ISOLATION POLICY FOR HOLME VALLEY MEMORIAL HOSPITAL INPATIENT AREA
Responsible Directorate:
Public Health
Responsible Director:
Dr Judith Hooper
Date Approved:
25 March 2009
Committee:
Governance Committee
NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
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Version Control Current versions of all policies can be found on NHS Kirklees internet and intranet. If printing a document, please check internet/intranet for most up-to-date version. Document Title: Document number: Author: Contributors: Version: Date of Production: Review date: Postholder responsible for revision: Primary Circulation List: Web address: Restrictions:
Isolation Policy 1 Louise Hodgson 1 February 2009 March 2011 Deputy Director Infection Prevention and Control
Standard for Better Health Map Domain: Core Standard Reference: Performance Indicators:
First domain safety C4, C4a, C4d, C4e 1. To reduce incidence of healthcare associated infections. 2. To reduce incidence from cross infections.
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Contents
Section
Page
1.
Introduction
4
2.
Associated policies and procedures
4
3.
Aims and objectives
4
4.
Scope of the policy
5
5.
Accountability and responsibilities
5
6.
Why is isolation necessary?
5
7.
When should isolation precautions be implemented?
6
8.
Who should be isolated?
6
9.
Where should patients be isolated?
6
10.
Staff responsibility
7
11.
Movement of patients
8
12.
Equality impact assessment
8
13.
Training needs analysis
8
14.
Monitoring compliance with this policy
9
15. References Appendices
10
1
Standard Isolation
11
2
Methods used in Standard Isolation
13
3
Respiratory Isolation
15
4
Methods used in Respiratory Isolation
16
5
Equality Impact Assessment Tool Key Stakeholders consulted/involved in the development of the policy/procedure
18
6
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19
Policy Statement Infection prevention and control is of prime importance within NHS Kirklees and is essential to the safety and confidence of patients, families and carers.
1.
Introduction
‘The correct and timely placement of infected patients (suspected or proven) into single rooms can be very effective in reducing the overall numbers of infected patients; it can also reduce the risk of colonisation in other patients within the ward. Isolation practices can also be carried out within ward areas; this is called ‘cohorting’. Through such measures, it is possible to control the spread and minimise the impact of infections such as MRSA, Clostridium difficile infection and other health care associated infections (HCAIs).’ (Saving Lives, DH 2007). It is the responsibility of NHS bodies to ensure that: ‘Patients presenting with an infection or who acquire an infection during treatment are identified promptly and managed according to good clinical practice, for the purposes of treatment and to reduce the risk of transmission’ (Health Act 2006). They also have a duty to provide ‘adequate isolation facilities for patients sufficient to prevent or minimise the spread of HCAIs.’ 2.
Associated policies & procedures
This policy should be read in accordance with the following Trust policies, procedures and guidance: • • • • • • • • • 3.
Hand Decontamination Policy Waste management guidelines Incident reporting Health and safety policies Decontamination, disinfectants and antiseptics policy Standard precautions policy Multi-resistant organisms policy Clostridium Difficile policy Dress Code Policy for Clinical Staff Aims and objectives
The aim of this policy is to set out guidance regarding the isolation and care of patients with known or suspected colonisation or infection, by multi-resistant or pathogenic microorganisms and to provide information regarding the following: • • • • • • •
Why isolation is necessary When should isolation precautions be implemented Who should be isolated How to prioritise the need for isolation Where should patients be isolated Staff responsibility Movement of patients Page 4 of 19
4.
Scope of the policy
This policy must be followed by all staff who work for NHS Kirklees, including those on temporary or honorary contracts, bank staff and students. This policy is concerned with the isolation practices of inpatients at the Holme Valley Memorial Hospital and reflects the guidance outlined in the Calderdale and Huddersfield Foundation Trust and must be followed by all staff caring for inpatients at HVMH including independent contractors. Breaches of this policy may lead to disciplinary action being taken against the individual. 5.
Accountabilities and responsibilities
The Chief Executive (CE) is accountable for ensuring that effective arrangements for infection prevention and control are in place within NHS Kirklees. The Director of Infection Prevention and Control has responsibility to provide assurance to the Board that infection prevention and control policies are in place and their compliance audited. The Infection Prevention and Control Team will ensure the policy is reviewed as required and work with Heads of Service to implement necessary changes in practice. Heads of Service (associated with the Holme Valley Memorial Hospital) are responsible for ensuring that the Isolation Policy is brought to the attention of staff and considered by them. 6.
