Isolation - Infection Prevention & Control

Publication: 01/06/2000  --
Last review: 05/02/2018  
Next review: 05/02/2021  
Clinical Guideline
CURRENT 
ID: 678 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Isolation

Summary of Guideline

This guideline describes the measures to be taken by clinical teams when a patient requires isolation.  Source isolation is required when a patient is identified with a suspected or known transmissible alert organism/condition; protective isolation is required for those patients who are at significant risk of infection due to a compromised immune system for their own protection.

The different categories of isolation are as follows: 

  • Source Isolation for patients who are sources of pathogenic micro-organisms that have the potential to spread to other patients and/or staff.

Protective isolation for patients who are at significant risk of infection due to a compromised immune system.

  •  Standard Infection Prevention and Control Precautions must be observed at all times with all patients, including those in isolation.
  • A risk assessment to identify if a patient requires isolation must be conducted on all patients on admission and at a minimum a daily re-assessment and re-evaluation of each patient in isolation must be documented in the nursing notes to ensure appropriate use of isolation facilities.
  • The decision to isolate a patient should be based on whether the patient has a suspected or diagnosed alert organism or condition.  A comprehensive list of alert organisms/conditions that require source isolated can be found in the LTHT guideline:  )Infections (Alert Organisms And Conditions) That Require Source Isolation  Every patient with a suspected or known transmissible alert organism or condition should be placed in isolation and the appropriate isolation practices should be taken.
  • Isolation should occur within two hours of the clinical area deciding there is a need to isolate.  If this is not possible in the patient’s current location, escalation procedures must be followed (Appendix K).
  • The number of staff entering the isolation room should be kept to the minimum required for patient care.
  • Staff with an infection or potential infection should not enter a room in which a patient is being nursed in protective isolation.
  • LTHT isolation signage must be activated at all times.

 

All staff entering the room must be aware of the necessary precautions.

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Background

Isolation precautions are adopted to minimise the risk of spread of an infectious
diseases in the hospital setting. Evidence has been found that patient isolation alongside other measures results in the reduction of the spread and colonisation of infections (Ho et al 2013).
Landelle et al 2012 state, it remains the most effective and essential method of preventing transmission. 

This guideline is based on national guidelines that review and require assurance that there is a managed environment, which minimises the risk of infection to patients, staff and visitors.

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Appendix A - Requirements for source isolation

Requirement for source isolation
The type of source isolation required will depend on the mode of transmission of the organism concerned and may be one of two types: 

  • Standard source isolation (contact precautions) where the route of transmission is through direct/indirect contact with an infected person
  • Respiratory isolation (airborne/droplet precautions) where the main route of transmission is airborne or through respiratory droplets

The principles below apply to both categories of source isolation.  Where respiratory isolation is indicated additional measures need to be taken as described below (page 7).
Assessing the need for source isolation
A requirement for isolation may be suggested by a clinical presentation (e.g. presence of an “alert condition” such as diarrhoea/vomiting with unknown cause) or a microbiological result (e.g. isolation of an “alert organism” such as MRSA).
The need to isolate is based on whether the patient has a suspected or diagnosed alert organism or condition. The following list identifies some examples of the common alert organisms/conditions that require isolation:

  • Diarrhoea (stool type 5-7 according to the stool record chart)/+/- vomitting - if of unknown origin until organism known or reason for diarrhoea/vomitting identified.
  • Clostridium difficile infection (CDI)
  • Suspected norovirus – patient must be vomiting or having diarrhoea and the cause is as yet unknown. Inform the Infection Prevention and Control Team (IPCT).
  • Confirmed MRSA positive infection.

A comprehensive list of alert organisms/conditions that require source isolated can be found in the Infections (Alert Organisms And Conditions) That Require Source Isolation that require source isolation. There are also specific LTHT guidelines and policies available for some individual alert organisms (ref. Leeds Health Pathways).

