Patient Placement, Isolation and Cohorting: Standard ...

Once printed or downloaded this document is uncontrolled. Always check the GMMH policies intranet site for the approved up to date version.

Greater Manchester Mental Health NHS

Foundation Trust

Patient Placement, Isolation and Cohorting: Standard Infection Prevention & Control and Transmission Based Infection Control Precautions


Ref: IPC07 Issue date: 19/12/2019 Version number: 1.0

Status: Approved Next review date: 05/12/2024 Page 1 of 24

Document Name: Patient Placement, Isolation and Cohorting: Standard Infection Prevention & Control and Transmission Based Infection Control Precautions

Executive Summary: This policy is intended to provide advice on isolation practices so that the spread of infections is minimised between patients, staff and ward areas.

Executive Lead: Gill Green (Director of Nursing & Governance)

Document Author: Tony Rogers (Senior Infection Prevention & Control Nurse) [email protected]

Document Purpose: Policy

Target Audience: All GMMH staff, service users, visitors and contractors

Additional Circulation List:

All staff via SharePoint

Date Ratified: TBC

Ratified by: Infection Prevention & Control Committee

Consultation: IPC committee members

Cross Reference: Related Trust policies and procedures including: Infection prevention policies such as:

IPC 01 Infection Prevention and Control Policy

IPC 03 Major Outbreak of a Communicable Infection

IPC 13 Standard Infection Control precautions and Hand Hygiene Policy

Cleaning disinfection and decontamination policies and procedures

In the Event of Death Policy

Superseded Docs: GMW Isolation Policy

Date of Equality Impact Assessment:

August 2019

Board Objective Reference:

Board Objectives 2019/20 1 To promote recovery by providing high quality care and delivering excellent outcomes Board Objectives 2020/21 1 Best Care Every day

CQC Regulation Reference:

CQC regulation 12 Safe and care treatment

Risk Register Reference: N/A

Contact Details for further information

Infection Prevention & Control Team Tel: 0161 271 0002 Email: [email protected]

Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the Trust intranet is the controlled copy.

mailto:[email protected]





Contents 1. Introduction .................................................................................................... 4

1.1 Purpose ........................................................................................................... 4

1.2 Scope ............................................................................................................... 4

2. Definitions ....................................................................................................... 4

3. Duties .............................................................................................................. 5

3.1 Board/Lead Committee .................................................................................. 5

3.2 Chief Executive ............................................................................................... 5

3.3 Director of Infection Control (DIPC) ............................................................. 6

3.4 Infection prevention and Control team ......................................................... 6

3.5 Managers / Matrons ........................................................................................ 6

3.6 Medical staff .................................................................................................... 6

3.7 Nursing staff ................................................................................................... 6

3.8 Employees ...................................................................................................... 6

4. Processes and procedures ............................................................................ 7

4.1 Standard Isolation .......................................................................................... 7

4.2 Making the Decision to Isolate ...................................................................... 8

4.3 Source Isolation ............................................................................................. 8

4.4 Negative Ventilation - Information Only ...................................................... 8

4.5 Communication .............................................................................................. 8

4.6 Isolation facilities ........................................................................................... 9

4.7 Cohort Nursing ............................................................................................. 11

4.8 Management of the Patient Once Isolated ................................................. 12

4.9 Cleaning and Decontamination ................................................................... 13

4.10 Movement and Visits to Other Departments, i.e. X-Ray, ECT ................ 14

4.11 Care of the Deceased Patient ................................................................... 14

4.12 When can isolation precautions be stopped? ........................................ 14

4.13 Visitors ....................................................................................................... 15

4.14 Vulnerable staff & Visitors........................................................................ 15

5. Training Requirements ................................................................................ 15

6. Monitoring ..................................................................................................... 15

7. Resource/Implementation Issues ............................................................... 16

8. Risk Issues .................................................................................................... 16

9. Requirements, Supporting Documents and References .......................... 16

9.1 Requirements ............................................................................................... 16

9.2 Supporting Documents ................................................................................ 16




9.3 References .................................................................................................... 16

10. Subject Expert and Feedback ..................................................................... 17

11. Review ........................................................................................................... 17

12. Appendices ................................................................................................... 17

Appendix 1 – Door Sign ........................................................................................ 18

Appendix 2 – Alert organisms ............................................................................... 19

Appendix 3 – Isolation leaflet ............................................................................... 21

Appendix 4 – Clarification statements on Isolation of prisoners ...................... 24




1. Introduction

The correct and timely placement of infectious patients, (suspected or proven infection), into single rooms can be a very effective way of reducing the overall number of infected patients; it can also reduce the risk of colonisation in other patients within the ward environment. The practice of patient isolation is just one aspect of a trust-wide strategy to reduce and prevent Health Care Acquired Infections (HCAIs). Strategies should also consider minimising the inappropriate movement of patients for non-clinical reasons. The procedure for isolation should be directed by this policy and be clearly stated and explained to staff, patients and visitors. In certain circumstances isolation practices may also be carried out within the ward area, in a procedure known as ‘cohorting’. Through such measures, it is possible to control the spread and minimise the impact of infections such as MRSA, C. difficile, norovirus and other health care acquired infections (HCAI).