Why isolation is necessary
Isolation is the placement of a patient within a single room and the implementation of strict standard precautions, plus additional precautions for specific conditions, can be effective in reducing the spread of infection, or a multi-resistant organism within a hospital environment and to patients, staff and visitors. The allocation of single rooms must be based on a clinical risk assessment with infection prevention and control requirements given priority over bed management / capacity issues (Healthcare Commission 2006). Isolation can be classified as Standard and Respiratory. The methods to perform isolation effectively are listed in Appendices 2 and 4. Standard isolation is necessary for patients who are known, or suspected of being colonised or infected with, pathogenic micro-organisms (Appendix 1) except those that require respiratory isolation. Respiratory isolation is necessary for specific respiratory infections (Appendix 3). There are a variety of routes by which organisms spread to find a new host and some organisms may spread by more than one route. The most common route of transmission is contact. Other routes of transmission include droplet and airborne. •
Direct contact is the physical transfer from body surface to body surface between an infected or colonised person and a susceptible host. This can be between patients or from staff to patient when performing patient care activities. Page 5 of 19
7.
•
Indirect contact involves the susceptible host having contact with an intermediate object, such as contaminated instruments or the environment.
•
Droplets are generated from the source patient through coughing, sneezing, talking or singing, as well as certain procedures such as bronchoscopy. Transmission occurs when droplets containing micro-organisms generated from the infected person are propelled a short distance through the air and deposited on the host’s conjunctivae, nasal mucosa or mouth.
•
Airborne transmission occurs by dissemination of either aerosol (small particle residue of evaporated droplets containing micro-organisms that remain suspended in the air for long periods of time) or dust particles containing the infectious agent.
When should isolation precautions be implemented?
The nurse in charge of the ward must undertake a risk assessment on the patient’s admission to ascertain if the patient is colonised or infected with a multi resistant organism. If the patient is transferred from another hospital the MRSA screen results should be obtained. Ward staff may be informed by the Infection Prevention and Control Team (IPCT), or by a member of staff from a secondary care provider, or a laboratory form of the presence of a multi-resistant organism. The IPCT will liaise with ward staff in order to prioritise the need for isolation and the necessary precautions that should be taken. If single room accommodation is not immediately available the IPCT should be informed and a clinical incident form completed. The IPCT will liaise with ward staff to ensure the appropriate placement of patients depending upon demand, capacity and epidemiology. 8.
9.
Who should be isolated? •
Patients with known or suspected infection or colonisation with a multi- resistant organism, including those with a past history of a multi-resistant organism.
•
Patients who are admitted with symptoms of diarrhoea and / or vomiting, or who develop these whilst an in-patient.
•
All patient transfers from overseas hospitals must be isolated on admission and screened for MRSA.
•
There are a number of communicable diseases where patients are required to be isolated during their period of infectivity (Appendices 1 and 2).
Where should patients be isolated?
The most effective form of isolation is a single room, if available, and should always be the first choice for placement of a patient with a known or suspected infection (DH 2007). Appropriate isolation door signage must be displayed and will be obtained from the Infection Prevention and Control Team (IPCT). The door should remain closed. Page 6 of 19
Due to the type of ward at HVMH (low risk – limited patients with invasive devices etc.) In most instances patients who are requiring isolation due to them being MRSA positive may have meals out of their rooms or for rehabilitation. However this must be discussed with the IPCT on a regular basis. If single room capacity is exceeded, cohort nursing may be implemented for patients with the same organism or who display similar signs and symptoms of infection (e.g. diarrhoea and / or vomiting). This should be discussed with the IPCT. If the area where patients are being cohorted is in a bay within the ward, the doors must be kept closed in order to provide physical separation from other patients and reduce the risk of cross-infection. Appropriate signage must be displayed. 10.
Staff responsibility: •
Provide affected patients and visitors with an explanation of their infection, the need for isolation precautions and treatment. The Infection Prevention and Control Nurses can be contacted if patients, relatives or visitors require further information.
•
Ensure that rooms, bays and areas used for isolated patients have dedicated hand hygiene and toileting facilities.
•
Ensure that there is clear signage to alert staff and visitors to infection control precautions (to be obtained from the IPCT).
•
Ensure that the doors are kept closed at all times.
•
Staff must adhere to the Dress Code Policy for Clinical Staff.
•
Appropriate personal protective equipment must be worn.
•
Where patients are identified as an infection risk and require isolation, but cannot be accommodated in a single room, this must be reported as a clinical incident using the risk management system.