Process for achieving source isolation

  • When a requirement for isolation is identified the time and date at which this decision is made should be documented.
  • The patient must be nursed in a single room with a hand wash basin and preferably an en-suite toilet.  If an en-suite toilet is not available, a commode for sole use of the isolated patient should be kept in the isolation room for the duration of the patient’s stay.
  • Isolation should occur within two hours of the clinical area deciding there is a need to isolate.  A Datix web must be completed by the clinical area on all occasions this does not occur.
  • If isolation within two hours is not achieved there must be escalation to the Matron for the clinical area (in hours), Clinical Site Manager (CSM) (out of hours), to ensure appropriate placement.
  • If the Matron or CSM is unable to find side room accommodation, this must be escalated to the Directorate Manager in hours or on call Manager out of hours.  
  • If isolation is not possible the Matron will contact the IPCT in hours and the CSM will contact the on call microbiologist out of hours, with the required patient information (Appendix J), for a risk assessment.
  • The date and time isolation is achieved must be documented.
  • Cohort source isolation may be considered for patients who have been identified as having the same, organism/suspected organism, or clinical risk category (Appendix L).  This must be in bay areas with doors and floor to ceiling partitions.  Cohorting patients carries a significant risk of re-infection/re-colonisation if one of the cohorted patients become clear of the organism/condition for which they are isolated therefore cohorting should be considered only in situations where single room source isolation is not possible and for the shortest time possible.  Cohorting should be reported on the incident reporting system (datix) as an ‘inability to isolate’.
  • Unless cohort source isolation is carried out according to the provisions of an existing policy/guideline. Where cohorting is advisable in certain situations) cohorting must be agreed with a member of the IPCT (in hours) or the on-call Consultant microbiologist (out of hours).  The Microbiologist will require specific information, found in Appendix J, in order to provide accurate advice.
  • There may be instances in which a more significant operational or clinical risk is identified and where assessment of the risks indicates the impact of IPC recommendation would be detrimental.  When it is not considered possible to implement the recommendations of the consultant microbiologist or IPCT this must be escalated to the Matron (in normal working hours) or Clinical Site Manager (out of hours).  Full details of escalation process can be found in Appendix K.
  • The matron for the clinical area must record all inability to isolate daily and report to the directorate manager. Out of hours the clinical site managers will include all inability to isolate in the clinical site managers daily out of hours report which is received by the Directorate Manager and Matron for that area.
  • The continuing requirement for isolation must be re-assessed at a minimum daily and documented in the nursing notes, in consultation with the IPCT if necessary.

Immunocompromised patients: immunocompromised patients displaying symptoms suggestive of certain infections should be source isolated in a negative pressure single-room, standard single-room or positive pressure ventilated lobby (PPVL) side-room.  Positive pressure single rooms (where there is airflow from room to corridor) are not suitable for patients with certain infections.  If these conditions cannot be achieved the escalation procedure should be followed.  The relevant Infection Prevention Guideline/Policy, e.g. for Respiratory viruses, and LTHT Adult Haematology Unit Ward Guide provide further guidance on which infectious conditions should be in source isolation.

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Appendix B - Protective isolation

Protective isolation is the term used to describe a range of practices to protect patients who are at increased risk of infection due to a compromised immune system.  These patients are at risk of infection from their own resident flora (endogenous infection) as well as cross infection from other people (patients, staff and visitors) and the environment (exogenous infection).

Immunosuppression may occur for many reasons including organ transplants, extensive burns, some genetic disorders and infection with HIV; however it most commonly arises in oncology and haematology services.  This is due to high dose chemotherapy and occurs especially in patients with haematological malignancies who are given bone marrow or other haematopoietic stem cell transplants.


Indications for protective isolation


Patients known to be at ‘high risk’ of acquiring infection (patients undergoing stem cell transplantation (SCT), haematology/oncology patients undergoing prolonged corticosteroid therapy and/or have severe immunodeficiency) should, for their own protection, be managed in protective isolation.  The decision to initiate protective isolation measures will be made by the clinical team as part of a patient’s care plan and should take into account the reasons for, and likely duration of, the patient’s immunosuppression.  These groups of patients are largely confined to the haematology and oncology wards where local policies and guidelines agreed by the Infection Prevention and Control team should be followed.


The most common reason for placing a patient in protective isolation is if their blood neutrophil count falls, or is expected to fall, below 0.75 x 109/l. 


