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Source Isolation Procedures Ratified by: Infection Control & Decontamination Assurance Group: 24

th January 2017

Review date: June 2019 of 33

Source Isolation Policy and Procedures for Hospital Patients

Post holder responsible for Procedural Document

Judy Potter, Lead Nurse/Director of Infection Prevention and Control

Author of Procedure/ Guideline Judy Potter, Lead Nurse/Director of Infection Prevention and Control

Division/ Department responsible for Procedural Document

Specialist Services /Infection Prevention & Control

Contact details x2355

Date of original document 1997

Impact Assessment performed Yes/No

Ratifying body and date ratified Infection Control & Decontamination Assurance Group: 24th January 2017

Review date (and frequency of further reviews)

June 2021 (every 5 years)

Expiry date January 2022

Date document becomes live 21 February 2017

Please specify standard/criterion numbers and tick other boxes as appropriate

Monitoring Information Strategic Directions – Key Milestones

Patient Experience Maintain Operational Service

Delivery

Assurance Framework Integrated Community Pathways

Monitor/Finance/Performance Develop Acute services

CQC Fundamental Standards - Regulation: 8 Infection Control

Other (please specify):

Note: This document has been assessed for any equality, diversity or human rights implications

Controlled document This document has been created following the Royal Devon and Exeter NHS Foundation Trust Development, Ratification & Management of Procedural Documents Policy. It should not be altered in any way without the

express permission of the author or their representative.

Source Isolation Procedures Ratified by: Infection Control Operational Group: 23

rd January 2014

Review date: June 2016

Full History

Status: Final

Version Date Author (Title not name)

Reason

1.0 1997 Lead Nurse New procedure

2.0 2002 Lead Nurse Routine revision

3.0 0226 Lead Nurse Routine revision

4.0 Aug 2007 Lead Nurse Routine revision

5.0 Aug 2009 Lead Nurse Routine revision

6.0 Nov 2011 Lead Nurse Routine revision

7.0 Jan 2014 Lead Nurse Routine revision

8.0 Nov 2016 Lead Nurse Routine revision harmonised with community services requirements

Associated Trust Policies/ Procedural documents:

Avian Influenza - Guidance for the Management of Suspected Cases of Severe Imported Respiratory Virus Infections (Including Avian Influenza & MERS Cov. Care of the Deceased Patient Policy CJD & Other Transmissible Spongiform Encephalopathies Policy Clostridium Difficile Infection Policy Decontamination Policy & Procedures Group A Streptococcal Infections - Policy for the Prevention & Control of Guidelines on the Management of PVL and Other High Risk Staphylococcus Aureus Infections Herpes Simplex Information & Guidance Incident Reporting Analysing Investigating and Learning Policy Influenza - Guidance on the Management of Seasonal Measles Information & Guidance MRSA Policy Multi-Drug Resistant Organism Policy Respiratory Syncytial Virus (RSV) - Guidance on the Management of Scabies Guidance Standard Infection Control Policy & Precautions (Including Hand Hygiene) Surveillance and Reporting of Infectious Disease, Healthcare Associated Infection and Antibiotic Resistant Organisms Terminal Cleaning Co-Ordination - Guidelines for Tuberculosis Management in a Hospital Setting Vancomycin/Glycopeptide Resistant Enterococci (VRE/GRE) Guidelines Varicella Zoster (Vz) Virus, Chickenpox & Shingles Guidance Viral Gastroenteritis Guidance Viral Haemorrhagic Fever – Guideline for Risk Assessment and Management of Ward Closure due to a Suspected or Confirmed Outbreak of Infection

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Source Isolation Procedures Ratified by: Infection Control & Decontamination Assurance Group: 24

th January 2017


Key Words Barrier nursing; isolation; infectious disease containment; transmission based precautions

In consultation with and date: Infection Control Operational Group: 14th November 2016 Community Professional Leads, Senior Nurses and Matrons: 19th December 2016 Infection Control & Decontamination Assurance Group: 24th January 2017 Policy Expert Panel (PEP): 1st February 2017

Contact for Review:

Lead Nurse/Director for Infection Prevention and Control

Executive Lead Signature: (Only applicable for Strategies & Policies)