1.1 Purpose

This policy is intended to inform isolation practices so that the spread of infections is minimised between patients, staff and ward areas.

1.2 Scope

This policy applies to all healthcare professionals delivering care in Greater Manchester Mental health Foundation NHS Trust. This includes medical staff, nurses, allied health professionals, locum/agency staff and students

2. Definitions

Airborne transmission: Aerosol generating procedures (AGP) are considered to have a greater likelihood of producing aerosols compared to coughing for instance. Aerosols are smaller than the droplets described below and can remain in the air for longer and, therefore, potentially transmit infection by mucous membrane contact or inhalation.

Cohorting: The process of grouping individuals with the same infections into an identified area to reduce the spread of infection. Cohorts are created based on clinical diagnosis, microbiological confirmation when available, epidemiology, and mode of transmission of the infectious agent.

Contact transmission: Contact transmission may be direct or indirect. Infectious agents can be inadvertently passed directly from an infected person, (for example after coughing into their hands), to a recipient who, in the absence of correct hand hygiene, may then transfer the organism to the mucous membranes of their mouth, nose or eyes.

Droplet transmission: Droplets greater than five microns in size may be generated from the respiratory tract during coughing, sneezing or talking. If droplets from an infected person come into contact with the mucous




membranes (mouth or nose) or surface of the eye of a recipient, they can transmit infection. These droplets remain in the air for a short period and travel one to two metres, so physical closeness is required for transmission.

Indirect contact transmission takes place when a recipient has contact with a contaminated object, such as furniture or equipment that an infected person may have coughed or sneezed on. In the absence of correct hand hygiene, the recipient may transfer organisms from the contaminated object to the mucous membranes of their mouth, nose or eyes.

Infection control precautions to minimise transmission of acute respiratory tract infections in healthcare settings.

Infectious period: The infectious period (or period of communicability) is the time period over which an infected person can spread the infection to someone else. This varies by pathogen and by individual. For many acute respiratory viral infections the infectious period is unknown; for practical purposes it is often assumed to equate to the duration of symptoms. In general, infectiousness is greatest in the early stages of infection. The infectious period for influenza is thought to be from about one day before the onset of symptoms until 3−5 days later. Children, immunocompromised individuals and seriously ill people may remain infectious for a longer period, and action should be considered to minimise prolonged shedding of influenza virus by patients with risk factors. Patients with pertussis infection may be infectious until three weeks after the onset of the paroxysmal phase of the disease.

Isolation – The process of separating an infected patient from all other uninfected patients.

3. Duties

3.1 Board/Lead Committee

It is the responsibility of the Infection Prevention Committee to:

Provide consultation on the contents of this policy and procedure.

Expert members of the committee to give support, advice and comments in line with regional and national guidelines.

Monitor the implementation of this policy and associated procedures.

3.2 Chief Executive

The Chief Executive is responsible for:

Designating the prevention and control of healthcare associated infection to a nominated Director.

Receiving assurances of compliance with this policy and associated procedures.

Receiving the Infection Prevention Annual Report from the DIPC.




3.3 Director of Infection Control (DIPC)

It is the responsibility of the Director of Infection Prevention and Control (DIPC) to:

Oversee this procedure and its implementation;

Report directly to the Chief Executive and Quality Improvement Committee

3.4 Infection prevention and Control team

It is the responsibility of the Infection Prevention Control Team to:

Provide advice on the management of infection prevention and control where required and to work with managers and matrons to ensure appropriate and timely isolation of patients with an infectious disease.

3.5 Managers / Matrons

It is the responsibility of Matrons/Operational Managers to:

Ensure compliance with the procedure.

Lead the immediate implementation of isolation requirements as directed by the Infection Control Team.

3.6 Medical staff

It is the responsibility of medical staff to ensure:

Request of appropriate samples.

Confirmation of initial diagnosis.

Ongoing medical assessment and prescribing of treatment.

Ongoing assessment of effectiveness of treatment.

Confirmation of non-infective cases.

3.7 Nursing staff

It is the responsibility of Nursing staff to ensure:

Appropriate samples are sent to laboratories.

NEWS and associated documentation is completed appropriately and in a timely manner.

Concerns are raised with Medical staff.

Clinical equipment is allocated and cleaned /disposed correctly.

3.8 Employees

All members of staff, including agency, contractors and bank staff contracted by the Trust, need to comply with this policy and associated Infection Prevention & Control,




Health & Safety, and COSHH policies, procedures, protocols and guidelines and legislation, and regulations applying to the safe provision of health care.

4. Processes and procedures

Patients must be promptly assessed for infection risk on arrival at the care area (if possible, prior to accepting a patient from another care area) and should be continuously reviewed throughout their stay. An assessment of the potential infection, route of infection transmission and potential spread of infection; risk factors associated with exposure to blood and body fluids; and spatial considerations should be made when considering where to place a patient. Patients who may present a particular cross-infection risk include those:

• Known to have been previously positive for a multidrug resistant organism

(MDRO), such as methicillin-resistant Staphylococcus aureus (MRSA) or Carbapenemase- producing Enterobacteriaceae (CPE).

