Isolation Policy (Protective and Source Isolation ...

Isolation Policy (Protective and Source Isolation – Infection Control)

Reference Number: TC4(05) Version Number: 1.8 Issue Date: 11/12/2018 Page 1 of 34

It is your responsibility to check on the intranet that this printed copy is the latest version

Isolation Policy (Protective and Source Isolation – Infection

Control)

Lead Author: Sandra Brady

Additional author(s) Linda Swanson

Division/ Department:: Corporate

Applies to: Salford Royal Care Organisation

Date approved: 05/12/2018

Expiry date: December 2021

Contents

Contents

Section Page 1 What is the policy about? 2

2 Where will this document be used? 2

3 Why is this document important? 2

4 What is new in this version? 3

5 What is the Policy 3

5.1 Precautions for specific infections/conditions 4

5.2 Isolation 9

5.3 Protective Isolation 9

5.4 Source Isolation 11

6 Roles and responsibilities 17

7 Monitoring document effectiveness 18

8 Abbreviations and definitions 19

9 References and Supporting Documents 19

10 Document Control Information 20

11 Equality Impact Assessment (EqIA) screening tool 21

12 Appendices 23

Appendix 1 Clinical Waste 23

Appendix 2 Disposal of Foul/Infected Linen 24

Appendix 3 Cleaning of Isolation Rooms 25

Appendix 4 Terminal Cleaning of Isolation Rooms / Cohort Areas 26

Appendix 5 Medical Equipment 27

Appendix 6 Care of the Deceased Patient 28 - 30

Appendix 7 Laboratory Specimens 31

Appendix 8 Management of Patients in Source Isolation Requiring Surgery 32

Appendix 9 Transfer of Patients to Departments within the Same Hospital 33

Appendix 10 Transport via Ambulance of an Infected Patient 34

Appendix 11 Visits to Out-Patients and Specialist Departments 35

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




1. What is this policy about?

This policy outlines the measures which should be taken to prevent the spread of infection from patients who are known to be a potential source of infection and to protect those patients who are at higher risk of infection e.g. neutropenic patients. Please note there are additional policies for specific problems e.g. Varicella Zoster infection, Mycobacterium tuberculosis, Scabies, Severe Acute Respiratory Infection (SARI – includes Avian influenza, MERS-CoV and SARS) and Transmissible Spongiform Encephalopathies including CJD, which should be used in conjunction with this policy.

This policy follows guidance from The Health and Social Care Act 2008: Code of

practice on the prevention and control of infections and related guidance (2010).

This policy provides the general principles of isolation for all patients (adult and child)

in the trust.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator. (do not remove this statement)

2. Where will this document be used?

All Trust staff who have patient contact, including:

o NHS Professionals

o Students

o Locum/Agency staff

3. Why is this document important?

There are two kinds of isolation for the control and prevention of infection:

Protective (or ‘reverse’) Isolation (also known as “Reverse Barrier Nursing”) This is to prevent the transfer of infective micro-organisms to patients at special risk of infection (those with diminished resistance to infections because of their illness or treatment).

Source (or ‘containment’) Isolation (also known as “Barrier Nursing”) This is the isolation of infected or colonised patients to prevent the transfer of their infection to others.

The following categories for source isolation will be used in this document:

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




Airborne precautions

Where the main route of transmission is airborne, e.g. droplet, aerosol, skin scales.

Contact precautions

Contact precautions should be utilised when direct or indirect contact with

contaminated body fluids, equipment or the environment is anticipated.

Enteric precautions

Enteric where the main route of transmission is faecal-oral.

Standard precautions

Standard precautions are the basic level of infection control that should be used in the

care of all patients in all settings to reduce the risk of transmission of organisms that

are both recognized and unrecognized. This includes possible transmission via blood

or other body fluids and replaces what was previously known as ‘blood precautions’.

NB: Some organisms may be spread by more than one route therefore more than one type of precaution will be necessary.

4. What is new in this version?

This is an update of a previous version with changes to:

Appendix 4 – Terminal cleaning of Isolation Rooms / Cohort Areas

Appendix 6 - Care of the Deceased Patient, this now includes a table of infections and the requirement of body bags.

5. Policy

For immunocompromised patients follow the Protective Isolation section. For patients with a known or suspected infectious disease/organism, please follow the Precautions for Specific Infections/Infections section.

Identify the route of transmission of the likely infecting organism

Take appropriate precautions

Ensure that the Infection Control Team has been informed. Ensure that all who come into contact with the patient or their environment are aware of the precautions to be taken. Infection Control Team via Microbiology Department – Ext 65026 / 65027 Infection Control Nurses – Ext 61971 24hr On-call – page via Switchboard




5.1 Precautions for Specific Infections/Conditions

Disease

Transmission

Isolation Priority

Isolation

Type

Comments

AIDS (See HIV)

Avian Influenza Airborne Red Respiratory precautions

See Severe Acute Respiratory Infection (SARI) Avian influenza, MERS CoV, and SARS policy

Campylobacter Faecal/Oral Red Enteric precautions Inform CCDC

Chicken Pox (Varicella) Airborne/Contact Red Respiratory & Contact

precautions

Notifiable See Varicella Policy

Cholera

Faecal/Oral Red Enteric precautions Notifiable Isolate until 48hrs asymptomatic

Clostridium difficile Faecal/Oral Red Enteric precautions Isolate until 48hrs asymptomatic

Cryptosporidium Faecal/Oral Red Enteric precautions Inform CCDC

Diarrhoea (unknown cause)

Faecal/Oral Red Enteric precautions Isolate until 48hrs asymptomatic or until an infectious cause has been ruled out

Diphtheria

Airborne Red Respiratory preacutions

Notifiable See Diphtheria Policy

Dysentery Faecal/Oral Red Enteric precautions Notifiable

Fungal skin(dermatophyte) infection

Contact Green Contact precautions

Gas Gangrene (myonecrosis)