Medical Director

Source Isolation Procedures Ratified by Infection Control & Decontamination Assurance Group: 24

th January 2017


CONTENTS

1. INTRODUCTION ................................................................................................ 5

2. PURPOSE .......................................................................................................... 5

3. DEFINITIONS ..................................................................................................... 5

4. DUTIES AND RESPONSIBILITIES ...................................................................... 6

5. RISK ASSESSMENT .......................................................................................... 8

6. COMMUNICATION ............................................................................................. 8

7. ACCOMODATION .............................................................................................. 9

8. HAND HYGIENE ................................................................................................ 9

9. PERSONAL PROTECTIVE EQUIPMENT (PPE) .................................................... 9

10. VULNERABLE STAFF & VISITORS .................................................................. 10

11. EQUIPMENT .................................................................................................... 10

12. LINEN .............................................................................................................. 10

13. WASTE DISPOSAL .......................................................................................... 10

14. EXCRETA ........................................................................................................ 11

15. SHARPS .......................................................................................................... 11

16. COLLECTION OF SPECIMENS ......................................................................... 11

17. CROCKERY AND CUTLERY............................................................................. 12

18. VISITS TO OTHER DEPARTMENTS .................................................................. 12

19 TRANSFER/DISCHARGE OF PATIENTS ........................................................... 12

20. VISITORS ........................................................................................................ 12

21. ROUTINE CLEANING ....................................................................................... 13

22. TERMINAL CLEANING ..................................................................................... 13

23. LAST OFFICES ................................................................................................ 13

24. ARCHIVING ARRANGEMENTS ........................................................................ 13

25. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF

THE PROCEDURES ......................................................................................... 13

26. REFERENCES ................................................................................................. 14

APPENDIX 1: TABLES OF COMMUNICABLE DISEASES AND APPROPRIATE

PRECAUTIONS ................................................................................................ 15

APPENDIX 2: TABLE OF SPECIFIC GASTROINTESTINAL INFECTIONS ..................... 27

APPENDIX 3: MANAGEMENT OF THE CONTACTS OF PATIENTS WITH PROBABLE

MENINGOCOCCAL DISEASE ........................................................................... 30

APPENDIX 4: COMMUNICATION PLAN ...................................................................... 31

APPENDIX 5: EQUALITY IMPACT ASSESSMENT TOOL ............................................ 32


th January 2017


1. INTRODUCTION 1.1 Standard infection control precautions are the principal strategy for the prevention

and control of healthcare acquired infection. However, additional transmission based precautions are required for the care of patients who are known or suspected to be infected (or colonised) with highly transmissible or epidemiologically important pathogens. Such precautions are known as source isolation precautions and are applied, primarily, to patients in hospital but may be helpful to health professionals delivering care in the community particularly with regard to the use of personal protective equipment.

1.2 The infected/patient, as the source of infection in hospital, is segregated from

unaffected patients, usually in a single room but, on occasions, within a cohort of similarly affected patients. Physical segregation, combined with other precautions such as the use of protective clothing, is aimed at reducing the likelihood of infections spreading via the airborne, droplet or contact routes.

1.3 The extent of isolation depends on: i The infecting organism and the route of transmission ii The physical and mental abilities of the patient. 1.4 Failure to comply with these procedures could result in disciplinary action.

2. PURPOSE 2.1 This policy and associated procedures provides the information required to determine

appropriate hospital isolation precautions based on the route of transmission. However, consideration must also be given to an individual patient’s mental or physical needs which often need to be balanced against the risk of transmission of infection. Care should be planned on an individual basis taking into account the needs of the patient and susceptibility of other patients.

3. DEFINITIONS 3.1 Route of Transmission - the method by which infection or organism is transmitted

from one person to another. Understanding of the possible route of transmission is necessary to apply isolation precautions appropriately and, in particular, to select appropriate personal protective equipment.

3.2 Contact transmission

This is the often the most important and frequent mode of transmission. This may be direct contact between an infected person and a susceptible individual and includes such as touching, biting, kissing, sexual transmission and the faecal oral route. It also includes indirect contact via employees hands, inanimate objects such as furniture and toys, contaminated sharp objects e.g. needles, blades and the contaminated environment and foodborne infection. .

3.3 Droplet transmission

Large droplets are generated from the source person primarily during coughing, sneezing, and talking, and during the performance of cough inducing procedures such as suctioning.. Transmission occurs when droplets containing micro-organisms


th January 2017


generated from the infected person are propelled a short distance (approximately 1 metre) and deposited on the host's conjunctivae, nasal mucosa, or mouth.

