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ISOLATION POLICY Infection Control Folder No: 10

Approved by:

Policy and Guideline Ratification Group (PGRG) Integrated Governance Committee (IGC)

Date 21st December 2010 20th January 2011

Date of Issue: February 2011 Version No: 1.2 Date of Review: January 2013 Author, title: Liz McLoughlin, Prevention & Control of Infection Senior Nurse and Jane Roberts Matron Thornbury Hospital.


NHS South Gloucestershire Document status: Current Version 1.0 Date 16/8/10 Comments Sent to Director of Infection Prevention & Control, Director of Public Health, Control of Infection Committee for comments DIPC comments incorporated Approved by Policy and Guideline Ratification Group (PGRG) Approved by Integrated Governance Committee (IGC)

1/9/10 1.1 1.2 21st December 2010 20th January 2011 1.2

If you need further copies of this document please contact Michelle Trigg PA to Prevention & Control of Infection Senior Nurse NHS South Gloucestershire has made every effort to ensure this policy does not have the effect of discriminating, directly or indirectly, against employees, patients, contractors or visitors on grounds of race, colour, age, nationality, ethnic (or national) origin, sex, sexual orientation, marital status, religious belief or disability. This policy will apply equally to full and part time employees. All NHS South Gloucestershire policies can be provided in large print or Braille formats if requested, and language line interpreter services are available to individuals of different nationalities who require them. The failure to comply/adhere to this policy may be investigated in line with the `Investigating (Employment) complaints and allegations policy and procedure' and may result in disciplinary action, up to and including dismissal.



Section 1 2 3 4 5 6 7 8 9 10 11 12 Introduction Scope Principles and Purpose of the Policy Definitions Modes of Transmission Roles and Responsibilities Consultation Equalities Impact Assessment Isolation Precautions Risk Assessment Implementation Audit Page 4 4 4 5 5-6 6 7 7 7 ­ 10 11 - 13 14 14 14 15 16 17 18

13 References and Links Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Isolation Notice ­ please see a nurse before entering Isolation Nursing in an open ward non invasive alert Transport Booking form Adapted Plymouth Risk Assessment



Introduction This document sets out the NHS South Gloucestershire policy on the isolation of service users in PCT Community Settings. Specific precautions are required to prevent the transmission of infectious organisms between patients, from patients to staff and from staff to patients. It is important staff are aware of and comply with proactive and source isolation procedures. Whilst this policy is mainly written for the ward inpatient facility area it is important that all community staff practice standard infection prevention and control precautions. It is the policy of the PCT that all service users with transmissible infections be nursed in isolation in order to prevent the spread of infection. Correct and timely placement of suspected or proven infected service users into single rooms can be very effective in reducing the overall numbers of infected service users within the ward. (DH 2007) Where this document refers to `the PCT', it shall be understood to mean NHS South Gloucestershire. When referring to users of health services in the PCT, e.g. patients, clients, service users etc, the word 'service user' has been used.


Scope This policy applies to all healthcare staff and students working on Henderson Ward, Thornbury Hospital and other visiting health professionals.


Principles & Purpose of the Policy All hospitals providing in-patient care must ensure that they are able to provide or secure the provision of adequate isolation facilities for service users sufficient to prevent or minimise the spread of Healthcare Associated Infection (DH 2003) To ensure that protective/source isolation procedures are instigated in order to minimise the risk of cross infection To identify service users presenting with colonisation, infection or infectious diseases that may be a risk to others To provide a safe environment for all service users on Henderson Ward To take timely action to prevent the further spread of infection or potentially infectious conditions by appropriate isolation of the source service user and the appropriate use of personal protective equipment (PPE). To ensure that service users at high risk of infections due to immunosuppression or neutropenia are appropriately isolated and protected to minimise their risk To ensure that all staff, departments and personnel from any outside agencies likely to be involved in the care of service users have a clear understanding of their roles and responsibilities in preventing the spread of infection To ensure the risks of Infection and cross infection are reduced to an acceptable level To ensure compliance with the Health Act (2006, r2008)



