HEALTHCARE ASSOCIATED INFECTIONS RISK ASSESSMENT PROCEDURE Author: Jenny Boyce, Lead Infection Prevention & Control Nurse Approved by and date: March 2016 Any other linked ICP 000 - Infection Prevention and Control Assurance Policies: Framework ICP 002 - Standard Precaution Policy Cleaning and Disinfection Procedure Decontamination Policy Outbreak Procedure Isolation Procedure Procedure number: ICPr006 Version control: Version 1:
Version Date Date of Next Reason for Change (eg. full No. Ratified/ Implementation Review rewrite, amendment to reflect Amended Date new legislation, updated flowchart, minor amendments, etc.) 1 01/03/16 30/09/2018 Changed from policy to procedure Page 2
TABLE OF CONTENTS 1. INTRODUCTION... 4 2. IDENTIFYING RISK OF INFECTION... 4 2.1 Communication... 4 2.2 Risk Assessment... 4 2.2.1. Risk assessment checklist... 5 2.2.2. Risk factors for contracting healthcare associated MRSA... 5 2.2.3. Risk Factors for Clostridium difficile-associated Diarrhoea... 5 2.2.4. Risk of Carbapenemase-producing Enterobacteriacea (CPE)... 6 3. REFERENCES AND BIBLIOGRAPHY... 6 4. APPENDIX 1 - Equality considerations... 8 APPENDIX 2 RISK ASSESSMENT TOOL FOR MENTAL HEALTH AND LEARNING DISABILITY SERVICES... 9 APPENDIX 3 RISK ASSESSMENT TOOL FOR Community Services... 10 Page 3
1. INTRODUCTION Healthcare associated infection (HCAI) risk assessments are undertaken to determine the risk of a patient contracting or spreading a healthcare associated infection and aids care planning and patient placement and transfer or discharge. A HCAI risk assessment should be undertaken on admission, transfer and if necessary on discharge of patients, using the risk assessment tool shown in Appendix 1, as part of the patient s assessment record on SystmOne or epex system. If completed prior to transfer or discharge to another hospital, or other care facility or where follow up by community staff is required, a copy of the assessment form should be included with the transfer/discharge summary paperwork which accompanies patient. 2. IDENTIFYING RISK OF INFECTION 2.1 Communication The presence of some infectious diseases such as MRSA does not usually prevent patient transfer to another ward or unit however; good communication before transfer will ensure that correct management measures are taken to reduce risks of spread. Good communication with the receiving facility within the Trust or external healthcare organisation will help determine e.g. whether the patient needs isolation facility or not. The Infection Prevention and Control Team (IP&CT) must be involved early in the management of HCAIs at the earliest opportunity. 2.2 Risk Assessment Once a risk assessment has been undertaken and infection hazards identified then an individual care plan must be put in place to minimise the risks. The patient and or the family must be informed of the status. This will include what level of personal protective equipment is needed, accommodation for patient, how to deal with any wounds, equipment management and if necessary transfer. For cases of MRSA or C.diff the integrated care pathway contained in the ICP006 and ICP007 policies must be used and any concerns must be discussed with the Infection Prevention and Control Team. A number of questions should be addressed when formulating the infection control care plan: Question What is the source or likely source of the infectious organism? How does the organism spread? Example Blood, faeces, urine or sputum. Direct or indirect contact, airborne or faecal oral.