Patient placement
‘High risk’ patients as defined above should be placed in an appropriately ventilated room:  a single en-suite room combined with High Extraction Particulate Air (HEPA) filtration designed to maintain positive pressure in relation to the corridor.  This may be achieved by positive pressure single rooms or a positive pressure ventilated lobby (PPVL) room with the door closed.  There are single rooms in LTHT Adult Haematology (SJUH 88 & 89) & Paediatric Haemato-Oncology wards meeting these criteria.  Normally, only patients with certain haematological diseases &/or those who are neutropenic post stem cell transplant are likely to need this additional protection from airborne pathogens such as moulds.  Prioritisation for these facilities should be given to ‘high risk’ patients as defined above. 


Where a single room with positive pressure ventilation or PPVL is not available a standard single en-suite room should be used with the door closed.


Immunocompromised patients should never be placed in the same room as, or adjacent to, people with a known or suspected infection.


Immunocompromised patients displaying symptoms suggestive of certain infections should be source isolated in a negative pressure single-room, standard single-room or positive pressure ventilated lobby (PPVL) side-room.  Positive pressure single rooms (where there is airflow from room to corridor) are not suitable for patients with certain infections.  If these conditions cannot be achieved the escalation procedure should be followed.  The relevant Infection Prevention Policy, e.g. for Respiratory viruses, and LTHT Adult Haematology Unit Side Room Use/Isolation for Infection Requirements Ward Guide provide further guidance on which infectious conditions should be in source isolation. 


Management of patients


Patients in protective isolation should be managed as non-infected patients using standard infection prevention and control precautions (Ref. Standard Infection Prevention and Control Precautions ) with the exception of the additional environmental (ventilation) controls described above, and according to local policy as agreed by the Infection Prevention and Control team. 


Staff with an infection or potential infection should not enter a room in which a patient is being nursed in protective isolation.


People with symptoms of infection should be discouraged from visiting other than in exceptional circumstances. This includes toddlers and children if they have symptoms of infection including a cold.

  • Ensure a protective isolation notice is displayed on the door.
  • The isolation room door must be kept closed.
  • Hand hygiene should be performed prior to entering the room, before and after patient contact and before leaving the room (Ref. Hand Hygiene Policy - LTHT ).
  • Personal protective equipment (PPE), including disposable gloves and apron, is not required for routine entry into the room.  This need not be worn unless the staff member is to nurse or examine the patient or undertake a clinical procedure.  PPE must always be worn where risk assessment identifies a risk of exposure to blood and body fluids according to the Standard Infection Prevention and Control Precautions guideline.
  • All unnecessary equipment should be removed from the room in order to facilitate cleaning.
  • Equipment must be dedicated for use with that patient whenever possible.
  • Flowers (dried and fresh) and potted plants should be removed because moulds, including Aspergillus and Fusarium species, have been isolated from the soil of potted ornamental plants (e.g. cacti), the surfaces of dried flower arrangements, and fresh flowers.
  • Charts and patient notes should be kept outside the room to reduce the risk of cross infection.
  • The requirement for protective isolation should be constantly reviewed and documented in the light of on-going clinical assessment.

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Appendix C - Management of patients in source isolation

  • A source isolation notice must be displayed on the door of the room.
  • The isolation room door must be kept closed, with minimal entrances and exits.
  • Hand hygiene should be performed prior to donning gloves when entering the room, before and after patient contact and before leaving the room (Ref.  Hand Hygiene Policy - LTHT ).  Soap and water must be used for hand hygiene purposes in all instances whilst inside the room. 
  • Personal protective equipment (PPE), including disposable gloves and apron, must be worn for routine entry into the room.
  • All unnecessary equipment should be removed from the room in order to facilitate cleaning.
  • Single patient use equipment must be used (e.g. stethoscope, blood pressure cuff, etc); where single use equipment is not obtainable, items must be dedicated for use with the isolated patient only whenever feasible.
  • An explanation of the need for and implications of Source Isolation should be given to the patient along with the relevant information leaflets (including source isolation and organism specific).  The explanation should include the need to remain in the source isolation room and the importance of the patient adhering to good hand hygiene practices. 
  • Charts and patient notes should be kept outside the room to reduce the risk of cross infection.
  • A Source Isolation care plan should be commenced.
  • The requirement for source isolation should be constantly reviewed and documented daily in the light of on-going clinical assessment.
  • All equipment within the source isolation room must be cleaned using a solution of 1000ppm available chlorine. (e.g. Chlorine based wipesor Chlor-Clean). Staff must be trained in the use of any cleaning products before use. If chlorine based wipes areused by healthcare workers it theybe stored in the isolation room unless the nursing specialist assessment triggers the requirement for enhanced care when they should be removed for safety. If Chlor-clean is used it should be made up in a separate room and any remaining fluid removed from the isolation room and carefully disposed of. Any items that cannot be cleaned must be discarded as infectious clinical waste.  Information regarding environmental cleaning of source isolation rooms can be found in Appendix M.
  • All waste arising out of the isolation room/cohort area must be treated as infected. 
  •  The bedpan should be covered and carefully transported to the sluice, changing PPE and washing hands as you leave the room.
  • All linen that has been in the isolation room/cohort area must be treated as contaminated, even if it has not been used, placing it into an alginate bag inside a red laundry bag.
  • If the patient requires a bath/shower and the isolation room is not en-suite, they must go directly into the bathroom and the bath/shower cleaned immediately after use using chlorine based disinfectant.
  • There may be circumstances when the patient requests to go out of the ward in which case a risk assessment must be undertaken; in no circumstances should the patient go to any communal areas of the hospital (including waiting areas) or mix with other patients unless this has been agreed by the IPC team.