Contact Green Contact precautions No person to person spread

Giardiasis Faecal/Oral Red Enteric precautions Inform CCDC

Glandular fever (Epstein-Barr virus)

Droplet Green Standard precautions No special precautions

Gonococcal infection Contact Green Contact precautions

Hepatitis A Faecal/Oral Red Enteric precautions Notifiable

Hepatitis B Blood borne Green Standard precautions Notifiable

http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/ic/tc305/








Disease

Transmission

Isolation Priority

Isolation

Type

Comments

Side room required when dialysing

Hepatitis C Blood borne Green Standard precautions Notifiable Side room required when dialysing

Herpes Simplex (cold sores)

Contact Green Contact precautions May need to consider Protective Isolation

HIV Blood borne Consider TB risk

See comments

Standard precautions Need to consider Protective Isolation if patient is immunocompromised. Source Isolation is only required if there is excessive/uncontrolled bleeding or leakage of serosanguinous body fluids.

Impetigo Contact Amber Contact precautions Remove precautions after 24hrs of appropriate antibiotic treatment

Influenza Airborne Red Respiratory precautions

See Influenza Plan

Legionella infection Airborne None Standard precautions No person to person spread – no isolation required

Louse Contact None Contact precautions See Louse policy – no isolation required

Malaria n/a None Standard precautions No person to person spread

Measles Airborne/Contact Red Respiratory/Contact precautions

Notifiable

Meningococcal Meningitis Confirmed/Suspected

Airborne Red Respiratory precautions

Notifiable – See Meningococcal Disease policy. Remove precautions after 24hrs of appropriate antibiotic treatment

Meningitis –Viral Airborne Faecal/Oral

None Standard precautions Notifiable – no additional precautions

Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV)













Disease

Transmission

Isolation Priority

Isolation

Type

Comments

Methicillin Resistant Staphylococcus aureus (MRSA)

Contact

See comments

Contact precautions See Methicillin Resistant Staphylococcus aureus policy for risk assessment regarding isolation priority

Mumps


Notifiable

Norovirus Faecal/Oral Red Enteric precautions See Outbreaks of Diarrhoea and Vomiting policy

Rubella Airborne Red Respiratory precautions

Notifiable - See Infection Risks to Pregnant Health Care Workers

Salmonella infection Faecal/Oral Red Enteric precautions Notifiable - Isolate until 48hrs asymptomatic

SARS



Scabies Prolonged contact

None Contact precautions See Scabies Policy

Shingles (Herpes Zoster) Contact Amber Contact precautions See Varicella Policy Contact Infection Control Team to discuss need for isolation or contact tracing

Streptococcus pyogenes (Group A Streptococcus)

Airborne/Contact Red Contact precautions Remove precautions after 48hrs of appropriate antibiotic treatment

Tuberculosis - Pulmonary Airborne Red Respiratory precautions

Notifiable – See Prevention and Control of Mycobacterium Tuberculosis Infection policy IC precautions are NOT required if the patient has had at least 2 weeks of treatment

Tuberculosis - Non-Pulmonary

n/a None Standard precautions Notifiable – See Prevention and Control of Mycobacterium Tuberculosis Infection policy

Viral Haemorrhagic Fever Airborne, Contact & Faecal/Oral

Red Respiratory/Contact & Enteric precautions

Notifiable – See Management of a Patient with Suspected Viral Haemorrhagic Fever

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Precautions Respiratory Contact Enteric Standard

Side Room Yes Assess risk Yes Rarely

Aprons Yes Yes Yes Yes

Gloves Yes Yes Yes Yes

Masks Risk Assess – See; Prevention and Control of

Mycobacterium Tuberculosis Infection policy Varicella Policy

Severe Acute Respiratory Infection (SARI) Avian influenza,

MERS CoV, and SARS policy Influenza Plan

Management of a Patient with Suspected Viral Haemorrhagic

Fever

Only if performing sputum generating procedures and/or

there is risk of splashing to the

mucous membranes



mucous membranes



mucous membranes

Goggles Yes – if risk of splashing/contamination with

fluid/ secretions

No No Assess risk

Hand washing Before and after contact with patient or the patient’s environment – see Hand Hygiene Policy

Equipment After use on patient or in patient’s environment – see Cleaning, Disinfection and Sterilisation

Crockery/Cutlery No special precautions

Linen Treat as infected – see Standard Infection Control Precautions Policy

Treat as dirty – unless visibly contaminated

Waste All clinical waste should go into an orange or yellow bag












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5.2 Isolation

The decision about whether a patient is to be isolated should be made in consultation with the clinician in charge of the patient, the named nurse and the Infection Control Team, taking into consideration the safety and needs of the individual patient and those of other patients on the ward. Appropriate isolation facilities will not always be available within the Trust e.g. for patients with suspected or proven multi-drug resistant M.tuberculosis, SARS, Diphtheria etc. In which case the need to transfer the patient to the Infectious Diseases Unit at North Manchester General Hospital should be arranged. Please discuss with the Infection Control Team who may be contacted on Ext 61971 or via Switchboard.

5.3 Protective Isolation

The purpose of protective isolation is to prevent the transfer of micro-organisms to patients at special risk from infection, especially those with severe neutropenia. Most infections acquired by immunosuppressed patients are endogenous. However, cross contamination from other patients, staff, visitors or the environment can be a hazard and the following measures are recommended: Accommodation A single room should be provided, where possible with a vestibule, positive pressure ventilation and filtered air. The room should have a wash hand basin, a toilet and preferably a shower. The door should be kept closed to reduce the risk from airborne infections. NB: If the patient has a concurrent communicable disease source isolation will be required in

which case positive pressure ventilation may be inappropriate. Please discuss this situation should it arise with the Infection Control Team.