Definition of Terms Host ­ A living organism (in this case man) which another organism can live and be sustained on or within Carriage / or Carrier ­ Can be defined as a person who harbours a specific organism in the absence of signs and symptoms of infection and is therefore potentially infectious to others. The carrier state may exist in the individual as unknown (healthy, asymptomatic carrier) or during a period of convalescence. In either case the carrier state may be of a short duration (transient carrier) or long term duration (chronic carrier) Cleanable ­ Capable of being cleaned easily and without damage Colonisation ­ the presence of bacteria found in a non infected site (therefore have not initiated a host response or any signs of infection), e.g. Staphylococcus aureus carriage in the nose Disposable ­ Designed to be discarded after single use Infection ­ The host reaction to microbes lodging and multiplying in the tissues, e.g. abscesses, wound infections or chest infections. (The host would exhibit symptoms of infection for example fever of >38 deg C and associated symptoms at/in the site of infection e.g. inflammation, accumulation of pus, diarrhoea.) Washable ­ Capable of being washed without shrinking, fading or being damaged Source isolation ­ Is the physical separation of one service user from another, in order to prevent spread of infection Protective isolation ­ Also know as reverse barrier nursing, is the physical separation of a service user at high risk from common organisms carried by others DIPC ­ Director of Infection Prevention & Control IPCSN ­ Infection Prevention and Control Senior Nurse


Modes of Transmission Contact ­ hands are the most common mode of spread but it can also occur indirectly via contact with contaminated equipment or the environment Airborne ­ occurs by the spread of small, airborne particles containing infectious agents that remain suspended in the air and are dispersed over distances by air currents where they are then inhaled by a susceptible individual Droplet ­ occurs when respiratory droplets carrying infectious agents travel over short distances (up to 3 feet) directly from the respiratory tract of an infectious individual to the mucosal surface of a susceptible individual. Coughing, sneezing or talking generates respiratory droplets. Droplets may also settle on horizontal surfaces and can cause indirect contact transmission via individual's hands Faecal-oral ­ the transmission of enteric bacterial infection from the gut of one person


that is ingested by another resulting in infection Vector ­ the spread of infection via a living creature Inoculation ­ the inoculation of an infected body substance into the tissue of another Vertical ­ the transmission of infection from mother to baby such as via placenta or breast milk


Roles and Responsibilities Chief Executive/PCT Board · Responsible for ensuring that Infection Protection and Control policies and procedures are in place for the PCT under the Health Act (2008)

DIPC · The DIPC has executive (Board) responsibility and authority for ensuring that the PCT at a strategic level has policies and procedures in place at all levels of the organisation to reduce or prevent avoidable healthcare acquired infections · Is accountable directly to the Chief Executive and the board for infection prevention and control · Communicating to the board any issues related Infection Prevention and Control i.e. MRSA bacteraemias, C Difficile or other infection outbreaks within the PCT and wider health community · Liaising with the Bristol, North Somerset & South Gloucestershire (BNSSG) wide health community, local providers, Strategic Health Authority and Health Protection Unit as appropriate · Provide written reports to the Board as necessary that includes an annual report that would detail any outbreaks IPCSN · Responsible to the PCT DIPC (until March 2011), and Governance lead nurse (Provider services) · Support and advise staff in relation to Infection prevention and control (IPC) practices and procedures · Identify the procedures required · Monitor and report on the implementation of these procedures Line managers must ensure that: All staff understand how organisms spread in order to apply correct isolation procedures relevant to the organism or service users need Staff are aware of and have access to this policy Staff responsibility: Must ensure that they comply with this policy Must ensure they are aware of and can demonstrate a good working knowledge of the PCT policies and the correct principles of Infection Prevention & Control Policy and Guidance



Consultation This policy has been updated in accordance with current practice. Consultation has taken place with the PCT Prevention & Control of Infection Committee, DIPC & Director of Public Health. Equalities Impact Assessment The trust equality impact assessment template has been completed and no potential discrimatory impacts have been found. Isolation Precautions For both source and protective isolation The decision to isolate a service user should be based on the infection risk to other service users, staff and visitors. An appropriate isolation notice is required and must be placed on the outside of the door, or behind the bed space outlining the precautions required (see Appendices 1&2) Daily assessment and evaluation of the need for ongoing isolation precautions must take place. The Prevention and Control of infection team is available for advice and guidance. Once the risk assessment has identified that the service user requires isolation the following precautions must be considered: Source Isolation This is indicated for conditions, which could be transmitted from the service user to other individuals. Examples include MRSA, Clostridium difficile, Chicken Pox, Tuberculosis (TB), service users with diarrhoea and or vomiting and service users with influenza, (refer to table and specific policies for further information). Please note that this list is not exhaustive. Ideally a single room should be allocated to service users with these conditions, but given the limited availability of side rooms a risk assessment needs to be undertaken. The risk assessment will include the risk factors of the other service users in isolation and the service users in the bays.