•
The number of staff entering the side room must be kept to a minimum, particularly during ward rounds when only staff essential to the review and / or care of the patient should enter the side-room.
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11.
Movement of patients •
The transfer and movement of patients should be kept to a minimum to reduce the risk of infection spreading and must only be undertaken for clinical reasons.
•
If an investigation is necessary at another hospital / health care setting, the receiving area must be informed so that appropriate infection control measures can be taken.
•
Arrangements need to be made to minimise contact with other patients, therefore the investigations should be performed ‘last on the list’. When this cannot be achieved, there should be no delays encountered by waiting in the department.
•
Hands must always be washed before and after direct contact with the patients. Refer to Hand Decontamination Policy.
•
Staff in direct contact with the patient, their immediate environment or blood / body fluids must wear single-use plastic aprons and gloves. Protective clothing must be removed and discarded after use. Refer to Standard Universal Precautions Policy.
•
Equipment used to transfer the patient and in the department must be decontaminated after use with detergent and water and / or detergent wipes (use hypochlorite for blood and body fluid contamination).
•
Staff should ensure that the following assessment has been made on the patient prior to transfer: o Urinary catheter bags should be no more than 2/3rd full should be emptied before transfer if required. o Wounds are covered with an impermeable dressing and the wound checked for visible exudate. o If patients are expectorating sputum staff should ensure that clean tissues are transported with the patient.
12.
Equality impact assessment
This Policy was found to be compliant with this philosophy (Appendix 5). 13.
Training needs analysis
In order to ensure that policies, guidelines and protocols are introduced and work effectively, there is a need to provide adequate training and instruction. As a result, the author of this document has carried out a training needs analysis which has identified the staff who require training, the methodology of training delivery and the frequency that the training will be provided. The policy author must ensure that the details of this training are passed to the Training and Education Team and where necessary, this will then be included in the Trust Training Prospectus. Page 8 of 19
14.
Monitoring compliance with this policy
The Trust will have key indicators for the monitoring of Infection Prevention and Control: •
Essential Steps audits to ensure key infection prevention and control policies are being implemented
•
Percentage of clinical and non-clinical staff at HVMH undertaking mandatory annual Infection Control training.
•
Quality indicators will be part of normal performance monitoring against a set of local, regional and national standards.
•
Healthcare associated infection identified after completion of root cause analysis investigations.
•
Annual isolation audits undertaken by the IPCT.
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15.
References
1.
Department of Health (2007). Saving Lives: Reducing infection and delivering clean and safe care
2.
Department of Health, Health Act 2006, Code of Practice for the Prevention and Control of Healthcare Associated Infections (revised January 2008).
3.
Fenelon Lynda (1998). Strategies for Prevention of Infection in Short-Duration Neutropenia. Infection Control & Hospital Epidemiology, August 1998.
4.
Rust S, Simpson JK and Lister J (2000). Nutritional Issues in Patients with Severe Neutropenia. Seminars in oncology nursing, Vol 16, No. 2 (May) 2000, P152-162.
5.
Hartkopf Smith L and Galford Besser S (2000). Dietary Restrictions for Patients with Neutropenia – A survey of institutional practices. Oncology Nursing Forum, Vol 27, NO. 3, 2000, P515-519.
6.
Parker L (2000). Is Protective Isolation Necessary? Nursing Times Plus, Nov 16 2000, Vol 96, NO. 46, P10-12.
8.
Department of Health 2008 – A Guide to Best Practice: Isolation of Patients London, Department of Health
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Standard Isolation
Appendix 1
Suspected or proven cases of the following infections should be placed in standard isolation (this is not a definitive list). Infection
Indications for ending isolation
Anthrax
Isolation is not strictly necessary, but patients with any form of anthrax should be isolated until after discussion with the Infection Prevention and Control Team.
Burns, wounds and bedsores with extensive sepsis
Dependent upon the infecting organism(s) – discuss with the IPCT.
Campylobacter
Asymptomatic for a minimum of 48 hours.
Chickenpox
Until all lesions have scabbed and no new lesions are appearing (minimum of 7 days from the onset of the rash).
Cholera
Asymptomatic for a minimum of 48 hours
Clostridium difficile associated diarrhoea or pseudomembranous colitis Diarrhoea of unknown cause
Asymptomatic for 48 hours. Until infective cause is excluded or patient has been asymptomatic for 48 hours.
Dysentery (bacillary or amoebic)
Asymptomatic for 48 hours.
E coli gastrointestinal infection
Asymptomatic for 48 hours.