In addition to those:

• With diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms.

Patient placement decisions should be based on risk assessment which should consider the route of transmission alongside patient factors and symptoms that increase the risk of cross transmission. A single-bed room should be considered as a minimum for patients on airborne precautions, and is preferred for patients on droplet and contact precautions. There are different levels of precautions and isolation required to prevent the spread of infection and these include:

Standard Isolation

Source (or ‘containment’) isolation – (also known as “Barrier Nursing”)

Negative Ventilation In rare occasions such as patients with suspected or proven multi-drug resistant M. tuberculosis, Diphtheria, etc, appropriate isolation facilities will not always be available within the GMMH Trust. In these special cases in order to ensure patient and public safety, arrangements will be made by the Director for Infection Prevention in conjunction with the Consultant in Communicable Diseases, Public Health England and the Infectious Disease Unit for the immediate transfer and admission of patients with high-risk infections to an appropriate facility.

4.1 Standard Isolation

These precautions are used in situations where the mode of transmission of the infecting organism is via the faecal-oral route, (e.g. viral gastroenteritis and other




enteric organisms), or by contact via hands, skin, mucous membranes or wounds (e.g. MRSA). Standard precautions are designed to reduce the risk of transmission of organisms and specific diseases by direct or indirect contact. These precautions are in addition to standard universal precautions may involve: appropriate patient placement, gowning, additional cleaning and environmental precautions. This is the most common type of isolation and is frequently used for most communicable diseases.

4.2 Making the Decision to Isolate

Patients cannot be enforced to stay in isolation. To do so would be a Deprivation of Liberty, (for prisoners see Appendix 4). The decision to isolate a patient should be based on the infection risk, and taken preferably after discussion with the Infection Prevention team. When there are competing demands for single rooms, Ward Managers, Matrons and the Infection Prevention and control team should jointly agree on the appropriate placement of patients. Where there are conflicting points of view the final decision will be led by the DIPC/Consultant.

4.3 Source Isolation

Source isolation is the physical separation of one patient from another, in order to prevent spread of infection. NB: Some organisms may be spread by more than one route therefore more than one type of precaution will be necessary, e.g. Influenza may require contact and airborne precautions.

4.4 Negative Ventilation - Information Only

GMMH does not have an enhanced single room (negative pressure). Negative Ventilation is to prevent the transmission of infectious diseases over short distances through the air. In order for this to be effective a single patient room is essential and those tending to patients will be required to wear a mask. Patients presenting with serious infections spread by the respiratory route will normally be transferred to an Acute NHS Trust for further management, (exceptions to this may occur for example during a Pandemic - see Pandemic Influenza Guidance). An example of when negative ventilation may be required is in the case of confirmed pulmonary tuberculosis (smear positive open pulmonary tuberculosis), severe acute respiratory syndrome (SARS) and avian influenza.

4.5 Communication

Explain the rationale for isolation to the patient and, where possible, the duration of




isolation anticipated. Where available, provide a patient information leaflet about the relevant infectious condition/disease. Place the appropriate isolation card on the door of the room/bay and indicate the appropriate precautions. Record in the patient's notes that isolation has been commenced and the reason why. Revise the nursing care plan accounting for infection control precautions to be maintained by staff, patient and visitors. Ensure isolation is communicated with the whole team in handovers Inform the Infection Control Team that there is a patient in isolation. Check whether the patient has a ‘Notifiable Disease’ and, if so, complete a downloadable ‘Notification Form’ available on the Infection Prevention pages of the intranet https://newintranet/departments/nursing-governance/infection-prevention/Pages/posters-resources.aspx.

4.6 Isolation facilities

Patients cannot be enforced to stay in isolation - to do so would be a deprivation of Liberty (for prisoners see Appendix 4). When in isolation the patient ideally should be nursed in a single room with a wash basin and preferably an en-suite toilet. If an en-suite toilet is not available, a commode for sole use of the isolated patient should be kept in the isolation room for the duration of the patient’s stay. Ensure the isolation room door is closed at all times apart from necessary entrances and exits, when airborne infection risk is present. Limit the number of staff entering the isolation room as reducing the number of staff who come into contact with the patient will further reduce the risk of spreading the infection. Where there are cases of multiple patients infected with the same infection the Infection Prevention & Control Team may consider the use of cohort isolation where infected patients are grouped in bays or isolation areas. Careful attention must be made to ensuring that the privacy and dignity of service users is maintained at all times. A risk analysis approach should be carried out when making any decision to isolate a patient. For example, patients who wander or have poor hygiene are more likely to cause cross-infection. Isolated patients may experience more anxiety and depression with isolation potentially hampering rehabilitation. Psychological support and reassurance must be

https://newintranet/departments/nursing-governance/infection-prevention/Pages/posters-resources.aspx

https://newintranet/departments/nursing-governance/infection-prevention/Pages/posters-resources.aspx




given to the patient whilst in isolation and to reduce these risks, preparatory information should be given wherever possible, (Appendix 3). This should include an explanation of the nature of disease or organism, symptoms and treatment, control methods and their rationale with advice for patients regarding their responsibility and their adoption of correct measures. Ensure a source isolation notice is displayed on the door. Ensure all staff are aware of the necessary precautions. Regular assessment and evaluation of the situation, in conjunction with the Infection Prevention and Control team is necessary to decide if isolation of the patient remains the most appropriate form of care. Depending on the nature of the patients mental health condition special consideration will be given to those with:

Severe mental illness requiring close observation

Patient’s mental state being contra-indicated to single room isolation. In these cases there may be an increased risk of infection spread however this must be managed appropriately and documented by the clinical team in the patients care plan and PARIS. Patients cannot be enforced to stay in isolation as to do so would be a deprivation of Liberty, (for prisoners see Appendix 4). Patients who cannot or will not be isolated will need to be managed with as limited association with others as possible. This is likely to involve a minimum of Level 1 continuous observations either 1:1 OR 2:1 etc in conjunction with the services risk assessment’ or similar such as:

STAR v2 Risk assessment, as per Observation policy (https://newintranet/GMMH-Policies/Pages/Clinical.aspx ).

HCR20 Allocate staff where appropriate if they have confirmed immunity, risk assess staff that do not have immunity.

Contain/manage risk whilst maintaining patient diagnosis/medical confidentiality.

This may require the allocation of additional staffing and ward managers should

discuss this with their immediate managers.

Where patients with transmissible infections continue to wander into communal areas, then, dependent upon the mode of transmission a minimum distance should be maintained /encouraged from non-infected patients

https://newintranet/GMMH-Policies/Pages/Clinical.aspx




Enhanced clinical and domestic cleaning may be required, e.g. frequently contacted doors, chairs etc. dependent upon the infective organism and mode of transmission

Bare below the elbow policy may not be appropriate, e.g. scabies where a patient may constantly hold onto a staff members wrist/arm for support. Discuss with IPC team.

4.7 Cohort Nursing

Patient cohorting may be required when single-bed rooms are not available and there is more than one patient with the same infection. Patient cohorting should be combined with other infection prevention and control measures e.g. hand hygiene, PPE and environmental decontamination In order to implement effective cohort nursing the following should be implemented under the direction of the Infection Prevention and control team:

The acceptable maximum number of beds in a multi-bed room is four.

Four-bed rooms should have access to hand wash facilities.

Multi-bed rooms must have en-suite sanitary facilities. Ideally, an assisted shower room (with WC, shower and wash-hand basin) and a separate semi-ambulant WC (with wash-hand basin) both en-suite.

En-suite doors should not open directly onto adjacent bed areas. This is to ensure that airborne microorganisms do not cross contaminate immediate bed spaces.

If there is a dedicated isolation ward available, place all patients infected with the same organism in this ward. Where possible gender sensitivity must be considered at all times.

If there is not a dedicated ward, consider cohorting patients into bays/areas within wards.

Ensure that rooms, bays and areas used for isolated patients have dedicated hand hygiene and toileting facilities.

The minimum bed space in both single and multi-bed rooms should not be less than 3.6m (width) x 3.7m (depth).

Spacing should allow clinical/care procedures to be carried out from either side of the bed, with adequate circulation space to allow medical emergency teams and medical equipment to gain access to the patient.

Minimise the movement of patients for non-clinical reasons.

Cohorted patients should be cared for by designated staff, (including cleaning staff).

For effective isolation, bays should have doors that can be closed to provide physical separation from other patients.




ensure that there is clear signage on the door or wall to alert staff and visitors to infection prevention precautions (Appendix 1).

4.8 Management of the Patient Once Isolated

Cohort nursing (staff cohorting) is defined as the use of a dedicated team of healthcare staff to care for patients infected with a single infectious agent. Evidence suggests that this approach may be beneficial when control methods have been unsuccessful and/or an outbreak is continuing. There is some evidence to suggest that cohort nursing is an effective intervention to further minimise the risk of cross contamination and should be implemented if there are adequate resources to do so. Cohort nursing (staff cohorting) may be implemented to minimise the risk of contamination between groups of symptomatic and non-symptomatic patients if there is adequate staff resource available to do so. Ensure that appropriate equipment is available Inside the room: Risk assess

Hand cleansing facilities

Gloves & Aprons

Clinical waste bag holder/bin. (With bag if safe to leave in the room)

Linen receptacle with water soluble bag (if safe to leave in the room)

Sharps Bin (if safe to leave within room)

Thermometer

Sphygmomanometer,

Stethoscope (if required)

Toileting and wash facilities (if no en suite bathroom). Outside the room: Risk assess

Appropriate protective clothing

N.B. The mental health of the patient may dictate that it is unsafe to leave some or any of this equipment within the room or outside. Always undertake a dynamic risk assessment.




Hand Washing Strict and thorough hand washing is mandatory after any direct contact with the patient or his/her immediate environment, e.g. bed making, moving the patient, cleaning, etc. Don’t forget to cleanse hands after removing gloves.