Nurse service user in a single room with the appropriate facilities available Ensure that the isolation door remains closed (particularly important when airborne infections have been isolated) The room must be cleaned daily with dedicated cleaning equipment Where possible use dedicated equipment for isolated service users Display appropriate isolation sign on the door (see appendix 1) to alert staff and visitors to the required precautions Charts and patient records must be kept outside of the room to reduce the risk of contamination, staff must decontaminate their hands before handling them Set up the appropriate protective clothing outside the room i.e. gloves, aprons, alcohol gel and specific equipment as required


Clinical waste bin should be kept inside the room Sharps bin as appropriate to be kept inside the service users room Infected linen bags as appropriate to be kept inside the service users room and all linen bagged in disposable inner bag at the bedside, when two thirds full sealed and placed into the outer bag on removal from the room Employ strict adherence to hand hygiene (refer to PCT Hand Hygiene policy) Encourage the service users to wash hands before and after entering the ward/room, after using the toilet and before eating Visitors should be instructed to wash their hands on entry and leaving the ward/room Protective clothing should only be worn by relatives if appropriate e.g. when carrying out `hands on care' Provide service users, relatives and carers with the relevant information, leaflets etc Transport of Infected/Infectious Patients Where at all possible the service user will not be transported to other venues unless emergency dictates, liase with ambulance control and complete appropriate Appendix 3 Visitors/Service Users/Carers Explain the precautions required whilst maintaining the service users confidentiality Discourage visitors from having contact with other service users in the ward Post Isolation Discharge/Death New service users must not be admitted to the room until it has undergone a special deep clean. Refer to PCT Cleaning policy Dispose of any unused disposable items that may be contaminated Clean all equipment and belongings before the service user comes out of isolation or prior to further use In the case of death follow standard infection control precautions Protective Isolation Protective isolation is required for service users who are immuno-compromised /immunosuppressed in order to prevent the acquisition of infection from other service users, staff or visitors. Immunocompromised service users vary in their susceptibility to infections, depending on the severity and type of immunosuppression. The measures that follow are in addition to standard infection control precautions. A single room is required for neutropenic service users (defined as a neutrophil count of <0.5) to prevent the acquisition of infection by immunocompromised service users. If a single room is not available then a risk assessment must be undertaken (For further advice check the table at the end of policy Appendix 4))


Preparation of room prior to admitting a neutropenic service user [these service users are unlikely to be admitted to Henderson Ward but it may occur] Side room must be cleaned before the service user is admitted including clean mop head. (Designated equipment for the use of cleaning protective isolation rooms should be used) Ensure that there are plastic aprons and non-sterile gloves available outside the service users' room Remove any unnecessary equipment and furniture from the room Equipment in the isolation room must, as far as possible, be dedicated for the use of that service user If an en-suite toilet is not available, then an adjacent toilet or commode must be thoroughly cleaned and placed for the dedicated use of the neutropenic service user Place `Protective Isolation' sign on the outside of the door Advise service user to keep personal effects to a minimum Keep the door of the room closed Please seek further advice/information from haematology specialist nurse at based at North Bristol Trust Care of the service users in protective isolation General precautions Hand decontamination must be strictly adhered to (refer to PCT Hand Hygiene Policy) Staff and visitors must wear plastic aprons if they are performing clinical care or assisting the service user with hygiene activities. Aprons must be disposed of as clinical waste in the room, except when transporting body fluids to the sluice Gloves are required for contact with blood or body fluids as per standard precautions Visitors Limit the number of visitors Prohibit visitors with symptoms of infections or known exposure to infections e.g. chicken pox Discourage visitors with small children Note neutropenic food guidelines No flowers or plants to be brought in for these service users