Handwashing/Disinfection Hands should be washed before and after each patient contact and immediately after leaving the room. See Hand Hygiene Policy Gloves Sterile gloves should be worn if in direct contact with sites such as wounds, exit sites etc. Non-sterile gloves should be worn for all other contact with these patients/their environment. Plastic aprons These should be worn for all contact with these patients/their environment. Masks These are not usually required. There is little evidence to indicate that masks protect the patient from communicable respiratory infections. Masks should only be worn if the procedure or patient’s infection requires it.

http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/ic/tc20n05/




Medical Equipment Any equipment used by or for these patients must be cleaned using Chlorclean or sterile as appropriate. Where possible, equipment should be single patient use. Waste ) Linen ) Crockery ) No special precautions Specimens ) Staff

All staff attending the patient including doctors, nurses, domestics, visiting staff e.g. radiographers must be free from infection e.g. colds and skin lesions.

Staff caring for these patients should not also care for patients with Herpes Zoster, MRSA or other communicable illnesses during the same period of duty.

Visitors

When the patient is admitted to protective isolation the family and friends who are to visit should be advised about the need for protective isolation and the measures explained. They should be asked to check with ward staff before any food or drink is brought in and given to the patient.

Visitors with infections (colds, sore throats, skin lesions etc) should be excluded.

Visitors should remove outer clothing before entering the room.

Visitors should wash their hands and wear plastic aprons.

Visitors should not sit on the patient’s bed.

Children under the age of 12 should be discouraged from visiting. Children who have been in contact with an infectious disease, should be excluded during the period of infectivity. (See Varicella Zoster Virus Infection Management of).

Visitors should notify ward staff if they develop an infectious disease so that appropriate action can be taken to protect the patient e.g. Zoster immunoglobulin for a patient who is a non-immune contact of Chicken Pox.

Food for the patient Uncooked food, particularly salads, should be avoided because of the risk of contamination with Listeria and Gram negative bacilli. Meals must not be retained for later consumption. Relatives should be discouraged from preparing meals for the patient. Food brought in by relatives may not have been prepared using a high standard of hygiene. Water for consumption by the patient It is recommended that the following groups have sterile water or water from a tap with an identified filter for cold drinks, ice cubes and oral hygiene (When discharged they should be advised to boil and cool their drinking water from whatever source. Commercially produced bottled water is not permissible:

Neutropenia (<0.5 x 109/l)

Anyone whose T cell function is compromised e.g.:

Immunosuppressed patient with HIV infection whose T cell function is compromised.

Children with severe combined immune deficiency (SCID).

Those patients with specific T cell deficiencies such as CD 40 ligand deficiency (Hyper IgM syndrome).





Cleaning of the room

The room must be thoroughly cleaned before the patient is admitted.

The room should be cleaned twice daily by the domestic using Chlorclean.

A separate colour coded mop should be used.

Disposable colour coded cleaning cloths should be used. These should be disposed of immediately after use.

It is important that waste e.g. clinical, linen, household is not allowed to accumulate in the patient’s room.

After discharge of the patient the room should be thoroughly terminally cleaned.

The domestic staff must be instructed to report to the nurse in charge if she/he is suffering from any infection (e.g. cold, sore throat, skin lesions, diarrhoea etc) before entering the room.

5.4 Source Isolation

The aim of source isolation is to prevent the transmission of microorganisms from patients with known/possible infection/colonisation to other patients, staff or visitors. The type of precautions required for source isolation are dependent on the mode of transmission and are divided into; Airborne, Contact, Enteric and Standard.

5.4.1 Airborne Precautions

Means of transmission Via droplets and aerosols. Conditions possibly requiring airborne precautions Pulmonary TB Prevention and Control of Mycobacterium Tuberculosis (TB)

Infection Influenza Influenza Plan Avian influenza Severe Acute Respiratory Infection (SARI) Avian influenza, MERS

CoV, and SARS MERS-CoV Severe Acute Respiratory Infection (SARI) Avian influenza, MERS

CoV, and SARS SARS Severe Acute Respiratory Infection (SARI) Avian influenza, MERS

CoV, and SARS Viral Haemorrhagic Fever Management of a Patient with Suspected Viral Haemorrhagic Fever Meningococcal Meningitis Meningococcal Disease Prevention and Control Single room A single room is necessary and the door must be kept closed. An orange triangle should be placed on the side room door/above the bed to indicate to staff that special precautions are in place and the patient should wear an orange name band (See Identification of patients who pose a risk of infection).

Hands Handwashing/ disinfection before and after each patient contact or contact with that patient’s environment, is the single most important means of controlling the spread of infection.
















NB: Alcohol rub may be used on socially (visibly) clean hands instead of handwashing. Ensure all surfaces of the hands are covered using the same technique as for handwashing.

Gloves and Plastic Aprons Well-fitting non-sterile gloves and plastic aprons should be worn when handling patients, body fluids or contaminated equipment and linen. Remove after completion of task and wash hands. Masks These are not usually necessary, but may occasionally be recommended by the Infection Control Team in special circumstances. Protection of the face and mucous membranes should be provided when there is a risk of splashing or spraying with secretions. Masks (both fluid repellent surgical and FFP3) and visors should be stocked on most wards/units. Patients should wear fluid repellent surgical masks when being transported through public or patient areas in the following circumstances:

If the patient has an uncontrolled cough (unable to cover both nose and mouth when they sneeze or cough with a tissue).

If the patient has infectious Multi-Drug Resistant TB (MDR-TB) - suspected or confirmed.

Staff should wear fit-tested FFP3 masks - When direct exposure to respiratory secretions is unavoidable, e.g.:

Bronchoscopy (All persons present in the room)

Cough inducing procedures (All persons present in the room)

Prolonged care of high dependency patients in Intensive Care Unit

Any member of staff entering the isolation room of a patient with MDR-TB and VHF

Intubation

Cardiopulmonary resuscitation

Surgical and post mortem procedures involving high speed instruments.

