APPROVING COMMITTEE / Patient Safety Council
DATE APPROVED / 10 September 2014
DATE IMPLEMENTED / 1 October 2014
NEXT REVIEW DATE / 1 October 2017
ACCOUNTABLE DIRECTOR / Sue Redfern, Director of Nursing, Midwifery & Governance
POLICY AUTHOR / Karen Allen, Director of Infection Prevention & Control
TARGET AUDENCE / All clinical staff
KEY WORDS / Isolation, barrier nursing, poster, chart.
Important Note:
The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as “uncontrolled” and, as such, may not necessarily contain the latest updates and amendments.
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical) Page 1 of 13
Issue Date: 1st October 2014 Policy Reference number: STHK0041
St Helens & Knowsley Teaching Hospitals NHS Trust
Document Version History
Date / Version / Summary of key changes / AuthorDesignation
March 1986 / 1 / Service Manager Infection Prevention & Control
December 1992 / 2 / Service Manager Infection Prevention & Control
December 1994 / 3 / Service Manager Infection Prevention & Control
September 2000 / 4 / Service Manager Infection Prevention & Control
November 2003 / 5 / Service Manager Infection Prevention & Control
1 November 2006 / 6 / Service Manager Infection Prevention & Control
1 November 2008 / 7 / Service Manager Infection Prevention & Control
1 October 2011 / 8 / Format changed.
Contact details updated.
Posters revised. / Service Manager Infection Prevention & Control
1 October 2014 / 9 / Format changed. / DIPC
1 October 2017 / Review
Date / Lead Nurse, Infection Prevention & Control
CONTENTS
1. / Scope / 4
2. / Introduction / 4
3. / Statement of Intent / 4
4. / Definitions / 4
5. / Duties, Accountabilities and Responsibilities / 4
6.
6.1
6.2
6.3
6.4 / Process
General Information
Isolation precautions
For further advice and guidance
Glossary / 5
5
5
6
6
7. / Training / 6
8. / Monitoring compliance / 6
8.1. / Key Performance Indicators of the Policy / 6
8.2. / Performance Management of the Policy / 6
9. / References and Bibliography / 7
10. / Related Policies and Procedures / 7
11. / Equality analysis / 7
12. / Appendices
Appendix 1 Contact Isolation Poster / 8
Appendix 2 Airborne Isolation Poster / 9
Appendix 3 MRSA and CDT Isolation Poster / 10
Appendix 4 Protective Isolation Poster / 11
Appendix 5 Isolation Audit Tool / 12
1. Scope
This policy applies to all clinical and Medirest staff within St Helens and Knowsley Teaching Hospitals NHS Trust to ensure that appropriate actions are taken when isolation precautions are required.
This policy assists staff in the choice of correct isolation poster, ensures correct isolation procedures are followed according to diagnosed infections and thereby prevents spread of the infection amongst staff and patients.
2. Introduction
When special precautions are required for patients with an infection/infectious disease an appropriate instruction poster should be used to indicate the specific recommendations needed to provide the patient with appropriate care whilst also promoting a safe environment.
Instruction posters are available for placing on the outside of the isolation cubicle, to indicate to those entering the room the special precautions to be taken.
The instruction posters can be obtained via the intranet, on the Infection Prevention and Control website. They can be downloaded and laminated.
3. Statement of Intent
The objective of the policy is to provide information to staff on the correct choice of isolation posters. This ensures that staff and visitors are aware of the precautions required to prevent cross infection.
4. Definitions
An isolation poster instructs the person entering the room on what protective clothing to wear and what precautions are required to prevent acquisition or transfer of infection.
5. Duties Accountabilities and Responsibilities
For full details of infection control responsibilities see Infection Control Policy, Chapter 28B Infection Control Manual.
5.1. Staff
It is the responsibility of all clinical staff to:
· be aware of the current guidelines.
· put these guidelines into practice.
· bring to the attention of the Unit Manager or Infection Prevention and Control Team any problems in applying these guidelines
Breaches of this policy may lead to disciplinary action being taken against the individual.
5.2. Unit managers (person in charge of a ward or department) must ensure that
· The policy is readily accessible to all staff.