Soap and running water is adequate for hand hygiene or use alcohol based hand rubs before and after patient contact

Alcohol based hand rubs are an alternative to hand washing on visibly clean skin or a supplement to hand washing to achieve a higher level of disinfection, (See IPC 13 Standard Infection Control precautions and Hand Hygiene Policy), however are ineffective against norovirus and Clostridium Difficile.

Encourage the patient to cleanse their hands before eating and after going to the toilet.

Protective clothing Wear single use gloves for direct patient contact, contact with body fluids, potentially infectious material or when touching items in the environment which may be contaminated. Wear single use plastic apron for close patient contact, (e.g. bed bathing, moving patient), when in close contact with potentially infected material (e.g. bed making), and any other situation when contamination of clothing may occur. Remove apron, then gloves and discard promptly into yellow clinical waste bag. Wash and dry hands thoroughly after having removed protective clothing and before leaving the isolation room. Use the alcohol hand rub/gel outside the room. Except in certain circumstances there is little evidence that the use of masks contributes to preventing cross infection. If in doubt, discuss with the Infection Prevention and Control Team. Protection of eyes, nose and mouth may be necessary if blood/body fluid sprays or splashes are possible. The following options are available: safety spectacles, goggles, masks and visors. Visors usually offer the best all-around visibility. But may not offer the best protection. Fans must not be used to control the patient’s temperature. Notes and charts should be kept outside the room/bay/area, (confidentiality risk).

4.9 Cleaning and Decontamination

Please refer to GMMH Decontamination Policy situated on the Trust’s intranet (https://newintranet/GMMH-Policies/Pages/Infection-Prevention.aspx ).

https://newintranet/GMMH-Policies/Pages/Infection-Prevention.aspx




4.10 Movement and Visits to Other Departments, i.e. X-Ray, ECT

Transfer and movement of patients should be kept to a minimum to reduce the risk of infection spreading and should only be undertaken for clinical reasons.

If a transfer is necessary, the receiving area must be informed so that effective infection prevention measures can be put in place.

Patients should spend the minimum amount of time in the department and must not be left in the waiting room with other patients. Ideally they should have the last appointment if clinically appropriate.

Staff should comply with hand hygiene and personal protective equipment procedures when transferring and infected patient.

The equipment and surfaces with which the patient has had direct contact e.g. trolley, couches etc. should be decontaminated after use using chlor-clean.

4.11 Care of the Deceased Patient

Last Offices Refer to: In the Event of Death Policy (https://newintranet/GMMH-Policies/Pages/Clinical.aspx ) Staff carrying out last offices for a patient with a known or suspected infectious disease should follow the routine procedure taking the same precautions as when the patient was alive. Cadaver (body) bags These should only be used:-

When there is a leakage from a body orifice or draining lesion, which cannot be prevented.

When the patient has been known or suspected of having a notifiable disease See Notification of Infection Diseases procedure on the Trust intranet.

Sharps safety must be maintained.

4.12 When can isolation precautions be stopped?

The decision to discontinue isolation should be based on clinical judgement. The clinical judgement and expertise of the staff involved in the patient’s management and the Infection Prevention and Control Team (IPCT) and/or Public Health England (PHE) should be sought. Make sure the vacated room is thoroughly cleaned in accordance with Cleaning disinfection and decontamination policies and procedures before the area is re used.






4.13 Visitors

Visitors must report to the nurses’ station prior to entering the isolation room/bay. It may be necessary to ask about immunisation status prior to visiting. In some circumstances visiting may be restricted. If visiting is allowed it is usually unnecessary for visitors to wear PPE but they should be advised to wash/clean their hands when leaving the room. Visitors may need to be shown how to do this effectively. Visitors should be advised not to visit other patients but if this is necessary they should do so before visiting the patient in isolation. They should be advised not to eat or drink whilst in the isolation room. Visiting by young children should be discouraged. If visitors insist on bringing young children they must be informed of any risks.

4.14 Vulnerable staff & Visitors

Some individuals may be more vulnerable than others to infection and may need to avoid entering the room In particular:

Pregnant women

Immunocompromised people (for any reason)

Staff with eczematous/psoriatic or similar skin lesions (particularly relevant with MRSA)

Staff and visitors receiving antibiotics (relevant to C.difficile infection) Staff with such risk factors must seek advice from occupational health prior to caring for patients in isolation.

5. Training Requirements

Mandatory and role related Infection control training can be accessed via the Trust’s Learning Hub. In the event of specialist training such as FFP3 fit testing being required this will need to be requested by service managers as appropriate.

6. Monitoring

Minimum Requirement

Frequency Process for monitoring

Evidence Responsible Individual(s)

Response Committee(s)

There should be no outbreaks of hospital acquired infection resulting from failure to follow this policy.

3 Monthly

Review of reported incidents and outbreaks

Meeting minutes and incident reports

Infection Prevention Committee

Infection Prevention Committee




7. Resource/Implementation Issues

None applicable.

8. Risk Issues

Failure to follow this policy could result in spread of infection with potentially harmful consequences.