Visitors a) Visitors to patients with infectious diseases e.g. Chicken Pox and those unsure of their

immunity should not visit. b) Advise visitors to remove outer coats before entering the room. c) Advise visitors about handwashing and wearing plastic aprons if they are assisting with the

patients care or are in contact with secretions. Crockery/Cutlery No special precautions




5.4.2 Contact Precautions

Means of transmission Direct or indirect contact via hands, equipment etc. Examples of conditions which require contact precautions

Group A -haemolytic streptococcus

Methicillin Resistant Staphylococcus aureus (MRSA)

Infected/discharging wounds and lesions

Herpes Zoster, Herpes simplex

Non-pulmonary tuberculosis (TB glands, renal TB etc) Single room This is advised where other patients may be particularly at risk from spread e.g. untreated

Group A -haemolytic streptococcus, MRSA, Herpes Zoster infections. If a single room is not immediately available alternative accommodation should be discussed with the duty bed managers or Infection Control Team. For any patients requiring infection precautions an orange triangle should be placed on the side room door/above the bed an the patient should wear an orange name band to indicate to staff that infection control precautions are in place. (See Identification of patients who pose a risk of infection).

Hands Handwashing/ disinfection before and after each patient contact or contact with that patient’s environment, is the single most important means of controlling the spread of infection. NB Alcohol hand rub may be used on socially (visibly) clean hands instead of handwashing.

Ensure all surfaces of the hands are covered with alcohol.

Skin conditions Any Health Care Worker (HCW) with a skin condition should attend the Health and Wellbeing Department for advice. The HCW should not attend patients who need contact precautions e.g. MRSA while psoriasis/eczema is active and present on exposed areas, e.g. hands, face, arms. Gloves Well fitting, non-sterile gloves should be worn when handling contaminated articles or when in contact with a contaminated area, dressings and for contact with all body fluids. Remove after completion of the task and wash hands.

Aprons To be worn for all patient contact and when handling contaminated equipment. These should be disposed of when the task is completed. NB: Medical and other staff should remove white coats before attending patients in isolation. Commodes No special precautions are required, but these should be cleaned after each and every patient use.






Visitors Staff should remind visitors to wash their hands before and after visiting. Protective clothing is only recommended if visitors assist with the patient’s care.

5.4.3 Enteric Precautions – Please also see separate Clostridium Difficile Policy

Means of transmission Faecal/oral Examples of infections which require enteric precautions

Salmonella/Shigella

Clostridium difficile

Hepatitis A

Rotavirus/Norovirus

Diarrhoea – cause unknown Single room A single room is necessary for most enteric pathogens and is desirable for other conditions. If diarrhoea is profuse or uncontained a side room is always necessary. Please discuss with the Infection Control Team if it is not possible to put the patient in a single room. For any patients requiring infection precautions an orange triangle should be placed on the side room door/above the bed and the patient should wear an orange name band to indicate to staff that infection control precautions are in place. (See Identification of patients who pose a risk of infection). Hands Handwashing/ disinfection before and after each patient contact or contact with that patient’s environment, is the single most important means of controlling the spread of infection.

Alcohol hand disinfectant is not recommended for viral gastro-enteritis and Clostridium difficile infections.

Handwashing with soap and water is effective against these organisms. Gloves Well-fitting non-sterile gloves should be worn when handling contaminated equipment (bed pan, commodes, linen) and for contact with all body fluids. Remove after completion of the task and wash hands. Plastic apron To be worn for any contact with these patients or their environment. Remove after completion of the task and wash hands with soap and water. Commodes/bedpan supports Clean surfaces with Chlor-clean (detergent & chlorine) using disposable cloths. Visitors Staff should remind visitors to wash their hands before and after visiting. Protective clothing is only recommended if visitors are assisting with the patient’s care. In the event of an outbreak of diarrhoea and vomiting advice will be given by the Infection Control Team.






5.4.4 Standard Infection Control (Universal) Precautions (SICPs)

SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of an infectious agent from both recognised and unrecognised sources. Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in the care environment that could have become contaminated. Whether infection is known to be present or not to ensure the safety of patients, staff and visitors in the care environment. The application of SICPs during care delivery is determined by an assessment of risk to and from individuals and includes the task, level of interaction and/or the anticipated level of exposure to blood and/or other body fluids. Standard infection control precautions against blood borne virus transmission should be undertaken by all healthcare professionals regardless of the patient’s known or suspected infective status. To be effective in protecting against infection risks, SICPs must be used continuously by all staff.

Single room This will only be required if spillage of blood or blood stained fluid is anticipated or the patient requires protective isolation. Hands Handwashing/ disinfection before and after each patient contact or contact with that patient’s environment, is the single most important means of controlling the spread of infection. Non-intact skin Staff with skin lesions who are involved in the care of patients should ensure that any exposed lesions are covered with waterproof dressings. Gloves Well-fitting non-sterile gloves should be worn when handling blood or all blood stained body fluids. Remove after completion of the task and wash hands. Plastic apron To be worn when contact with body fluids is expected. Remove after completion of the task and wash hands.

Goggles/Visor To be worn if splashing of blood or blood stained body fluids is likely.

Bedpans No special precautions. Risk of exposure Before undertaking any procedure, assess the risk of exposure to blood and take appropriate measures as described on following page.




Immunisation

All health care workers (HCWs) who have direct contact with blood or blood stained body fluids should be immunised against Hepatitis B.

All HCWs who perform “exposure prone invasive procedures” should have evidence of immunity to Hepatitis B (See below).