· The required facilities and equipment are available to enable compliance with the policies.
· All staff within their area of responsibility have received training in the appropriate procedures with respect to infection control.
· The ADT/HEARTS/EDMS systems are checked for infection alert status when a patient is admitted.
5.3 Medirest
It is the responsibility of Medirest management to ensure that all domestic, catering and portering staff adhere to the Trust Isolation Policy.
6. Process
6.1 GENERAL INFORMATION
Isolation Poster: What is it?
The Infection Prevention and Control Team has devised four isolation posters. These are simple instructions to be placed on the outside of the door of a patient in a single room who has a condition that could potentially spread infection. There is another poster, a protective isolation poster that should be placed on the outside of the door of patients particularly vulnerable to the acquisition of infections.
Transfers to other wards and departments
The receiving ward or department should always be informed in advance when a patient is transferred. Staff should indicate on investigation request forms when a patient has an infection/infectious disease. This ensures that staff handling patients with infections are aware of the precautions required to prevent cross infection and promote a safe environment. The infection has to be documented on the transfer form or discharge letter.
6.2 ISOLATION PRECAUTIONS
A. Contact isolation poster
Used to prevent the dissemination of infections normally spread by direct contact/or contact with any body fluids or secretions and articles which have been in close contact with the infected patient e.g. antibiotic resistant coliforms/pseudomonas, Group A streptococci, gastro-intestinal infections.
B. Airborne isolation poster
Used to prevent infection with airborne pathogens: those that are transmitted by large/small droplet nuclei and generated in the course of talking, coughing, sneezing and during procedures involving the respiratory tract i.e. suction. e.g. tuberculosis (TB), chickenpox, shingles.
C. Meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile (CDI) isolation poster
Used specifically for patients with MRSA and CDI. These are compliant with national guidelines on the prevention of spread of MRSA and CDI.
D. Blood and body fluid isolation poster (universal/standard precautions)
(No poster required)
Used to prevent infection with blood borne disease. Health Care Workers who come into contact with blood, secretion and excreta may be exposed to pathogens including blood borne viruses such as HIV (human immunodeficiency virus), hepatitis B and C. As it is impossible to identify all those with infection it is recommended that all body fluids are regarded as potentially infectious and universal precautions are used.
E. Protective isolation
This is used to prevent both airborne infections and those spread by direct contamination to susceptible patients (e.g. those immune-suppressed by disease or drug therapy). Precautions are therefore to prevent contamination by direct contact and by self infection (endogenous) from patient’s natural flora.
NB. These patients should not be nursed in the vicinity of infected patients.
Copies of isolation posters are available from the Infection Prevention and Control Nurse Specialists. Copies of isolation posters can also be obtained from the Infection Prevention and Control website. Do not photocopy posters. Only computer-generated posters or those available from the Infection Prevention and Control Nurse Specialists are acceptable. All posters need to be laminated. If in doubt as to which precautions to use, check Chapter 12, Infection Control Manual.
6.3 Further advice
For further advice and guidance please contact:
Lead Nurse, Infection Prevention and Control
Ext: 1193
Clinical Nurse Specialists, Infection Prevention and Control
Ext: 2452/1384
Consultant Microbiologists
Ext: 1836/1622/1834 or duty microbiologist out of hours
6.4 Glossary
CDI: Clostridium difficile infection
MRSA: Meticillin resistant Staphylococcus aureus
7. Training
Training required to fulfil this policy will be provided in accordance with the Trust’s Induction Mandatory and Risk Management Training Policy - Training Needs Analysis.