9. Requirements, Supporting Documents and References

9.1 Requirements

Board Objectives 2019/20 1 To promote recovery by providing high quality care and delivering excellent outcomes

Board Objectives 2020/21 1 Best Care Every day

CQC regulation 12 Safe and care treatment

9.2 Supporting Documents

IPC 13 Standard Infection Control precautions and Hand Hygiene Policy

9.3 References

Jeanes A, Macrae B, Ashby J. Isolation prioritization tool: Revision, adaptation and application. British Journal of Nursing20 (9):09.

The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance 2015 https://assets.publishing.service.gov.uk/government/uploads/system/uploa

ds/attachment_data/file/449049/Code_of_practice_280715_acc.pdf

Infection control precautions to minimise transmission of acute respiratory tract infections in healthcare settings October 2016 https://assets.publishing.service.gov.uk/government/uploads/system/uploa

ds/attachment_data/file/585584/RTI_infection_control_guidance.pdf

Isolating patients with healthcare associated infection: A summary of best practice https://webarchive.nationalarchives.gov.uk/20120118171850/http://hcai.dh

.gov.uk/files/2011/03/Document_Isolation_Best_Practice_FINAL_100917.

pdf

Health Building Note 04-01 Supplement 1 Isolation facilities for infectious patients in acute settings https://hberm.com/wp-content/uploads/2015/10/HBN-04-01-Supplement-1-

Isolation-facilities-for-infectious-patients-in-acute-settings-20131.pdf

Health Building Note 03-01: Adult acute mental health units https://assets.publishing.service.gov.uk/government/uploads/system/uploa

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_acc.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_acc.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/585584/RTI_infection_control_guidance.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/585584/RTI_infection_control_guidance.pdf

https://webarchive.nationalarchives.gov.uk/20120118171850/http:/hcai.dh.gov.uk/files/2011/03/Document_Isolation_Best_Practice_FINAL_100917.pdf



https://hberm.com/wp-content/uploads/2015/10/HBN-04-01-Supplement-1-Isolation-facilities-for-infectious-patients-in-acute-settings-20131.pdf

https://hberm.com/wp-content/uploads/2015/10/HBN-04-01-Supplement-1-Isolation-facilities-for-infectious-patients-in-acute-settings-20131.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147864/HBN_03-01_Final.pdf




ds/attachment_data/file/147864/HBN_03-01_Final.pdf

10. Subject Expert and Feedback

[email protected] https://newintranet/departments/nursing-governance/infection-prevention Microbiology/Virology - appropriate lab. Public Health England – Local area office (https://www.gov.uk/health-protection-team)

11. Review

This document will be reviewed in five years (this is applicable to new or revised documents on approval of this policy revision), or sooner in the light of organisational, legislative or other changes

12. Appendices

See following pages.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147864/HBN_03-01_Final.pdf


https://newintranet/departments/nursing-governance/infection-prevention

https://www.gov.uk/health-protection-team

https://www.gov.uk/health-protection-team




Appendix 1 – Door Sign

Print and laminate

Please speak to

ward staff before

entering this

room




Appendix 2 – Alert organisms The following list is provided as guidance and is not exhaustive. For complicated presentations, please contact the Infection Prevention Team.

Alert Organism Risk Factors Isolation Requirement

Abscesses e.g. quinsy

Assess the patient Isolate until 24-48 hours of appropriate antibiotics. Discuss with the Infection Prevention Team

Blood borne virus e.g. HIV, Hepatitis B,C

Assess the patient Isolation not required unless there is a high risk of blood or blood stained body fluid splash. Additional precautions may be required within the renal dialysis unit

Campylobacter Immunocompromise Isolate whilst acutely symptomatic (80-90% of cases resolve by day 7) but excretion in stools may continue for 2-7 weeks

Carbapenemase-producing Enterobacteriaceae (CPE)

Hospital (particularly ICU) admission in at risk areas

Isolate and full precautions for the duration of hospital admission (and any readmission)

Chicken Pox

Rash developed within the previous 10 days or vesicles not crusted over

Immediate isolation required. Only staff with a history of Chicken pox (or serologically confirmed immunity) should have contact with this patient. Patient can be removed from isolation once vesicles fully crusted

Clostridium difficile Toxin positive Isolate for duration of diarrhea.

Carriage (GDH or PCR positive, Toxin negative)

No need to isolate

CJD Isolation not required. See CJD policy for advice re surgical procedures. Inform microbiologist on call immediately if diagnosis is suspected to ensure safe handling of specimens

Cryptosporidium

immunocompromise Isolate whilst symptomatic (2 days to 4 weeks), immunocompromised patients will take longer to clear infection

Diarrhoea (infectious)

Exclude overflow, laxatives, ng feeds, crohns/colitis etc

Immediate isolation, preferably within 2 hours of onset of symptoms until full resolution of diarrhoea and formed stool

Extended Spectrum Beta-Lactamase (ESBL) producing organisms in urine

Incontinent patient

Isolation required. Encourage good hand and personal hygiene. Dedicated commode (or lavatory) cleaned between each use

Catheterised or fully continent patient

Isolation or single room required. Encourage good hand and personal hygiene. Dedicated commode (or lavatory) cleaned between each use

ESBL producing organisms in other sites

Assess individual risks e.g. weeping wounds etc.