Encephalitis
Discuss with the Infection Prevention and Control Team.
Gastroenteritis (viral)
Asymptomatic for 48 hours.
Gonorrhoea (including conjunctivitis, pharyngitis, and opthalmia neonatorum) streptococcal infection Group A Haemolytic(sore throat, scarlet fever puerperal sepsis, erysipelas, impetigo, etc.) Hepatitis A
24 hours of effective antibiotic therapy.
Hepatitis B, C
48 hours effective treatment. Until one week after the onset of jaundice. Isolation is not required to prevent infection of other patients unless the patient is bleeding or felt to be at high risk of bleeding (e.g. oesophageal varices, thrombocytopenia, etc.)
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Infection
Indications for ending isolation
Hepatitis, acute (unknown cause)
Isolate until the diagnosis is made.
Herpes zoster (shingles)
Until lesions are dry.
MRSA (colonisation infection)
Discussion with Infection Prevention and Control Team
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Methods used in Standard Isolation
Appendix 2
Signs
The appropriate sign should be placed prominently on the door of the patient’s single room, or above the patient’s bed if s/he is being nursed on the main ward. Signs denote Standard Isolation, Protective Isolation or Respiratory Isolation (see appendices). Signs can be requested by Infection Control.
Door
The door of the side-room should be kept closed at all times.
Hand hygiene
Hands must be decontaminated before entering and leaving the room regardless of glove use. Hands may be decontaminated by washing with soap and water or applying alcohol gel if hands are already visible clean. Hands must be washed with soap and water in cases of Clostridium difficile.
Aprons
Disposable plastic aprons must be worn by all staff having direct contact with patients, used bed linen, and when handling secretions and excreta. All staff should be bare below the elbow. Plastic aprons should be disposed of inside the room, with the exception of removing items to the sluice.
Gloves
Disposable gloves must be worn when providing direct patient care; where there is contact with body fluids; when dressing wounds or when handling any contaminated items. NB: the use of gloves does not replace the need to decontaminate hands. Hands should be decontaminated before and after wearing disposable gloves. Gloves should be disposed of as healthcare waste within the room, with the exception of removing items to the sluice.
Masks and/or eye protection
These are not usually necessary, but should be worn during procedures with a high risk of generating droplets of blood or body fluids which might contaminate eyes or mucous membranes, e.g. during suctioning procedures or the patient receiving chest physiotherapy.
Equipment
It is recommended that equipment should be single-use or designated for an individual patient. Where equipment is not single use or designated to a specific patient, it should be decontaminated with detergent and water, or detergent wipes, following use. If contaminated with blood or body fluids. Fans should not be used to control the patient’s temperature.
Linen
All linen should be treated as infected linen, sealed in a red water-soluble bag within the room and then placed in a red nylon outer bag and removed to the sluice before being sent to Laundry.
Secretions, excretions
These are treated as infected waste and disposed of in accordance with the waste disposal policy.
Crockery and cutlery
The use of disposable items is not usually necessary.
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Notes and charts Waste Terminal cleaning
These should be kept outside the room / bay / area. All waste should be treated as hazardous / infectious waste. On the patient’s discharge, a thorough clean is required of all surfaces of the room / bed area, mattress, bed frame, call bells, duvets and pillows, with detergent and water and hypochlorite (Chlorclean). Care must be taken when cleaning electrical equipment. Curtains should be changed; this includes those curtains in the side room and any bed space curtains if the patient was cohorted in a bay.
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Respiratory Isolation
Appendix 3
Suspected or proven cases of the following infections should be placed in respiratory isolation (this is not a definitive list). Infection
Indications for ending isolation
Bronchiolitis in infants
Clinical recovery. Note that cohort nursing with Respiratory Syncytial Virus (RSV) infection is acceptable if single-room isolation is not possible.
Croup
Isolation may be appropriate in some circumstances. Discuss with the Infection Prevention and Control Team.
Invasive Haemophilus Influenzae infection (meningitis, epiglottitis, etc.) Influenza, human metapneumovirus
24 hours appropriate antibiotic therapy. Clinical recovery.
Measles
5 days after the onset of the rash.
Mumps
9 days after the appearance of parotid swelling.
Pulmonary tuberculosis (smear positive)
2 weeks after the start of effective chemotherapy or three consecutive smearnegative sputum results.
Rubella
5 days after the onset of the rash.
Whooping cough
5 days of effective chemotherapy.