 

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Appendix D - Visitors to patients in isolation

 

  • Explain the reason for isolation, maintaining confidentiality where appropriate.  Provide a Source Isolation information leaflet (Print Unit WNA 974).
  • Visitors should be advised to wash their hands with liquid soap and water as follows:
  • Immediately before entering and prior to leaving the isolation room
  • Following close physical contact with the patient or his/her immediate environment
  • After removing gloves and apron when worn (see below)
  • Disposable gloves and apron need only be worn by visitors when they are going to have close contact with the patient (e.g. helping with patient’s physical care). The IPCT may advise on other situations when this is necessary.
  • Visitors should be advised not to have contact with other patients on the ward.
  • For some infections it may be necessary to exclude visitors from isolated patients, due to disease susceptibility. Advice should be sought from the IPCT and/or the specific disease policy.

 

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Appendix E - Investigations/visits to other departments

Ideally, investigations should be performed in the isolation room.

  • If visits to other departments/wards are unavoidable, the receiving department must be contacted to ensure that adequate IPC measures, (e.g. single room accommodation or segregated area within the department, appropriate PPE and hand washing practices) are taken to reduce the risk of cross infection. If there are any problems the IPCT should be contacted immediately.
  • The patient from the isolation room should be seen last in the visiting department.  If waiting occurs in that department the patient in isolation needs to be physically separated in another room to minimise contact with other non- infected patients.
  • Hand hygiene and personal protective equipment procedures should be closely followed when transferring an infected patient, therefore porters and escorting staff should wear aprons when transferring patients.

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Appendix F - Transfers to other wards and healthcare organisations

 

  • Transfer and movement of patients should be kept to a minimum in order to reduce the risk of transmission of infection and should only take place for clinical reasons (see Transfer and Handover of Care Procedure).
  • The Transfer check list form should be completed for all patients
  •  The receiving ward must be informed so that a room for source isolation can be arranged.
  • The patient’s health should take priority over the infection problem and will require clarification by the clinical team, e.g. if the patient is required to be transferred to ICU or CCU.
  • Hand hygiene and personal protective equipment procedures should be closely followed when transferring an infected patient, therefore porters and escorting staff should wear aprons when transferring patients.

 

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Appendix G - Ending source isolation

  • A patient should be removed from isolation when he/she is no longer at risk of spreading infection to others (Ref.) Infections (Alert Organisms And Conditions) That Require Source Isolation). This may be decided following consultation with a member of the IPCT or on the basis of an IPCT guideline or policy (e.g. after 48 hours free of symptoms following gastroenteritis).
  • If in doubt, discuss with the IPCT.
  • The vacated room must be cleaned thoroughly following the Trust Discharge Cleaning Protocol using the same solutions and equipment that have been used for source isolation cleaning.  Some source isolation rooms will require decontamination using Hydrogen Peroxide Vapourisation in addition to thorough cleaning with a Chlorine-based agent and curtain change; the level of clean/decontamination required for different situations is indicated on the LTHT RAG guidance poster for terminal bed space cleaning.
  • All equipment and belongings must be cleaned before being brought out of the room or used again.  Any unused items that cannot be cleaned must be discarded as infectious clinical waste.  Any linen, used and unused, must be treated as infected and placed into an alginate bag inside a plastic laundry bag.  Walls do not need to be washed unless visibly soiled or otherwise requested by the Infection Prevention and Control Team.