Contact the Occupational Health Department for further advice. Exposure prone procedures These are invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient’s open tissue to the blood of the worker. These include procedures where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. Sharps Injury Report all Sharps injuries and body fluid exposure immediately (See Policy “Code of Practice for Needlestick/ Sharps Injury, Body fluid exposure for staff and patients). HIV prophylaxis is available if appropriate. Spillages Spillages of blood and blood stained body fluids should be cleaned up as soon as possible.

a) Plastic aprons and gloves should be worn. b) If possible first mop up excess with paper towels. Take care to avoid handling broken

glass or sharp objects. c) Spillages should be cleaned up using paper towels and a fresh solution of

Hypochlorite 1% (10,000ppm available chlorine). Currently Haz tabs are supplied – make dilutions as per instructions provided in each ward and department.

d) The area involved should be dried with paper towels. e) The gloves, plastic apron and paper towels should be placed in orange or yellow bags

as clinical waste. f) Hands should be washed and dried thoroughly. g) The area may then be cleaned in the usual way. h) Use disinfectants in a well ventilated area; avoid splashing skin, eyes or mucous

membranes. Follow COSHH advice. Visitors Normally there is no need to restrict visitors. However visitors to patients who need additional isolation precautions e.g. protective isolation or other source isolation should be advised about the relevant precautions.




5.4.5 Management of HIV Infected HCWs

Task categorisation according to risk of exposure to blood Category

Examples Protective

Measures

A 1 Contact of HCW with blood probable; potential for uncontrolled bleeding or splattering

Major surgical, gynaecological, obstetrical procedures

Full range of protective clothing, including masks and goggles

A 2 Contact of HCW with blood probable but splattering unlikely

Minor surgical procedures

Gloves/apron to be worn. Mask/protective eyewear to be available

A 3 Low probability of personal contact with blood

Administration of intramuscular, intra-dermal or subcutaneous injections

Gloves should be worn

B No Risk of Exposure to Blood

6. Roles and responsibilities

The Executive Director of Nursing on behalf of the Chief Executive will ensure that the Clinical Directors take clinical ownership of the policy. The Clinical Directors on behalf of the executive director of nursing will

ensure that all health care workers comply with this policy

ensure that all healthcare workers attend mandatory infection control training The Senior Nurses and Matrons on behalf of the Executive Director of Nursing and the Clinical Directors will:

ensure that all health care workers comply with this policy

ensure that all healthcare workers attend mandatory training

The infection control team will:

Act as a resource for information and support

Monitor the implementation of this policy within clinical areas

Regularly review and update the policy The senior nurse and doctor must ensure that all staff are aware and comply with the infection control precautions that need to be taken and follow the advice in this policy.




Consult other infection control policies which should be used in conjunction with this document. These can be found on the Intranet:

Management of patients with Mycobacterium tuberculosis (TB).

Assessment of a patient with Viral Haemorrhagic fever (VHF).

Management of Transmissible Spongiform Encephalopathies (CJD).

Management of Scabies.

Management of Varicella Zoster Virus infection (Chicken Pox/Shingles)

Policy to be followed in hospital outbreaks of diarrhoea and vomiting and other communicable disease.

Louse Infestation.

Management of patients with SARS (Severe Acute Respiratory Syndrome)

Ensure that the Infection Control Team has been informed.

Ensure that all who come into contact with the patient or their environment are aware of the precautions to be taken.

7. Monitoring document effectiveness

The policy will be held on the Intranet.

The policy will be promoted by Matrons, Ward Managers and the Infection Control Team.

The policy will be promoted at the induction of medical staff.

The policy will be promoted at Infection Control Training Sessions for clinical staff.

Key Staff identified by their Matrons/Nursing Leads will audit standard infection control precautions using the Saving Lives high impact intervention audit tools and will act accordingly on audit findings

Audit results will be a standing agenda item at ward/department meetings and directorate clinical governance meetings

The Infection Control Team will provide education with regard to standard infection control precaution practices

The Infection Control Team will review this policy annually or more frequently in line with

best available evidence.

For staff who enter the clinical area it will be checked at appraisal that they have undertaken annual infection control training.

Clinical directorates will carry out saving lives high impact intervention audits and report

as part of the quality dashboards and service reviews

8. Abbreviations and definitions

Terms explained in document.

9. References and Supporting Documents

Department of Health. (2010). Health and Social Care Acr 2008: Code of Practice on the

prevention and control of infections and related guidance.

Wilson, J. (2006). Infection Control in Clinical Practice. (3rd Ed.). London: Bailliere-Tindall.













Fraise, AP., Bradley, C. (Eds).(2009). Ayliffe’s Control of Healthcare-Associated Infection: A

Practical Handbook. London: Hodder Arnold.

Health and Safety Executive (HSE) (2018). Managing infection risk when handling the

deceased. Guidance for the mortuary, post-mortem room and funeral premises, and

during exhumation. http://www.hse.gov.uk/pUbns/priced/hsg283.pdf

Infection control policies which should be used in conjunction with this document can be found on the SRFT Intranet:

o Management of patients with Mycobacterium tuberculosis (TB). o Assessment of a patient with Viral Haemorrhagic fever (Management of a Patient

with Suspected Viral Haemorrhagic Fever). o Management of Transmissible Spongiform Encephalopathies (CJD). o Management of Scabies. o Management of Varicella Zoster Virus infection (Chicken Pox/Shingles) o Policy to be followed in hospital outbreaks of diarrhoea and vomiting and other

communicable disease. o Louse Infestation. o Management of patients with SARS (Severe Acute Respiratory Syndrome)














10. Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of

the document prior to submission for upload. .

Nominated Lead author:

Sandra Brady Specialist Nurse, Infection Control

Lead author contact details:

0161 206 5017 [email protected]

Lead Author’s Manager:

Linda Swanson Group Associate Director Infection Control

Applies to:

Salford CO

Oldham CO North Manchester CO

Bury & Rochdale CO

Northern Care Alliance Group (NCA)

Document developed in consultation with :

The Mortuary Staff, Microbiologist, Domestic Team

Keywords/ phrases:

Isolation, Neutropenic, Protective, Airborne, Contact, Handwashing, Gloves, Aprons

Communication plan:

Communication via the intranet, siren. To be raised at the infection control link nurse meetings and at divisional meetings.