If it is not necessary to isolate patients with smear-negative pulmonary tuberculosis (TB) or those with extra-pulmonary tunberculosis. Further information regarding patients with known or suspected multi-drug resistant TB should be sought from the consultant physician or specialist TB nurse. Isolation of patients with pulmonary TB can normally be discontinued after two weeks of effective chemotherapy. However, in some patients it is recommended that three consecutive smear-negative sputum results (taken on separate days) be obtained before ending isolation is considered. Such patients include: • • •
Highly infectious patients Patients in whom drug-resistant TB is known or suspected Patients who are to be transferred to a ward containing immuno compromised patients. Page 15 of 19
Methods used in Respiratory Isolation
Appendix 4
Sign
The appropriate sign should be placed prominently on the door of the patient’s single room, or above the patient’s bed if she / he is being nursed on the main ward. Signs denote Standard Isolation or Respiratory Isolation (see appendices).
Door
The door of the side-room must be kept closed at all times.
Hand hygiene
Hands must be decontaminated before entering and leaving the room regardless of glove use. Hands may be decontaminated by washing with soap and water or applying alcohol gel if hands are visibly clean. Hands must be washed with soap and water in cases of Clostridium diffcile.
Aprons
Disposable gloves must be worn by all staff having direct contact with patients, used bed linen, and when handling secretions and excreta. All staff should be naked below the elbow. Plastic aprons should be disposed of inside the room, with the exception of removing items to the sluice.
Gloves
Disposable gloves must be worn providing direct patient care; where there is contact with body fluids; when dressing wounds or when handling any contaminated items. NB: the use of gloves does not replace the need to decontaminate hands. Hands should be decontaminated before and after wearing disposable gloves. Gloves should be disposed of as healthcare waste within the room, with the exception of removing items to the sluice.
Masks and/or eye protection (excluding pulmonary TB)
These are not usually necessary, but should be worn during procedures with a high risk of generating droplets of blood or body fluids which might contaminate the eyes or mucous membranes, e.g. during suctioning procedures or the patient receiving chest physiotherapy.
Masks (this section applies only to pulmonary tuberculosis)
For the patient: not normally required; patients should be instructed to cough into tissues and dispose of these as Infectious Waste. They should be encouraged to cover their mouth and nose when coughing and sneezing. All smear-positive patients should wear a mask if being transported through public or patient areas of the hospital. A HEPA mask should be worn until the patient is known not to have multi – drug resistant TB. For staff: masks are only required when there is unavoidable exposure to respiratory secretions, e.g. cough-inducing procedures. A mask (HEPA) is also appropriate when nursing a patient who is unable to cover their mouth and nose when coughing or sneezing.
Equipment
Non-disposable equipment should be cleaned with detergent and water or wiped with a detergent wipe following use.
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Linen
All linen should be treated as infected linen, sealed in a red water soluble bag within the room and then placed in a red nylon outer bag and removed to the sluice before being sent to laundry.
Secretions, excretions
These are treated as infected linen, sealed in a red water soluble bag within the room and then placed in a red nylon outer bag and removed to the sluice before being sent to laundry.
Waste disposal
Waste that is visibly contaminated with blood and body fluids should be treated as infectious waste.
Notes/Charts
These should be kept outside the room / bay / area.
Terminal clean
On the patients discharge, a thorough clean is required of all surfaces of the room / bed area, mattress, bed frame, call bells, duvets and pillows, with detergent and water and hypochlorite (chlor clean). Care must be taken when cleaning electrical equipment.
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Appendix 5 Equality Impact Assessment Tool
Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favorably than another on the basis of: • Race
No
• Ethnic origins (including gypsies and travellers)
No
• Nationality
No
• Gender
No
• Culture
No
• Religion or belief
No
• Sexual orientation including lesbian, gay and bisexual people
No
• Age
No
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
2.
Is there any evidence that some groups are affected differently?
No
3.
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
No
4.
Is the impact of the policy/guidance likely to be negative?
No
5.
If so can the impact be avoided?
n/a
6.
What alternatives are there to achieving the policy/guidance without the impact?
n/a
7.
Can we reduce the impact by taking different action?
n/a
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Comments
Key stakeholders consulted/involved in the development of the policy/procedure Key Participant Yes/No
Feedback requested Yes/No
Feedback accepted Yes/No
Caroline Summer and Kath Barraclough
No
Yes
Yes
Infection Prevention and Control Team
Yes
Yes
Yes
Kirklees Infection Prevention and Control Committee
No
Yes
Yes
NHS Kirklees Policy Development Group
No
Yes
Yes
Stakeholders name and designation
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