 

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Appendix H - respiratory isolation

Where the route of transmission is airborne or through respiratory droplets additional measures to those outlined in standard source isolation (above) must be taken:
Personal protective equipment:

  •  
    • See Respiratory Viruses and Tuberculosis (Including Multi drug and Extensively Drug Resistant Tuberculosis) guideline.:
    • There may be a requirement to wear masks when looking after patients with certain respiratory infections. In certain circumstances this requires a FFP3 mask to be worn
    •  An FFP3 mask/respirator is a specially designed face mask and staff must be fit tested prior to initial use for their own protection, in order to ensure adequate protection, and to comply with Health and Safety regulations.  Fit testing will need to be repeated if the make of mask is changed or if their face shape changes.
    • If an individual fails the fit test for FFP3 masks then they must use a respirator hood which can be obtained from J20, A&E (at both sites) and theatres (Jubilee and Geoffrey Giles).

 

Management of patients: 

  • As for standard source isolation (above)

Respiratory hygiene/cough etiquette:

  •  
    • Patients should receive active instruction and adequate supplies to ensure they cover their mouth and nose when coughing/sneezing and use tissues to contain respiratory secretions.
    • Provision should be made for patients to dispose of tissues into an appropriate waste receptacle prior to discarding into infectious clinical waste bin.
    • Provision should be made for patients to perform hand hygiene after contact with respiratory secretions and contaminated items.

Movement/Transportation of patients:

The movement and transport of patients from the segregated area must be limited to essential purposes only. If transport or movement is necessary, minimise patient dispersal of droplets by ensuring that, when medically possible, the patient wears a surgical mask during transport and until their return to the segregated area.

 

 

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Appendix I - Psychological impact of isolation

Studies have shown the association between isolation and patients’ psychological well-being. Some patients may find it beneficial to leave their isolation room for short periods of time for mobilisation periods. Through discussion with the IPC team it may be agreed that some patients can leave their source isolation rooms for short periods of time as long as they avoid public spaces (e.g. shops, canteen), other patients and people with infections whilst maintaining hand hygiene upon exit and re-entry onto the ward and side room. This must be explained to patients. 

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Appendix J - Information required before contacting IPC for source isolation risk assessment

The information that needs to be available when assessing the risk of transmission of infection (cross-infection) includes:

  • Symptoms of clinical infection e.g. purulent discharge, diarrhoea and/or vomiting and coughing/expectorating patient
  • The site or specimen from which the infection has been isolated (e.g. wound swab, sputum etc.)
  • The environment in which the patient is being managed (i.e. the susceptibility  of other patients to the infection)
  • The organism that is causing the infection (if known)
  • The behaviour of the patient (e.g. tendency to wander, disruptiveness, mobility etc.)
  • Psychological and other medical factors (e.g. presence of depression/anxiety, need for observation etc.)
  • Existence of failure to isolate resulting in patients with infections being nursed in open bays
  • Clinical requirements e.g. speciality specific treatment/care

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Appendix K - Escalation procedure for inability to isolate within two hours

On occasions it may not be possible to place all patients who require source isolation appropriately within two hours. Inability to isolate will require escalation to senior staff. This Appendix details the process that must be followed in this situation.

Risk Assessment process for Source Isolation
The risk assessment process is described in the Source Isolation section of this guideline, which states that if isolation is not achieved within two hours ‘’there must be escalation to the matron for the clinical area (in hours), clinical site manager (out of hours), to ensure appropriate placement. ‘’If the Matron or Clinical Site Manager (CSM) is unable to find side room accommodation, this must be escalated to the Clinical Service Unit (CSU) Manager in hours or the manger on call out of hours.

The Consultant Microbiologist on call is responsible for the clinical decision on which patient(s) should be isolated/cohorted in order to control the spread of infection.  During normal working hours this is done in conjunction with the Infection Prevention & Control (IPC) nursing team, and out of hours with the CSM. Consultant Microbiologists are on call 24 hours per day for a week at a time (Monday-Monday 09:00-09:00) therefore out of hours calls must be for emergencies only, i.e. those that require urgent action before the next working day.