3.4 Airborne transmission This route of transmission can be divided into two types, droplet nucleii and dust.

i Droplet nucleii Small respiratory droplets rapidly evaporate into small-particle residues [5 µm or smaller in size] known as droplet nuclei, that may contain micro-organisms. Droplet nuclei remain suspended in the air for long periods of time and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient.

ii Dust

Skin squames are shed from the skin surface at a rate of approximately 300 million a day and are the main component of dust. Some of the squames carry micro-organisms. Small dust particles may remain airborne for several hours and can be inhaled or settle in wounds.

3.5 Single room A single occupancy room with a door that can be closed. 3.5 Negative pressure isolation room

A single room that includes a ventilation system that generates negative pressure to allow air to flow into the isolation room but not escape from the room, as air will naturally flow from areas with higher pressure to areas with lower pressure, thereby preventing contaminated air from escaping the room.

3.6 Aerosol generating procedures

Aerosol-generating procedures (AGP) are those that stimulate coughing and promote the generation of aerosols e.g.

Intubation

Manual ventilation

Non-invasive ventilation (e.g., BiPAP, CPAP)

Tracheostomy insertion

Bronchoscopy

4. DUTIES AND RESPONSIBILITIES 4.1 The Board of Directors have a responsibility to promote a high level of compliance

with this policy. This responsibility is delegated to the Joint Directors for Infection Prevention and Control.

4.2 Each Divisional Management Team has a responsibility to actively encourage compliance with the policy by:

giving due consideration to the recommendations of the Infection Prevention and Control Team with regard to the provision and use of single room and cohort isolation facilities.

consulting at an early stage in planning of any service developments or building works to enable the Infection Prevention and Control Team to assess impact and advise on infection prevention and control.

https://en.wikipedia.org/wiki/Ventilation_(physiology)


th January 2017


Considering lapses to this policy at Divisional Governance Group meetings and identifying corrective measures

4.4 Infection Prevention and Control Team (ICT) including the Directors for Infection Prevention and Control are responsible for

Advising the Trust on current best practice/policy for isolation or segregation of infectious patients.

Advising the Trust on current best practice in planning isolation facilities for new construction and refurbishment work.

Providing advice to clinical teams regarding individual patient infection risks, risk assessment and minimisation, and isolation. The ICT cannot provide advice in response to every new alert organism identified in the laboratory but they provide policies, guidelines and training to ensure that clinical teams have the knowledge and resources to implement appropriate control measures in most circumstances. However, they will provide advice on request of the clinical team or when extraordinary measures are required that ward staff cannot be expected to determine for themselves.

4.5 Site Management Team is responsible for ensuring that:

Isolation facilities are provided promptly when the need is identified.

Allocation of single rooms is based on a clinical risk assessment with infection prevention and control requirements given priority over bed management/capacity issues (Healthcare Commission, 2006).

When isolation facilities are not available that the Infection Prevention and Control Team are informed and their advice taken on risk minimisation

Patients with infection prevention and control alerts are not transferred to other wards unless their clinical need dictates (refer section 9).

4.6 Clinical staff providing patient care are responsible for:

Assessing patients on admission for risk of infection including ensuring that there are systems in place to check for infection prevention and control alerts on PAS on admission and, following admission on the e-whiteboard on a daily basis.

Ensuring that suspected and confirmed infectious conditions/infection risks are clearly documented in the care record.

Ensuring that infection prevention and control alerts for patients with short term infectious conditions are added to and deleted from the e-white board when appropriate so that infectious status is apparent.

Ensuring that patients with infection prevention and control alerts are not

transferred to other wards unless clinically indicated. (refer section 8 and 9)

Ensuring that information about the infectious condition is communicated to receiving wards and departments in advance to ensure that appropriate facilities are available and any special arrangements are in place.


th January 2017


Completing an incident report if it is identified that patients with an infection prevention and control alert have been transferred unnecessarily and/or without communication in line with the Incident Reporting Analysing Investigating and Learning Policy.

5. RISK ASSESSMENT

5.1 All patients identified with suspected or confirmed infectious diseases or alert organisms will be risk assessed for the need for isolation by their admitting doctor or nurse.

5.2 Risk assessment is the assessment of the factors that influence the transmission

of a pathogen and its impact. It enables staff to prioritise the use of isolation facilities.