8. Monitoring compliance with this document
8.1 Key performance Indicators of the Policy
Describe Key Performance Indicators (KPIs) / Frequency of Review / LeadInfection Prevention Society Audit Tool for isolation precautions (Appendix 5) / Annual / Lead Nurse, Infection Prevention & Control
8.2 Performance Management of the Policy
Aspect of compliance or effectiveness being monitored / Monitoring method / Individual responsible for the monitoring / Frequency of the monitoring activity / Group / committee which will receive the findings / monitoring report / Group / committee / individual responsible for ensuring that the actions are completedCompliance with audit tool Appendix 5 / Ward audit / IPCT / Annual / HIPG / HIPG
9. References/ bibliography
9.1. Department of Health 2008. The Health Act 2008. Code of Practice for the Prevention and Control of Health Care Associated Infections.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110435.pdf
10. Related trust policy/procedures
Chapter 4
Policy for the Patient in Isolation
Chapter 5
Personal Protective Equipment Policy
Chapter 12
Isolation Policy
11. Equality analysis
Please refer to the overarching document which covers all chapters of the Infection Control Manual. http://nww.sthk.nhs.uk/MANAGE/library/documents/EqualityAnalysisforICM.pdf
Appendix 1: Contact Isolation Poster
STAFF MEMBERS
VISITORS/PORTERS/DOMESTICS
REPORT TO THE NURSE-IN-CHARGE OR
SEEK ADVICE FROM THE NURSING STAFF
BEFORE ENTERING THIS ROOM
ISSUE DATE: JUNE 2007 REVIEW DATE: DECEMBER 2014
Appendix 2: Airborne Isolation Poster
STAFF MEMBERS
VISITORS/PORTERS/DOMESTICS
REPORT TO THE NURSE-IN-CHARGE OR
SEEK ADVICE FROM THE NURSING STAFF
BEFORE ENTERING THIS ROOM
ISSUE DATE: JUNE 2007 NEXT REVIEW DATE: DECEMBER 2014
Appendix 3: MRSA and CDT Isolation Poster
Appendix 4: Protective Isolation Poster
STAFF MEMBERS
VISITORS/PORTERS/DOMESTICS
REPORT TO THE NURSE-IN-CHARGE OR
SEEK ADVICE FROM THE NURSING STAFF
BEFORE ENTERING THIS ROOM
ISSUE DATE: JAN 2011 REVIEW DATE: JAN 2014
Appendix 5: Infection Control audit tool: clinical practices- isolation precautionsStandard: Clinical practices are based on best practice and reflect infection control guidance to reduce the risk of cross infection to patients whilst providing appropriate protection to staff
N.B. This audit should be undertaken over a period of time to allow for the observation of as many practice elements as possible
Date ………………………. Ward ………………………………….. Auditor……………………………………….
Yes / No / N/A / Comments1 / Isolation facilities are available in inpatient areas
2 / Patients requiring isolation facilities due to infection have access to them
3 / Where a patient is being isolated for infection control reasons, the precautions are appropriate and according to local policy
4 / Protective clothing is readily available upon entering the isolation room
5 / Hand hygiene facilities are available, accessible and clean within the room
6 / No inappropriate or unnecessary items are stored in the isolation room (no clutter)
7 / Where a patient is being isolated for infection control reasons, the patient is aware of the need or rationale for this
8 / Clear instructions for staff and visitors are in place when a patient is in isolation (e.g. confidential notice on the door)
9 / Appropriate information leaflets are available to patients for common infections e.g. MRSA, Clostridium difficile infection (CDI)
10 / Visitors are advised that they do not routinely need to wear protective clothing
11 / Reusable equipment which may become readily contaminated is dedicated for the patients use only (e.g. Commode, hoist, sling) are they clean?
12 / Used linen, waste and crockery have been removed from the room in a timely manner
Continued / Yes / No / N/A / Comments
13 / Housekeeping staff are aware of the local policy and procedures for cleaning isolation rooms
14 / Separate colour coded cleaning equipment is in use for isolation facilities
15 / Isolation precautions are discontinued when no longer necessary
16 / Nursing documentation is outside the side room
17 / Are staff following infection control policy? i.e. wearing PPE, decontaminating hands.
18 / Are MRSA/CDI care plans evident in nursing documentation?
19 / Have CDI patients had referral to dietetics?
20 / Are fluid balance/stool posters evident in CDI patient’s documentation?
Comments:
Infection Control Manual - Chapter 4B-Isolation Instruction Posters-Version 9 (clinical) Page 4 of 13
Issue Date: 1st October 2014 Policy Reference number: STHK0041