In order to clarify the decision-making process, requests will be considered by the on-call Microbiologist only if they are made by the IPC Team (in hours) or CSM (out of hours), and when all possibilities to isolate the patients who require isolation have been exhausted.  Other staff requiring these decisions should work through the IPC Team or CSM.


In order to make this decision the Microbiologist will require the following information:

  • The infection status of each patient on the ward
  • A description of the physical layout of the wards (ideally with a map) including
    • Number of beds
    • Number and type of bays
    • Number and location of side rooms
    • Whether any parts of the wards patient are part of a corridor for through traffic bed areas
    • Symptoms of clinical infection e.g. purulent discharge, diarrhoea and/or vomiting and coughing/expectorating patient
    • The site or specimen from which the infection has been isolated (e.g. wound swab, sputum etc.)
    • The organism that is causing the infection (if known)
    • The behaviour of the patient (e.g. tendency to wander, disruptiveness, mobility etc.)
    • Psychological and other medical factors (e.g. presence of depression/anxiety, need for observation etc.)
    • Current/recent incidences of ‘’inability to isolate’’ resulting in patients with infections being nursed in open bays.
    • Clinical requirements (e.g. speciality specific treatment/care or clinical reasons why Source Isolation might compromise patient safety)

It will not be possible for the Microbiologist to make a decision on source isolation if this information is not available.
When the Microbiologist is satisfied that he/she has all the information required, he/she will make a decision as to which patient(s) should be isolated/cohorted according to his/her best judgement, and will communicate this to the IPC Team or CSM as appropriate.

Reporting
Decision to isolate/cohort
The Microbiologist will notify the IPC Team of the decision either directly (in hours), by voicemail to the IPC contact telephone number (out of hours) or by telephone at the start of the next working day.


Inability to isolate
The Matron for the clinical area must record all inability to isolate daily and report to the CSU Manager.  Out of hours the CSM will include all inability to isolate in the CSM morning hand over report, which is sent to the CSU Manager and Matron for that area.  Inability to isolate should be recorded and reported as above, but not communicated to the on-call Microbiologist.
There may be instances on which, for operational or clinical reasons, it is not considered possible to implement the recommendations of the consultant microbiologist or IPC Team. The decision to overrule the final IPC recommendation must be escalated to the level of Matron (in normal working hours) or CSM (out of hours) if the reason is operational, or clinical consultant, if the reason is clinical. This would need to be recorded as "inability to isolate" on the incident reporting system (datix).

All instances of "inability to isolate" should be recorded by the clinical team using datix and any other local reporting process. Out of hours in addition to datix, each instance should be included in the CSM morning hand over report which is received by the CSU Manager and Matron for that area.

The CSM will include all out of hours instances of inability to isolate. There is no requirement to report instances of inability to isolate to the on-call Microbiologist.

 

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Appendix L - Cohort source isolation

Standard Operating Procedure for Cohort Isolation
Cohort isolation may be considered for patients who have been identified as having the same organism/suspected organism or clinical risk category.  Cohorting patients carries a significant risk of re-infection/re-colonisation if one of the cohorted patients becomes clear of the organism/condition for which they were isolated.  Cohorting of patients, therefore, should only be considered in situations where single room isolation is not possible and for the shortest possible time.

The basic principles of source isolation must be used for cohort nursing

Preparation of the bay

  • Ensure the bay has floor to ceiling partitions
  • Ensure that the bay has doors on and these are closed
  • Ensure there is a sign on the bay door indicating that the bay is closed and instructions for hand hygiene and use of PPE
  • Ensure that single use gloves and yellow aprons are available inside and outside the bay  If there is no enclosed apron dispenser in the bay use a pouch apron dispenser for the duration of the bay closure.  A trolley must not be used in the bay as the contents would become contaminated
  • Ensure that the bay has a sharps bin present
  • Ensure that the waste bins contain infectious clinical waste bags
  • Dedicate a toilet for use by patients within this bay (use sign) -if is this is not possible a risk assessment will be undertaken by the ward staff and the IPN 
  • Remove any unwanted items from the bay
  • Ensure the patients lockers and tables are clutter free
  • Patients Kardex are kept in a cleanable folder
  • Dedicate a stethoscope and BP cuff for use in the bay which is cleaned with the Trust approved chlorine releasing agent in-between patient use