5.3 The following factors will be considered:

The classification of the pathogen and the ability to protect against or treat individual infections

The probable route of transmission and evidence of transmission

Susceptibility of the other patients near to the infected patient in the same bay i.e. do the other patients have open wounds or an invasive device

Whether the organism is antibiotic resistant.

Possible detrimental effects of isolation to the patient i.e. risk of falls, confusion or depression weighed against severity of the risk of transmission to other patients.

6. COMMUNICATION 6.1 Explain the rationale for isolation to the patient and, where possible, the duration of

isolation anticipated. Where available, provide a patient information leaflet about the relevant infectious condition/disease.

6.2 Place the appropriate isolation card on the door of the room/bay and indicate the appropriate precautions.

6.3 Record in the patient's notes that isolation has been commenced and the reason why.

6.4 Revise the nursing care plan accounting for infection control precautions to be

maintained by staff, patient and visitors. 6.5 Inform the Infection Control Team that there is a patient in isolation.

6.6 Check whether the patient has a ‘Notifiable Disease’ and, if so, complete a

downloadable ‘Notification Form’ available on Hub.



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th January 2017


7. ACCOMMODATION 7.1. Identify appropriate isolation facilities e.g. single room or cohort bay.

A single room with negative pressure ventilation may be required for airborne infections - refer Appendix 1 for details.

It is particularly important to keep the door closed when the room is used for isolating a patient with an airborne infection.

If a single room is indicated it is preferable that it has en-suite toilet and washing facilities.

7.2 Remove any unnecessary furniture and equipment prior to admission of the patient. 7.3 Ensure that appropriate equipment is available:

Inside the room Hand cleansing facilities Gloves & Aprons Clinical waste bag holder/bin. Linen receptacle with water soluble bag. Sharps Bin (if safe to leave within room) Thermometer Sphygmomanometer, Stethoscope (if required) Toileting and wash facilities (if no en suite bathroom).

Outside the room Appropriate protective clothing Alcohol hand rub

N.B. The mental health of the patient may dictate that it is unsafe to leave some of this equipment within the room. Always undertake a dynamic risk assessment.

8. HAND HYGIENE 8.1 Hands must be cleansed prior to leaving the isolation room. Hand hygiene must also

be performed prior to donning gloves and between different patient care activities to prevent cross contamination of different body sites ( gloves must also be changed). If the patient has diarrhoea, soap and water should be used for hand hygiene rather than alcohol rub.

8.2 Immediately after leaving the room, cleanse hands.

9. PERSONAL PROTECTIVE EQUIPMENT (PPE) 9.1 It is often unnecessary and inappropriate to require every person entering an isolation

room to wear PPE. 9.2 If worn, PPE must be removed immediately prior to leaving the room and must be

disposed of inside the room into a clinical waste bag (except when leaving the room to dispose of used bedpans etc. when it is removed in the sluice after placing bedpan in macerator/bedpan washer).

9.3 The type of PPE required is dependent on the mode of transmission and the type of

contact.


th January 2017


9.4 Guidance regarding the need for gloves and aprons is provided in the Index of

Infections at Appendix 1 and has been divided into the following three categories:

Limited to Standard Precautions (LSP)

If the infectious agent is transmitted in blood or other body fluids then protective clothing is only required when contact with such material is anticipated

Direct contact and cleaning (DCC)

For many conditions PPE is only required for direct patient contact and activities such as bed making and room cleaning. In this situation PPE is not required for social contact by staff or visitors.

All staff and visitors (ALL) For a small number of conditions it is appropriate for all persons entering the room to wear protective clothing.

9.5 Occasionally, additional PPE, such as masks or gowns, is required. Where this is

appropriate it has been identified in the Index of Infection ( Appendix 1).

10. VULNERABLE STAFF & VISITORS

10.1 Some may be more vulnerable than others to infection and may need to avoid entering the room In particular:

Pregnant women

Immunocompromised people (for any reason)

Staff with eczematous/psoriatic or similar skin lesions (particularly relevant with MRSA)

Staff and visitors receiving antibiotics (relevant to C.difficile infection)

10.2 Staff with such risk factors must seek advice from occupational health prior to caring for patients in isolation.

11. EQUIPMENT

11.1 Disposable equipment should be used whenever possible. Non disposable equipment must be decontaminated in accordance with the Decontamination Policy & Procedure when removed from the room. Wherever possible equipment should be allocated for sole use of the patient and decontaminated when no longer required.