Service Users Hygiene Service users must receive education on good hygiene practices Disposable single use wipes / cloths should be provided for washing Face cloths / flannels must not be used


Skin must be kept clean by daily bathing or washing Service users may use the baths in the ward providing they are cleaned thoroughly before each service users' use. No sharing of toiletries / equipment Oral hygiene must be performed Service users psychological care Service users in protective isolation must receive psychological support and reassurance regularly throughout each shift Ensure service user has contact with the outside world where possible by facilitating access to services such as television, radio and newspapers Diet Service users must be provided with sterile drinking water available to order from Southmead Pharmacy Service users must not be given ice from ice machines Service users should receive a clean diet which is cooked / provided by the hospital to protect from food borne organisms Further advice for neutropenic service users can be sought from the haematologist on duty at NBT and the Infection Control Team.



Risk assessment of alert organisms and the use of the available isolation rooms Also refer to relevant individual policies relating to the specific organism. Any service user suspected or known to be colonised or infected with an infectious agent that may pose a risk to others must be isolated in line with this policy. Due to the lack of isolation facilities it is recognised that at times single rooms will need to be prioritised. The following information will help in this risk assessment process. Code 3 2

1 *

High priority for an isolation room. Discuss with Infection Prevention and Control Senior Nurse (IPCSN) if a single room is not available. Single room required. Assess all service users currently in side rooms. If side room still unavailable nurse in a main bay away from other vulnerable service users e.g. service users with open wounds, or invasive devices, immunocompromised service users etc. Move to a single room as soon as possible. Discuss further with Prevention and Control of Infection Senior Nurse if required. Low risk. Single room or cohort bay preferable, but may be nursed in a bay providing other service users in the bay are not vulnerable. Contact tracing may be required for these service users.

This is not an exhaustive list please discuss with the Prevention and Control of Infection Senior Nurse or the NBT microbiologist on call if there are any major concerns regarding individual service users. NB. Consider the possibility of a transmissible infection for any service user with an undiagnosed rash if associated with symptoms attributable to possible infection

Adapted from Jeanes et al 1999

Alert Organism Avian influenza Blood borne virus e.g. HIV, Hepatitis B,C Clostridium. Difficile (c.diff) Risk Factors Level 3* Assess the service user. Diarrhoea Asymptomatic CJD Rash developed within the previous 10 days Rash still wet All lesions crusted and at least 10 days 0 3 0 0 Isolation Requirement Inform Infection Control or Microbiologist on call immediately if diagnosis is suspected. Isolation not required unless there is a high risk of blood or blood stained body fluid splash. Symptomatic with diarrhoea and C diff toxin positive or suspicion of C diff. Once symptom free for 48 hours the service user no longer requires isolation, but watch carefully for recurrence of symptoms. See CJD policy for advice re surgical invasive procedures. Inform microbiologist on call immediately if diagnosis is suspected to ensure safe handling of specimens. Only staff with a history of Chicken pox (or serologically confirmed immunity) should have contact with this service user As above

Chicken Pox

3* 3* 0


since onset Extended Spectrum BetaLactamase (ESBL) producing organisms in urine

Catheterised or incontinent Service users


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

ESBL producing organisms in other sites. vancomycinresistant enterococci (VRE) Influenza Measles Suspected meningitismeningococcal Meticillin Resistant Staphylococcus aureus

Continent service user Assess individual risks e.g. weeping wounds etc. Lesions dry. Assess individual risks e.g. diarrhoea, catheter Respiratory symptoms/fever

2 2 1 2

Encourage good hand and personal hygiene, clean toilet after use. If possible use a dedicated toilet. Encourage good hand hygiene and personal hygiene. If possible use a dedicated toilet. Discuss with IC team if required.

Encourage good hand hygiene and personal hygiene. Dedicated toilet if service user has diarrhoea Discuss with PCIN if required. Up to 7 days after onset in children and immunosuppressed individuals until 5 days clear of symptoms. Until 5 days after onset of rash Until 24 hours of antibiotics. Staff should inform Occupational Health if in direct contact with respiratory secretions e.g. during resuscitation of the service user. See South Glos MRSA policy and risk areas table. Isolation in high risk areas advised. Discuss with infection control if necessary. Until 9 days after onset of rash Until symptoms resolved. Only staff with a history of Chicken pox (or serologically confirmed immunity) should have contact with this service user.