Before entering the Closed Cohort Bay

  • Decontaminate your hands 
  • Put on yellow single use apron to indicate that you are entering a closed bay
  • Close the door behind you
  • Leave all unnecessary items e.g. personal stethoscopes, medical note trolley outside the bay
  • Decontaminate your hands 

In the Closed Cohort Bay

  • A yellow single use apron must always be worn in closed cohort bay.
  • If you are to have minimal contact with the patient’s environment, e.g. giving out meals or medication, decontaminate your hands after this contact; there is no need to change apron unless it has come into physical contact with a patient’s immediate environment.  For example 
  • A dedicated member of staff in the closed bay gives out meal trays by placing them on the patients table:  decontaminate hands, there is no need to change apron between patients, however if patients require assistance with their nutritional needs then aprons must be changed after every patient/patient environment contact. 
  • If going to perform patient care or be in potential contact with body fluids single use gloves must be worn.  These must be changed (and hands decontaminated) along with the apron once the procedure is finished. 
  • The bedpan should be covered and carefully transported to the sluice, changing PPE and washing hands as you leave the room.  
  • Minimise the number of people entering the closed bay, for example
  • When giving out meals one member of staff should remain in the bay while a second   passes meals through
  • One doctor only to enter the cohort bay during ward rounds.

 

On leaving the Closed Cohort Bay

  • Remove apron (and gloves if you are wearing them) and dispose as infectious clinical waste.
  • Wash your hands with soap and water and leave the bay closing the door behind you.

Cleaning
The bay and patient care equipment must be cleaned as in source isolation (see Appendix D).

 

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Appendix M - Environmental cleaning in source isolation

  • The nursing staff on the ward will notify the facilities supervisor for patient environment and ward housekeepers when Source Isolation cleaning is required. 
  • A source isolation sign will be displayed at the entrance to the isolation room or cohort facility by the nursing staff to alert clinical and non-clinical staff that the patient/s are in source isolation.
  • The facilities supervisor for patient environment will ensure that all staff working in the area are aware of the cleaning procedure for the cleaning of isolation rooms, areas or cohort facilities.
  • It is the nurse’s responsibility to ensure that all patient care equipment that is used in isolation rooms is cleaned. Please see Cleaning Information Portfolio for list of patient care (shared) equipment.  A copy of this is kept by the ward manager.
  • All patient care equipment in the room should be cleaned daily using a solution of 1,000 ppm available chlorine (e.g. Chlorine based wipes 1000ppm or Chlor-Clean). Staff must be trained in the use of any cleaning products before use. If chlorine wipes used by healthcare workers it should be stored in the isolation room unless the nursing specialist assessment triggers the requirement for enhanced care when it should be removed for safety. If Chlor-clean is used it should be made up in a separate room and any remaining fluid removed from the isolation room and carefully disposed of.
  • Showers and baths must be cleaned with Chlor-Clean after use.
  • The bed space vacated by the patient being moved into source isolation must be cleaned following the Discharge Cleaning Protocol.
  • Source Isolation room cleaning must be carried out twice a day with the exception of floors that will receive one full clean and one spot clean.

 

Cleaning Equipment

  • The facilities supervisor for patient environment will supply the ward housekeepers with the necessary special cleaning equipment which is designated yellow and the Chlor-Clean tablets.
  • Chlor-Clean is obtained by the ward from supplies and should be stored in a secure cupboard.
  • The cleaning equipment and materials must be kept outside the isolation room.
  • Non sterile single use gloves and single use yellow aprons should be kept on a trolley/ shelf or dispenser outside the room.

 

How to clean the isolation room on a daily basis

  • Isolation rooms, bed spaces or cohort facilities should be cleaned after the other rooms, bays and general areas on the ward.
  • Put on single use yellow apron and gloves before entering the isolation room, area or cohort facility. Staff may have to wear facemasks on rare occasions; the nurse in charge or Infection Prevention and Control Team will advise when this is necessary. These items will be kept on a trolley/table/shelf outside the room.
  • Damp dust all surfaces with the Chlor-Clean solution using a single use disposable micro-fibre cloth. After use, dispose of cloth into an infectious clinical waste bag.  Mop the floor with a solution of Chlor-Clean.
  • When the cleaning process has been finished remove apron and gloves, dispose of into infectious clinical waste bags and wash and dry hands thoroughly with soap and water before leaving the isolation room or cohort facility.