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Approval: Add name of Committee and Chairpersons name and role:

Dr Janet Hegarty, Deputy Medical Director, Chair Hospital Infection Control Committee

05/12/2018

How approved: Chair’s actions Formal Committee decision X

mailto:[email protected]




11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

yes

1b) Have any amendments been made as a result? If yes, specify what.

no

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect

age groups in different ways?) x

Sex (e.g. is gender neutral language used in the way the policy or

information leaflet is written?) x

Race (e.g. any specific needs identified for certain groups such as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

x

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;

dietary needs that may conflict with medication offered.) x

Sexual orientation (e.g. is inclusive language used? Are there different

access/prevalence rates?) x

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or

breastfeeding women?) x

Marital status/civil partnership (e.g. would there be any difference

because the individual is/is not married/in a civil partnership?) x

Gender Reassignment (e.g. are there particular tests related to gender? Is

confidentiality of the patient or staff member maintained?) x

Human Rights (e.g. does it uphold the principles of Fairness, Respect,

Equality, Dignity and Autonomy?) x

Carers (e.g. is sufficient notice built in so can take time off work to attend

appointment?) x

Socio/economic (e.g. would there be any requirement or expectation that

may not be able to be met by those on low or limited income, such as costs incurred?)

x

Disability (e.g. are information/questionnaires/consent forms available in

different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

x




Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

x

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? By infection control audits to establish its effectiveness. By review of available relevant guidance. 4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? N/A

Will this policy require a full impact assessment? Yes / No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Sign off from Equality Champion: Simon H Gray Date: 20/11/18

mailto:[email protected]




12. Appendices

Appendix 1 Clinical Waste

NB: See also Waste Disposal Policy in the Health & Safety Policy Manual. The following should be disposed of as clinical waste in orange/yellow plastic bags:

All disposable material which is contaminated with blood or other body fluids.

All disposable material which is used in an isolation room including paper hand towels. Sharps and disposable sharp instruments should be disposed of immediately after use in an approved sharps container. Ensure security of waste and sharps containers. General points:

Always follow the policy

Seal bags before removing them from isolation rooms and label according to current policy. The bag should not be labelled with the patient’s details or the reason for isolation.

Do not overfill waste bags

Carry away from body

Always wear protective clothing when handling waste

Always wash hands after handling waste even if gloves have been worn




Appendix 2 Disposal of Foul/Infected Linen Linen which is contaminated with blood or other body fluids and linen which is used by a patient in source isolation should be treated as foul/infected linen.

Wear gloves and apron when handling foul/infected linen.

Handle linen carefully to avoid airborne dispersal of infecting organisms.

All foul/infected linen must be placed in a red (plastic) alginate stitched bag and sealed. On removal from the room the bag should be placed in a white outer plastic bag and labelled according to current policy. The bag should not be labelled with the patient’s details or the reason for isolation.




Appendix 3 Cleaning of Isolation Rooms It is important that the room is cleaned daily and that any spillage is cleared up promptly. The domestic should be advised as follows by the nurse caring for the patient:

Gloves and aprons to be worn when cleaning the room. They should be removed before leaving the room and disposed of as clinical waste.

Hands to be washed before and after leaving the room.

A separate colour coded mop and bucket should be used for cleaning. After use the mop head should be returned to the domestic cleaning area for laundering (transported in a clear plastic bag). The bucket and any other container e.g. bowl should be washed with Chlor-clean, dried and stored inverted in the sluice/dirty utility (NOT in the patient’s room).

Disposable cloths for cleaning surfaces should be used and disposed of as clinical waste in the patient’s room.

Floors should be cleaned by wet mopping with Chlor-clean.

Horizontal surfaces, lockers, window ledges etc should be cleaned with Chlor-clean.

Any spillage of blood or body fluids should be reported to the nursing staff for removal.

All disposable waste should be put in clinical waste bags. Waste bags should be sealed before removal from the room.




Appendix 4 Terminal Cleaning of Isolation Rooms/Cohort Areas Domestic supervisor to be contacted to arrange terminal clean. Terminal clean is to be organised in conjunction with the ward team and the domestic team.

Nursing

•Where possible, decant patients into an empty bay or dayroom.

•Ward/ bay to be decluttered including patient belonging.

Nursing

•Dispose of any disposable patient care items, including wipes, pads, oxygen tubing. Put all disposable waste into an orange or yellow clinical waste bag.

•Remove bed linen and place into red alginate bags. Seal the bags in the room as per policy.

Domestic

•Remove curtains and place into red alginate bags. Seal the bags in the room as per policy. The screen curtains around the patient’s bed must be changed if visibly soiled and if the patient has been in for 24hrs or longer. During an outbreak ALL curtains must be changed.

Domestic

•Top layers of consumables (aprons, gloves, hand towels) must be removed from dispenser. Not all stock has to be disposed of.

•Clean air vents

Domestic

•Clean curtain rails, overhead lights and ‘patientline’ equipment (dispose of headphones).

•There is no need to wash walls unless they are visibly contaminated.

Domestic

•All surfaces, including ledges, shelves, beds, bed tables, patient line equipment, suction/oxygen points and other furniture should be cleaned using Chlor-clean.

•Clean bed tables, chairs and lockers. This includes inside, underside and all wheels.

Nursing

•Clean mattresses, bedrails/ bedframes, headboards, footboards with Chlor-Clean

•Mattresses should be opened and inspected to ensure it is in a good state of repair. i.e. no staining should be visible and cover should pass the permeability test

Domestic

•Clean underneath bed, including frame and wheels. Ensure that beds are pulled away from the wall (when possible) to ensure backs of beds are cleaned.

•Hard flooring – should be mopped clean with Chlor-Clean

Domestic

•Clean hand wash basins and any ensuite facilities

•Hang clean curtains

Nursing

•Ensure all equipment (dripstands, obs machines) are cleaned using Chlor-Clean

•Patients can be moved back in to the area when the bay is clean and dry.