Isolation required. Encourage good hand hygiene and personal hygiene. If possible use a dedicated toilet. Discuss with Infection Prevention Team if required

GRE Glycopeptide resistant enterococci (including VRE)

Isolate for duration of hospital admission, regardless of symptoms. Isolate if readmitted. Patient will have long- term skin and intestinal carriage. Dedicated bathroom facilities. Encourage good hand hygiene and personal hygiene

Influenza (including Avian flu and H1N1)

Isolate until patient has completed course of antivirals and is symptom free. FFP3 face masks to be worn for aerosol generating procedures. FFP1 face masks to be worn during non aerosol generating close contact. For avian influenza inform microbiologist on call immediately if diagnosis is suspected

Legionella (legionnaires disease)

Not transmitted between individuals, no isolation required

Malaria Confirmed Not transmitted between individuals, no isolation required

Suspected Febrile illness with a history of travel to tropical/subtropical area should be managed as high risk until malaria diagnosis confirmed




Alert Organism Risk Factors Isolation Requirement

Measles Isolate until 5 days after onset of rash

Suspected meningitis-meningococcal

Isolate until 24 hours of antibiotics. FFP1 face mask to be worn during any procedure likely to generate respiratory droplets. Inform occupational health if in direct contact with respiratory secretions e.g. during resuscitation

Methicillin Resistant Staphylococcus aureus (MRSA)

Sputum Positive with productive cough, flaking skin condition, wet wounds with break through

Single room . Discuss with the Infection Prevention Team

Skin colonisation only If no single room available, may be treated in a main bay if located next to a hand washing sink with full transmission precautions

Mumps Isolate until 9 days after onset of rash

Norovirus Isolate immediately on first episode of projectile vomiting or diarrhoea, until 48 hours after complete cessation of symptoms

Isolate infants until clinical recovery occurs. Cohort nursing may be considered in certain circumstances if all patients RSV status known

Salmonella (inc. typhi (typhoid fever))

Isolate immediately (excretion may continue for 2 days to 2 months, median 5 days)

Shigella Isolate whilst acutely symptomatic (excretion may continue for 2-4 weeks post acute illness)

Shingles

Rash in an exposed area with wet lesions

Isolate until lesions are fully dried. Only staff with a history of Chicken pox (or serologically confirmed immunity) should have contact with this patient

Rash in a covered area with wet/drying lesions

May be treated in a main bay provided no immunocompromised patients are in the room

Tuberculosis

Confirmed pulmonary TB with a productive cough

Isolate until 14 days continuous, compliant treatment. Use FFP 2 or 3 facemask for contact

Suspected pulmonary TB

Isolate until 3 negative sputum specimens on microscopy

AFB negative pulmonary TB/ TB closed site

No requirement to isolate

Suspected/ Confirmed drug resistant TB

Discuss with TB nurse specialist and Infection Prevention Team. Will require isolation in a negative pressure side room and transfer to alternative site

Norwegian Scabies

Often affects immuno-compromised patients

Highly transmissible, isolate until full course of treatment has been completed (minimum 2 treatments)

Classical scabies Awaiting diagnosis Discuss with Infection Prevention Team

Group A Streptococcus

Isolate until 48 hours of appropriate antibiotics

SARS

Immediate isolation required. Inform Infection Prevention or Microbiologist on call immediately if diagnosis is suspected

Vancomycin resistant enterococci (VRE)

See GRE

Viral Hemorrhagic Fever

Discuss with Infection Prevention Team or Microbiologist on call immediately if diagnosis is suspected. Will require isolation in a negative pressure side room and transfer to alternative site




Appendix 3 – Isolation leaflet

Isolation This factsheet provides information about being cared for in isolation during a stay in hospital. We hope it will answer some of the questions you are likely to have. If you would like more information or have any concerns, your healthcare team will be pleased to advise you further. What is isolation? Isolation in a hospital setting is a precaution taken to prevent the spread of infection. Infections can spread easily in hospitals, putting patients, visitors and staff at risk. Special care must be taken to prevent infections with a particular risk of spreading from being passed on to others (for example, infectious diarrhoea, MRSA, tuberculosis (TB) and chickenpox). Therefore, if you are infected you may need to be cared for separately from other patients. Sometimes this will be in a separate room, or it may be possible to care for you on the ward with additional precautions. During this time good hand hygiene is very important. Isolation will be continued until there is no longer a risk of the infection being spread to others. Why do I need to be isolated? • You may have, or are suspected to have, an infection that could be passed on to other patients or staff. • You may need protecting from picking up an infection because you have a weakened immune system or are taking certain drugs. This is called ‘protective isolation’. What you can expect from us during your isolation • You will be given clear information about why you are being cared for in isolation. • We will place an ‘Isolation care’ sign on your door. • Hospital staff will clean their hands on entering and leaving the room. • Protective clothing: - Staff will wear protective clothing, for example gloves and an apron, in order to reduce the risk of passing the infection/germ to other patients that they are caring for. The type of clothing worn will depend upon the type of care being carried out and how the infection is spread. If the infection is likely to be spread by breathing in the germs that are causing it, staff will wear masks. - It is very unlikely that your visitors will need to wear protective clothing. If this is required, nursing staff will tell you. • We will try to provide you with a single room with en-suite toilet facilities. However, this isn’t always possible, so a dedicated commode may be provided in your room or a dedicated toilet allocated to you on the main ward. • Being in isolation will not affect your care. Ward staff will advise other departments of any precautions required should you need to visit them (to go for an x-ray, for example). The infection prevention team is available if further advice is needed.




