vertical surfaces thoroughly changing the cloth as necessary. 9. Submerge mop in cleaning solution in the mop bucket then wring out excess liquid 10. Mop the edges with straight strokes then working backwards use a figure of eight pattern working side to side, turning the mop frequently, move to the next section and repeat the process. 11. Extendable handle with standard mop head to be used for cleaning high surfaces and ceilings 12. On completion clean all equipment that isn t disposable 13. Dispose of personal protective equipment as infectious waste West London Mental Health NHS Trust Page 17 of 21
Appendix 3 Patient Restricted Items Disposal Form Name: Date: Item to be disposed of: Comments: Staff signature: Patient Signature; West London Mental Health NHS Trust Page 18 of 21
Appendix 4 Decontamination of Personal Protective Equipment (PPE) (Equipment utilized in conjunction with Protective Clothing) All staff trained in PPE procedures have been issued with there own personal PPE kit bag. If staff have utilized their own personal protective equipment and it has been contaminated during a dirty protest or an operational incident where there is contact with bodily fluids the following guidelines should be followed: 1.1 It is the responsibility of the individual to place any contaminated kit in a red bag securing the top and relocating it to the designated decontamination area. It is then the responsibility of the Controller of the incident to designate an individual(s) to decontaminate the equipment. All PPE that has been decontaminated needs to be left to dry naturally 1.2 Before returning to the individual kit bags. This same individual(s) will then be responsible for returning the kit to the appropriate kit bags after it has been inspected by the Operational PPE Advisor. 1.3 Depending on the severity of the decontamination, some equipment may need to be destroyed by incineration (this will be assessed by PMVA/PPE Operational Lead in conjunction with Infection Control). 1.4 For Infection Control purposes a designated area has been provided for the decontamination of the above equipment. This area will have the appropriate cleaning materials and equipment for the process to be carried out. Appropriate equipment (i.e., gloves, aprons, facial protection) should be worn whilst carrying out the decontamination. The Operational PPE Advisor will inspect all PPE after decontamination to ensure that it is intact and fit for purpose prior to reuse. Decontamination Process: Will be performed within the nominated area within the PPE operational centre (PPE Advisors will provide the necessary advice, cleaning materials and support throughout the decontamination process of both the equipment and cleaning environment). Shields 1.5 Shields can be cleaned using a cloth and hot soapy water, then rinsed with warm water and then left to dry naturally. Overalls 1.6 These can be sent in a red alginate bag which must be placed inside a red linen bag as infected linen. Gloves, helmets, arm/leg guards and anti stab vests 1.7 These should be cleaned according to the manufacturer s guidelines. Disposable non-latex gloves West London Mental Health NHS Trust Page 19 of 21
1.8 Immediately after removing these they can be placed in an orange infectious waste bag. All PMVA Advisors will be shown how to clean the PPE; this will then be cascaded down to all staff who are PPE trained. Any individual who feels they have had direct contact with bodily fluids i.e., through breaks in skin should refer to ICP6 and ICP7 of the Infection Control Policy Manual. West London Mental Health NHS Trust Page 20 of 21
Appendix 5 POLICY / PROCEDURE: ICP9 Tuberculosis D13 Dirty Protest and Decontamination of Equipment Policy MONITORING TEMPLATE WHO (which staff/team/dept) WHAT / TYPE (Audit/process/report - list details) HOW MANY (No of records/%) FREQUENCY (monthly/quarterly/annual) WHERE REVIEWED (which meeting/committee) OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting) Infection Control Team Incident Reporting Forms All Quarterly Quarterly IC Meeting; Infection Control Team Audit All Quarterly Quarterly IC Meeting; t 13