3* 3* 3*

(MRSA) Mumps Respiratory Syncitial virus (RSV) Shingles

Sputum Positive with productive cough or broken skin

2-3 see MRSA policy 3* 3*

Rash in an exposed area with wet lesions. If rash area covered Confirmed pulmonary with a productive cough.


2 NB. Only staff with history of BCG vaccination or positive heaf/mantoux test should have contact with service users who have possible or confirmed TB. Until 14 days continuous treatment and resolution of fever. Seek advice from microbiology re sensitivity test results. Isolate until 3 negative sputum specimens on microscopy.

Tuberculosis$ Suspected pulmonary Tuberculosis$ (TB) Suspected/ Confirmed MDR-TB$




Discuss with NBT respiratory nurse specialist and Infection Control. Seek advice from microbiology re sensitivity test results.


Non Pulmonary TB Quinsy Scabies Group A Streptococcus SARS ­ suspected or confirmed Often affects immunocompromised patients

0 3 3*

Unless aerosolising procedures are being under taken or draining wounds etc or undergoing surgery. Until 48 hours after appropriate antibiotics commenced Until course of treatment has been completed

3 3*

Until 48 hours of appropriate antibiotics. Inform Infection Control or Microbiologist on call immediately if diagnosis is suspected.

Henderson Ward to use adopted Plymouth Infection Priority system to risk assess patients ­ see appendix 4



Implementation All Ward staff will understand Plymouth screening policy following ward-training sessions


Audit Appropriate use of side rooms will be monitored monthly using monitoring chart for MRSA screening + treatment form

13 References & Links to other PCT Documents: Ayliffe, G.A.J, Babb, J.R, Taylor, L.Z (2001) Hospital Acquired Infection, Principles and Prevention. Third Edition, Arnold Page 99 Department of Health (2006) The health Act 2006 Code of Practice for the prevention and Control of Health Care Associated Infections London DH, 2006 (revised 2008) Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care. London DH, 2007 Department of Health (2003) Winning Ways: Working together to reduce healthcare associated infections in England. London: DH, 2003 Jeanes A & Gopal R (1999) Lewisham Isolation Priority System (LIPS). University Hospital Lewisham Infection Control Team Plymouth NHS Trust 2009 ­ Plymouth Infection priority system Acknowledgment to: North Bristol NHS Trust North Bristol NHS Trust ICT Plymouth NHS Trust ICT SG PCT Infection Prevention & Control Policy & Guidelines Manual Parts B & C SG PCT Hand Hygiene Policy SG PCT MRSA Policy SG PCT Outbreak Policy SG PCT Standard Infection Control Precautions Policy SG PCT Cleaning Policy


Appendix 1



SG Infection Control Team


Appendix 2 ­ Isolation Nursing in an open ward non-invasive alert



Box 1 DATE: (fax sent) Box 2 ORIGIN: (Hospital/Clinical/Unit/GP's Practice) TOTAL NO OF PAGES:

Avon (West) Sector Tel: 01179280101 / 9280110 Fax: 01179292497 / 9254748

TELEPHONE NO: AUTHORISING GP/CONSULTANT: Box 3 PATIENT'S NAME: Mr Mrs Miss First Name: Surname: Box 4 FROM: (Hospital/Clinic/Unit/Home Address)

SENDERS INITIALS: (Child age .........) Other

Date of Birth:

HOSPITAL CLINIC CODE: Postcode: (If home address) Box 5 To: (Hospital/Clinic/Unit/Home Address) HOSPITAL CLINIC CODE: Postcode: (If home address) Box 6 JOURNEY DIRECTION: INWARD OUTWARD BOX 7 TYPE OF APPOINTMENT: OP ADM TRANSFER BOX 8 MOBILITY: CAR1 CAR2 BOX 9 TRAVEL DATES DAY: DATE: Time IN OUT APPOINTMENT TIME: RETURN TIME: (no returns accommodated After 1616hrs) End date: Applicable to REPEAT Bookings UFN (until further notice) Mon Tue Wed Thu Fri Sat Sun


Type of Wheelchair: Manual W/Chair STR

T/L Electric W/Chair Repeat journeys required every: Start date:


AGE ..........)