Question Are there additional risk factors? What is the general mental and physical health of the patient? Are other patients, staff or visitors at risk? Availability of staff and facilities? What could be contaminated? Example Indwelling devices, wounds, antibiotics, incontinence, diarrhoea, impaired immunity, age, environmental conditions and Staff practice. Underlying diseases, dementia, immobility and poor personal hygiene. Sharing rooms, pregnant staff or visitors, older patients. Isolation facility, adequate staffing levels. Hands, face, clothing, linen, equipment and environment. 2.2.1. Risk assessment checklist The risk assessment checklist Appendix 2 & 3 contained in this procedure will assist you in deciding on the level of infection risk the patient faces or poses to others. The more Yes selected the higher the infection risk. 2.2.2. Risk factors for contracting healthcare associated MRSA Current or recent hospitalisation. MRSA remains a concern in hospitals, where it can attack those most vulnerable such as older adults and people with weakened immune systems and or recent surgery. Open wounds or burn, skin conditions or serious underlying health problems. Residing in a long-term care facility. MRSA is also prevalent in these facilities and carriers of MRSA have the ability to spread it, even if they're not showing signs of infection. Invasive devices. People who are catheterised, intravenous drips in situ or have feeding tubes or other invasive devices in situ are at higher risk. NB: If yes to questions marked * on assessment checklist, then patient should be considered high risk for MRSA acquisition and MRSA screening should be undertaken and if screening positive discuss further actions with IP&CT. 2.2.3. Risk Factors for Clostridium difficile-associated Diarrhoea Advanced age. Antibiotic therapy - The overuse of antibiotics, especially penicillin (ampicillin), clindamycin and cephalosporins. Placement of nasogastric tube. Prolonged hospital stay. Repeated enemas. Gastrointestinal tract surgery Sharing a room with a C.diff infected patient. Use of antacids Page 5
C. difficile-associated disease occurs when the normal intestinal flora is altered, allowing C. difficile to flourish in the intestinal tract and produce a toxin that causes a watery diarrhoea. The environment and equipment and hands can become contaminated and help to spread the infection. 2.2.4. Risk of Carbapenemase-producing Enterobacteriacea (CPE). Been in-patients in a hospital abroad, Serious medical conditions, Received multiple antibiotics, Complex surgery, Stayed in an intensive Care Unit, Insertion of foreign materials such as urinary catheters, ventilators or intravenous catheters. CPE is a group of bacteria that have become very resistant to antibiotics including those called carbapenems such as meropenem. Many of these bacteria usually live harmlessly in the gut of humans or animals and help digest food. However, if they get into the wrong place such as the bladder or blood stream they can cause infection such as urinary tract infections, wound infections and pneumonia. 3. REFERENCES AND BIBLIOGRAPHY Antibiotics: 'national threat' from steep rise in patients who are resistant to drugs. The Daily Telegraph, March 6 2014 Antibiotic resistance soars: Cases of gut bacteria not destroyed by drugs increase by 12,000% in seven years. Mail Online, March 6 2014 Department of Health (2007), Essential Steps to safe, clean care Inter-healthcare patient infection risk assessment form DH: London Fears that cases of antibiotic-resistant bacteria could get 'out of control'. The Independent, March 6 2014 The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (2010) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216227/d h_123923.pdf epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (due for publication in the Journal of Hospital Infection January 2014) Page 6
Public Health England. Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae (PDF 1.6Mb). March 2014 UK Standards for Microbiology Investigations: Laboratory Detection and Reporting of Bacteria with Carbapenem-Hydrolysing β-lactamases (carbapenemases) (2013) published at: http://www.hpa.org.uk/ Page 7
4. APPENDIX 1 - EQUALITY CONSIDERATIONS The Trust has a duty under the Equality Act and the Public Sector Equality Duty to assess the impact of Policy changes for different groups within the community. In particular, the Trust is required to assess the impact (both positive and negative) for a number of protected characteristics including: Age; Disability; Gender reassignment; Marriage and civil partnership; Race; Religion or belief; Sexual orientation; Pregnancy and maternity; and Other excluded groups and/or those with multiple and social deprivation (for example carers, transient communities, ex-offenders, asylum seekers, sex-workers and homeless people). The author has considered the impact on these groups of the adoption of this Policy and does not believe that there are any specific equality considerations that need to be taken into account. Page 8
APPENDIX 2 RISK ASSESSMENT TOOL FOR MENTAL HEALTH AND LEARNING DISABILITY SERVICES Admission Transfer Date... Patient/Service User details Name: Consultant: DOB: GP: Address Current Patient Location: MRSA Yes No N/K Is the patient known to be infected or colonised with MRSA? Has the patients been previously positive to MRSA? Has the patient had an MRSA screen undertaken? *Has the patient any wounds/skin lesions/pressure sores/leg ulcers? *Has the patient a history of frequent acute hospital admissions? Has the patient any indwelling devices i.e. urethral catheters, supra-pubic catheters and peg sites? If yes: Where...When... Result...(N/K = Not Known) NB: If yes to all questions * consider high risk and undertake MRSA screening as per procedure. If MRSA positive on admission or positive on screening please use integrated pathway in the procedure. Diarrhoea Yes No N/K Does the patient have diarrhoea? Is the diarrhoea thought to be of an infectious nature? Has a specimen been sent? Has an organism been identified? If yes: Where...When... Result... Has patient had treatment? If yes: What...and when completed... NB: Patients with diarrhoea caused by Clostridium difficile toxins or enteric pathogens such as E.coli or salmonella should be isolated in single room until 48 hours symptom free. There is also an integrated Clostridium difficile pathway available in the Procedure for the management of Clostridium difficile. Other communicable disorders Does the patient has or is suspected of having any of the following communicable disorders: Chicken pox or Smear positive TB Influenza Impetigo Scabies shingles Other please specify... Page 9
APPENDIX 3 RISK ASSESSMENT TOOL FOR COMMUNITY SERVICES The screenshot below is where the staff identify the level of risk of infection. All System One users must complete this form.