Domestic

•Ensure all communal areas are also cleaned thoroughly. This includes bathrooms, showers and the main ward thoroughfare.

•Clean all patient handrails and door handles

Nursing

•Ensure the dirty utility/ sluice rooms are clean thoroughly. This includes all parts of the commode (seat, lid, backrest, legs and underside)

•Dispose of open pulp products.

Both

•The standard of the terminal clean should be checked with both the domestic supervisor and the ward co-ordinator to ensure that the clean meets the standard requirements. Any issues or concerns can be raised with the infection control team.




Appendix 5 Medical Equipment Remove unnecessary equipment from the isolation procedural area before admitting the patient. Reserve equipment e.g. stethoscopes, sphyg cuffs for individual patient use. Use disposable equipment where possible.

Disinfection Ensure disinfection of equipment before re-use on another patient. The routine disinfection process in place in wards and departments should suffice. If in doubt contact the Infection Control Team.

Equipment going to SSD (Except equipment used on patients with CJD – See below) Equipment used on a patient in source isolation which goes to SSD should be placed unwashed into the SSD bin on the ward/department. Staff should not attempt to retrieve items from the bin. They will be collected by SSD staff. There is no need to separate equipment as all equipment is processed in a washer/disinfector.

Equipment going to SSD from Theatre (NB Except equipment used on patients with CJD – refer to Policy for “Management of Transmissible Spongiform Encephalophathies TSE including Creutzfeld Jakob Disease – CJD” on the Trust Intranet. 1. All equipment which can be processed in the washer/disinfector should be treated in the

same way including instruments used on known or suspected infected patients:

The equipment should be placed on trays and sent to SSD in the usual way.

The equipment should be transferred to the washer/disinfector by staff wearing appropriate protective clothing (gloves, aprons/gowns and goggles).

The washer/disinfector must have a cycle which achieves a temperature of 80oC for at least one minute. This is recommended as an initial decontamination process to remove gross soil from surgical instruments and to make them safe to handle.

The equipment should not be washed before being loaded in the washer/disinfector. 2. Equipment which cannot be processed in the washer/disinfector is listed below:

(Items may be added or removed by the SSD Manager) A-O implants Black Max neuro drills

This equipment should be rinsed at the theatre table by staff wearing appropriate protective clothing (gloves, aprons/gowns and goggles) placed in a decon bag sealed and sent to SSU. (Avoid contamination of the outside of the bag).




Appendix 6 Care of the Deceased Patient Last Offices 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 e.g. TB, SARS, MERS. See Table 1 and Notification of infectious diseases policy.

When the patient is known or suspected of having CJD/VCJD/TSE. In addition for patients suffering from a known or suspected infectious disease:

A dedicated label that details whether the patient is and infection risk should be attached to the shroud. (Labelling of the body should not disclose the patient’s diagnosis).

Special precautions for transporting the body are not necessary.

If for religious or cultural reasons the last offices are performed by other persons they should be made aware of the necessary precautions.

The nurse in charge must notify the Mortuary Technician of bodies prior to transfer to the Mortuary during normal working hours. At other times the nurse in charge must ensure that the Mortician is notified as soon as possible after transfer on the following working day.

Relatives and friends wishing to visit the body should be advised by nursing staff of the precautions to be taken. These relatives may have already visited the patient and are aware of the precautions to take. If they wish to know about the patient’s diagnosis they should be referred to the clinician in charge of the patient. This also applies if relatives/friends are concerned about being exposed to an infection.

If a cadaver bag is required and the ward does not have their own stock these can be obtained from the Mortuary.

The Mortuary Technician will notify the undertaker that precautions need to be taken maintaining patient confidentiality.




Table 1 adapted from HSE, (2018).Managing infection risk when handling the deceased Infection Causative Agent Hazard

Group Is a body bag needed?

Can the body be viewed?

Airborne - Small particles that can remain airborne with potential for transmission by inhalation

Tuberculosis Mycobacterium tuberculosis

3 Yes Yes

Middle East respiratory syndrome (MERS)

MERS coronavirus

3 Yes Yes

Severe acute respiratory syndromes (SARS)

SARS coronavirus

3 Yes Yes

Droplet - Large particles that do not remain airborne for very long and do not travel far from source with potential for transmission via mucocutaneous routes (ie mouth, nose or eyes)

Meningococcal septicaemia (meningitis)

Neisseria meningitidis

2 No Yes

Flu (animal origin) eg H5 and H7 influenza viruses

3 No Yes

Diphtheria Corynebacterium diptheriae

2 No Yes

Contact - Either direct via hands of employees, or indirect via equipment and other contaminated articles where transmission is primarily via an ingestion route

Invasive streptococcal infection

Streptococcus pyogenes (Group A)

2 Yes Yes

Dysentery (shigellosis) Shigella dysenteriae (type 1)

3 No #

Yes

Hepatitis A

Hepatitis A virus 2 No #

Yes

Hepatitis E Hepatitis E virus 3 No #

Yes

Enteric fever (typhoid/ paratyphoid)

Shigella dysenteriae (type 1)

3 No #

Yes

Brucellosis Brucella melitensis

3 No Yes

Haemolytic uraemic syndrome

Verocytotoxin/ shiga toxinproducing E.coli (eg O157: H7)

3 No #

Yes

# When there is a leakage from a body orifice or draining lesion which cannot be prevented please use a body bag




Infection Causative Agent Hazard Group

Is a body bag needed?

Can the body be viewed?