 

Curtains

  • When a patient has a newly suspected or diagnosed infection and is moved into source isolation from a general ward area, in most situations the curtains around the bed from which the patient is moved must be changed as part of the terminal bed space cleaning process.
  • Patients with suspected or diagnosed infection who are in source isolation, in most situations curtains will need to be changed and laundered (or replaced if disposable paper curtains are used) as a component of the terminal cleaning process.

 

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Provenance

Record: 678
Objective:

Aims

To ensure that source / protective isolation procedures are in place in order to minimise the risk of infection to patients and staff.

Objectives

To minimise the risk of transmission of harmful micro-organisms to patients, staff and visitors from patients with suspected or known transmissible alert organism/condition.

Clinical condition:

Any patient with a known or suspected transmissible alert organism/condition

Target patient group: All patients at LTHT
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Ayliffe GAJ, Lowbury EJL, Geddes AM and Williams JD.  Control of Hospital Infection – a Practical Handbook, 3rd Edition.  London: Blackwell Scientific Publications, 1988: 70.

CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee

 

Day, H., Perencevich, E., Harris, A., Gruber-Baldini, A., Himelhoch, S., Brown, C., & Morgan, D. (2013). Depression, Anxiety, and Moods of Hospitalized Patients under Contact Precautions. Infection Control & Hospital Epidemiology, 34(3), 251-258.

DH (2011) Isolating patients with healthcare associated infection:  A summary of best practice. . [online]. [Accessed 03/10/11].  Available from World Wide Web http://hcai.dh.gov.uk/files/2011/03/Document_Isolation_Best_Practice_FINAL_100917.pdf

Fawley, W., Underwood, S., Freeman, J., Baines, S., Saxton, K., Stephenson, K., . . . Wilcox, M. (2007). Efficacy of Hospital Cleaning Agents and Germicides Against Epidemic Clostridium difficile Strains. Infection Control & Hospital Epidemiology, 28(8), 920-925. doi:10.1086/519201

Friefield, Alison G et al Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases  2011:52 e56-e93

 

Ho, C., Lau, A., Cimon, K., Farrah, K. and Gardam, M., 2013. Screening, isolation, and decolonization strategies for vancomycin-resistant enterococci or extended spectrum beta-lactamase-producing organisms: a systematic review of the clinical evidence and health services impact. CADTH technology overviews, 3(1).

 

Horton R and Parker L (2002) Informed Infection Control Practice Edinburgh: ChurchillLivingstone

Humphreys H.  (2004) Positive-pressure isolation and the prevention of invasive aspergillosis. What is the evidence? Journal of Hospital Infection, 56(2) 93-100.

 

Landelle, C., Pagani, L. and Harbarth, S., 2013. Is patient isolation the single most important measure to prevent the spread of multidrug-resistant pathogens?. Virulence, 4(2), pp.163-171.

 

 Loveday, H. P., et al. "epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England." Journal of Hospital Infection 86 (2014): S1-S70.

National Institute for Health and Care Excellence (2014). Infection, prevention and control: Quality Standards. [Online]. https://www.nice.org.uk/guidance/qs61. [Accessed 8 June 2017].   

National Institute for Health and Care Excellence (2003) updated 2012. Infection: prevention and control of healthcare-associated infections in primary and community care. [Online]. https://www.nice.org.uk/guidance/cg139/evidence/control-full-guideline-pdf-185186701. [Accessed 8 June 2017].

 

Tomblyn M et al 2009 Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective. Biology of Blood and Marrow Transplantation, 15: 1143-1238.

 

Wassenberg MWM, Severs D and Bonten MJM (2010) Psychological impact of short-term isolation measures in hospitalised patients. Journal of Hospital Infection, 75(2), 124-127

Wigglesworth N and Wilcox MH (2006) ‘Prospective evaluation of hospital isolation capacity’. Journal of Hospital Infection, 63, 156-161

Wilson JA, Loveday HP, Hoffman PN, Pratt RJ (2007) Uniform:an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England). Journal of Hospital Infection, 66(4), 301-307

 

Verity P, Wilcox MH, Fawley W and Parnell P (2001) ‘Prospective evaluation of environmental contamination by Clostridium difficile in isolation side rooms., Journal of Hospital Infection, 49, 204-209.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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