Confidentiality Notice: The document accompanying this information contains information which is legally privileged. This information is intended only for the use of the individual named above. You are notified that any disclosure, copying, distribution is prohibited. If you have received this fax in error, please notify us immediately by telephone. THANK YOU.


Appendix 4 Plymouth Infection Priority System (PIPS) Date: Clinical area: Patient Name: Hospital Number: Does the patient have an infection?: the risk assessment below) YES/NO (if Yes, please complete

Criteria ACDP Category Route Evidence of transmission Significant resistance Susceptibility of other patients* Prevalence Dispersal Total score




Characteristics of common infectious conditions

Condition or infection

Chickenpox (varicella) Clostridium difficile Diarrhoea &/or vomiting of unknown origin Ectoparasites (scabies, lice) Encephalitis (viral) Glycopeptide-resistant enterococci Gastroenteritis (campylobacter, salmonella, shigella, E.coli O157, viral incl. norovirus) Hepatitis A & E Influenza Measles, Mumps & Rubella Meningitis (viral & bacterial) Meningococcal septicaemia Meticillin-resistant Staphylococcus aureus and PVL-producing S. aureus Multi-resistant gram-negatives (incl. ESBLs) Penicillin-resistant pneumococci Respiratory syncytial virus Rotavirus Shingles (zoster) Streptococccus pyogenes (incl. scarlet fever) TB (pulmonary) Typhoid/paratyphoid fever Viral Haemorrhagic Fever Whooping Cough

ACDP Category

2 2 2 2 2 2 2 or 3* 2 or 3 ** 2 2 2 or 3*** 2 2 2 2 2 2 2 2 3 3 4 2

Mode of transmission

Air-borne/contact Faeco-oral Faeco-oral/droplet Contact Faeco-oral/contact Contact Faeco-oral/droplet Faeco-oral Droplet Droplet Droplet/faeco-oral Droplet Contact Contact Droplet Droplet Faeco-oral/droplet Contact Droplet/contact Air-borne Faeco-oral Blood-borne Droplet

Evidence of Transmission

Strong Strong Strong Strong Poor Strong Strong Poor Strong Strong Moderate Moderate Strong Strong Strong Strong Strong Moderate Strong Strong Weak Moderate Moderate

Specific guidance

Isolate until 48 hours symptom-free Review with Microbiology results Isolate for first 24 hours of treatment

Moderate risk of E.coli O157 Isolate for first 7 days of jaundice

Isolate for first 24 hours of treatment High risk for skin disperses and expectorating infected sputum

Isolate for first 24 hours of treatment Isolate for first 14 days of treatment Contact On-Call Microbiologist Urgently Isolate for first 5 days of treatment

*Shigella dysenteriae Type 1 and verocytotoxigenic E.coli (e.g. O157:H7, O103) are ACDP Category 3 ** Hepatitis A is ACDP Category 2 and Hepatitis E is Category 3 *** Rare imported causes that are ACDP Category 3 include Japanese B, Murray Valley, St Louis, Russian Spring Summer, Eastern Equine, Western Equine and Venezuelan Equine Encephalitis, as well as West Nile Fever.


Scoring for the Plymouth Isolation Priority System Criteria

ACDP Category


2 3 4 Air-borne Droplet/Faeco-oral Contact Blood-borne Strong Moderate Poor Nil Yes No Yes No Sporadic Endemic Epidemic High risk* Moderate risk** Low risk


5 10 40 15 10 5 0 10 5 0 -10 5 0 10 0 0 -5 -5 10 5 0



Evidence of transmission

Significant drug resistance High susceptibility of other patients Prevalence

MRSA, GRE, resistant coliforms Specific for different infection and patient populations


For contact and droplet transmission

Total Score

* Includes exfoliative skin conditions (e.g. eczema, psoriasis), faecal incontinence, expectorating infected sputum and tracheostomy secretions ** Includes organism in catheter urine sample or wounds



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