Contact - Either direct or indirect contact with blood/other blood containing body fluids via a skin-penetrating injury or via broken skin and through splashes of blood/ other blood containing body fluids to eyes, nose and mouth

Acquired immune deficiency syndrome (AIDS)-related illness

Human immunodeficiency virus

3 No Yes

Anthrax Bacillus anthracis 3 Yes No

Hepatitis B, D and C Hepatitis B, D and C viruses

3 No Yes

Rabies Lyssaviruses 3 No Yes

Viral haemorrhagic fevers

Specifically Lassa fever, Ebola, Marburg, Crimean-Congo haemorrhagic fever viruses

4 Yes (Double body bag).

No

Contact - Either direct or indirect contact with body fluids (eg brain and other neurological tissue) via a skin-penetrating injury or via broken skin

Transmissible spongiform encephalopathies (eg CJD)

Various prions 3 Yes Yes

# When there is a leakage from a body orifice or draining lesion which cannot be prevented please use a body bag




Appendix 7 Laboratory Specimens All clinical specimens should be collected with care, avoiding contamination of the outside of the container and the request form. The patient’s details including hospital number and date of birth should be on both container and form. Specimens should always be sent sealed in the integral bag with the request form. When multiple investigations are requested ensure that separate specimens are taken for each Pathology Department e.g. Haematology, Biochemistry, where this can be achieved from a single venepuncture.

Danger of Infection labels The ‘Danger of Infection’ label should be affixed to the specimen container and the request form. The following specimens should be labelled with ‘Danger of Infection’ labels:

Specimens from patients who are known or suspected of having blood borne viruses.

Specimens from patients known or suspected of having a notifiable disease.

Specimens from patients known or suspected of having CJD. The laboratory should be notified before specimens from patients known or suspected of having CJD are to be sent so that the appropriate procedures can be followed. NB: ‘Danger of Infection’ labels should be available at all times in wards and departments.

Supplies are available from the Department of Microbiology. See also separate Policies for patients with :

Prevention and Control of Mycobacterium Tuberculosis (TB) Infection

CJD (Transmissible Spongiform Encephalopathies)

Viral haemorrhagic fever

Severe Acute Respiratory Infection (SARI) (Avian influenza, MERS CoV, and SARS)









Appendix 8 Management of Patients in Source Isolation Requiring Surgery

Transfer to Theatre The patient should be transferred on a trolley with clean linen. If being transported on a bed the patient should, if possible, be transferred to a clean bed with clean linen before leaving the ward.

Except in emergencies the patient should be treated at the end of the list.

All staff handling the patient should wear aprons.

Gloves should be worn if contact with secretions, excretions is likely.

Staff should avoid direct contact with other patients whilst dealing with this patient. If this is not possible protective clothing must be changed and hands washed/disinfected between contacts.

Surfaces with which the patient has had direct contact should be cleaned with Chlorclean.

Linen and waste should be disposed of as infected linen and clinical waste.

Instruments may go to SSD in the usual way. See Appendix 5.

The Theatre may be used again ten minutes after cleaning is completed.

If possible the patient should be recovered in the operating theatre or in a room not occupied by other patients to avoid contamination of the usual recovery area.

The patient should return to the ward as soon as possible. NB: Theatre should have their own policy for managing “infected cases”.

See Separate Policy for patients with:



Viral haemorrhagic fever Severe Acute Respiratory Infection (SARI) (Avian influenza, MERS CoV, and SARS)









Appendix 9 Transfer of Patients to Departments Within the Same Hospital

The patient may be transported by trolley or wheelchair as appropriate.

The trolley or wheelchair should be covered with a clean sheet folded around the patient.

The porter or other staff transporting the patient should wash their hands before handling the patient and put on a plastic apron. No other protective clothing is required except in special circumstances which will be advised by the Infection Control Team. For transfer of patients with TB – See also “Management of patients with M.tuberculosis in hospital” in the Infection Control Manual.

On arrival at the department, the chair or trolley should be kept in the department for the return journey. If this is not possible the linen should be removed and treated as infected linen (red bag) and the chair/trolley wiped over with disinfection wipes before being used for another patient.

After the patient has returned to the ward all surfaces of the chair/trolley should be cleaned with disinfection wipes or Chlorclean. Any linen should be disposed of as infected linen (red bag).

The porter and other staff should wash their hands with the disinfectant detergent as provided before leaving the patient.

NB: See Separate Policy for patients with:













Appendix 10 Transport via Ambulance of an Infected Patient

The ambulance service must be notified in advance of the precautions to be taken. These will be already in place e.g. contact precautions, blood precautions.

Ambulance staff must wash their hands prior to handling the patient and put on protective clothing appropriate to the precautions being taken. This applies to any staff accompanying the patient. No other protective clothing is required except in special circumstances and individual advice will then be given by the Infection Control Team.

The patient should be given clean clothing and clean bed linen before transfer.

After transfer, any linen remaining in the ambulance should be treated as for infected linen.

Local areas of patient contact, e.g. chair or stretcher should be disinfected using a disinfectant such as Chlorclean. (Take appropriate precautions when using disinfectants).

When the transfer is completed ambulance and attending staff must wash their hands using a disinfectant detergent.

NB: See Separate Policy for patients with:













Appendix 11 Visits to Out-Patients and Specialist Departments Visits by patients in source isolation to other department should be kept to a minimum where possible. When a visit is necessary, either for investigation or treatment, prior arrangement must be made with the senior staff in the department concerned, so that the control of infection measures can be planned. Persons with any skin abrasions or active dermatitis (e.g. eczema) should not have direct patient contact. Preparation

Except in emergencies patients should be seen or treated at the end of the working session and should spend the minimum necessary length of time in the department. They should be sent for when the department is ready to see them; they must not be left in a waiting area with other patients.

Staff coming into direct contact with the patient should wear aprons. Gloves should be worn if contact with secretions, excretions is likely.

Staff should avoid direct contact with other patients whilst dealing with this patient. If this is not possible protective clothing should be changed and hands washed between contact.

Linen and disposable waste should be treated as Trust policy for infected linen and clinical waste.

Surfaces with which the patient has had direct contact should be cleaned with Chlorclean.

Staff must wash their hands thoroughly after dealing with the patient using liquid soap and water, followed by alcohol rub.

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