• We will adapt our care to your personal circumstances and you may have special assessments from other teams, such as physiotherapy or occupational therapy, if required. • We have a number of information leaflets on specific infections such as MRSA, diarrhoea and vomiting and Clostridium difficile (C. diff). If you would like to read these, please ask a member of staff.

www.uhs.nhs.uk What we ask from you during isolation • You should remain in your room unless instructed otherwise. • The door to your room should be kept closed to help control the spread of infection. If you have any concerns about this, please talk to your nursing staff. • Don’t visit other patients on the ward or in the next single room. • You must not share personal items, food or equipment with other patients. • Ensure that you clean your hands before eating and after using the toilet. If you are unable to reach the sink, please ask a member of nursing staff to provide hand cleaning materials/wipes. • If you have a wound, do not take the dressing off to show the wound to visitors. • Keep your personal items to a minimum, so that the table and locker tops are uncluttered and easy to keep clean. • Please ask your visitors not to bring in any food cooked at home or from outside food suppliers (such as takeaway restaurants). Pre-packaged snacks such as biscuits and crisps are acceptable. Important information for visitors We ask that your visitors follow the steps below to help prevent the spread of infection: • A maximum of two visitors are allowed at one time. •If you are pregnant please inform the staff who will advise accordingly.

• Do not visit the hospital at all if you have recently been unwell or have had diarrhoea and vomiting within the previous 48 hours. • Clean your hands on entering and leaving the isolation room. • Do not bring young children to visit as they are particularly vulnerable to infection. • Use the chairs provided. Please do not sit on the bed. • Avoid bringing food and drinks to consume at the bedside. • Do not visit other patients within the hospital when you are visiting a person in isolation. You do not usually have to wear gloves or aprons unless providing personal care to your relative. The nursing staff will be able to advise you further.




Tips for coping with a period of isolation Occasionally patients in isolation experience feelings of anxiety and/or loneliness. The steps below can help to minimise these feelings: • If you have questions, talk to your healthcare team about why you are in isolation and why precautions are necessary. Remember that isolation is intended to keep you safe and healthy. Asking questions before and during isolation can reduce some of the anxiety you may experience during this time. • Having some of your personal objects with you can help reduce feelings of separation and boredom. You may find it helps to have your favourite books and music available. It can also be helpful to arrange telephone calls, video chats or visits from loved ones. • Keep several activities on hand to occupy you. You may tire of doing the same thing every day, so make sure you have a variety of games, films, books, magazines and arts and crafts to help pass the time. • Try to maintain a daily routine as much as possible. Open your blinds during the day and close them at night if possible. Be aware that sleeping during the day to cope with boredom can lead to trouble sleeping at night. • If you become aware of major changes in your mood or behaviour, for example you notice yourself feeling increasingly sad or irritable, discuss these concerns with your healthcare team. Not everyone has negative feelings about isolation precautions. Some patients enjoy the extra privacy a single room offers, while others appreciate not being disturbed by other patients. How long will isolation last for? This will depend on the reason for your isolation. It may be anything from a few days to the whole length of your stay. When isolation is no longer necessary you will be moved to the open ward or discharged. The room or bed space will be cleaned before it is used by another patient. Discharge from hospital or transfer to another hospital Usually there will be no delay if you are returning to your own home. Having been in isolation should not usually stop you going into a nursing or residential home. Although you may have a single room, you should be able to mix freely with most other residents. If you need to be transferred to another hospital, You may experience a slight delay as the hospital may want to place you in a single room and this could take time to organise. What happens when I get home? You may be discharged from isolation to your home. This is because the infection does not have the same risk in a non-hospital setting and it’s not necessary to take the same precautions at home. However, if a relative or carer is helping you with washing or dressing a wound, it’s important that they wash their hands before and afterwards. Bed linen and clothes can usually be washed as normal in a domestic washing machine. If you need to continue taking special care at home, you will be told by the hospital staff before you leave. Further information Infection prevention team [email protected]





Appendix 4 – Clarification statements on Isolation of prisoners Clarification statements on Isolation of prisoners

See https://newintranet/departments/nursing-governance/infection-prevention/Pages/guidance.aspx

https://newintranet/departments/nursing-governance/infection-prevention/Pages/guidance.aspx

https://newintranet/departments/nursing-governance/infection-prevention/Pages/guidance.aspx

Patient Placement, Isolation and Cohorting: Standard ...

Documents

Transcript of Patient Placement, Isolation and Cohorting: Standard ...