12. LINEN

12.1 All laundry from isolation rooms must be managed as fouled/infectious laundry and therefore be placed in water soluble bags within the room and then into an outer linen sack.

13. WASTE DISPOSAL

13.1 All waste must be disposed of into clinical waste bags inside the room. Double bagging is not necessary. The bag should be placed immediately at the designated



th January 2017


collection point. (Additional measures are required for suspected viral haemorrhagic fevers and waste should be kept within the room until arrangements are made for special containers to be brought to the ward).

14. EXCRETA

14.1 Excreta can be disposed of directly into the toilet adjoining the room. If no en-suite facilities, cover commode/bed pan and take directly to the sluice - avoid touching anything other than the pan/urinal whilst en route. Pans and urinals must be placed directly into the macerator ensuring that any wipes have been removed and disposed of as clinical waste. Gloves and aprons should then be removed and discarded in clinical waste bin and hands washed.

15. SHARPS

15.1 A sharps bin should be kept inside the room for sharps disposal, unless this will be a hazard to the patient.

16. COLLECTION OF SPECIMENS

16.1 Specimens should be obtained within the room. Care must be taken to avoid contaminating the outside of the specimen container. All clinical specimens should be regarded as potentially infectious and handled as such. Specimens from patients likely to have the following organisms have to be treated as ‘high risk ‘and identified on the accompanying form, with a label to indicate this or if using electronic test requesting (i.e. order-comms/Medway) include information under the clinical details.

INFECTION SUSPECTED ORGANISM SPECIMEN

HEPATITIS Blood Borne Viruses Hepatitis B&C

Blood and body fluids

HIV / AIDS HIV I+II HTLV I+II

Blood and body fluids

TB Mycobacterium tuberculosis (MTB)

Specimens from site of infection Eg: sputum, urine

TYPHOID Salmonella typhi Salmonella paratyphi

Faeces & Blood Cultures

BRUCELLOSIS ("UNDULANT FEVER")

Brucella abortus/melitensis Blood Cultures Bone Marrow

PLAGUE Yersinia pestis Specimens from discharging lesions Sputum

ANTHRAX Bacillus anthracis YELLOW FEVER Arboviruses Blood

ON NO ACCOUNT SHOULD ANY SPECIMENS BE TAKEN FROM PATIENTS WITH SUSPECTED VIRAL HAEMORRHAGIC FEVER (eg: LASSA/EBOLA, etc., A POTENTIALLY LETHAL CROSS-INFECTION HAZARD) WITHOUT CONTACTING A MEDICAL MICROBIOLOGIST FIRST.


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17. CROCKERY AND CUTLERY

17.1 Crockery and cutlery is adequately decontaminated by dishwasher. Return items to kitchen promptly.

18. VISITS TO OTHER DEPARTMENTS

18.1 The department should be notified in advance so that arrangements may be made to prevent possible spread of infection i.e. patients with infections spread by the airborne route should be seen at the end of a list/session. Ward staff should advise of any necessary precautions. The Infection Control Nurse can also be contacted for advice. After the investigation/treatment is completed, surfaces with which the patient has had contact should be cleaned with hot water and detergent or detergent wipes.

18..2 Portering staff and other staff accompanying the patient do not need to wear PPE but

must clean their hands thoroughly after having direct contact with the patient.

18.3 Wheelchairs/trolleys used to transport patients to other departments must be cleaned with hot water and detergent or detergent wipes.

19 TRANSFER/DISCHARGE OF PATIENTS

19.1 Patients can be transferred from one ward to another ward or unit, if clinical need dictates. The receiving area must be informed in advance of the nature of the infection to ensure that the appropriate facilities are available and the required precautions are applied. Movement for non clinical reasons, e.g. outlying medical patients who are in isolation rooms to surgical wards to increase bed availability in medicine, should be avoided.

19.2 On discharge ensure that receiving hospital/nursing home or community services are

informed of any necessary precautions. If transport by ambulance is required, the ambulance service must be informed of any necessary precautions.

20. VISITORS

20.1 Visitors must report to the nurses’ station prior to entering the isolation room/bay. It may be necessary to ask about immunisation status prior to visiting. In some circumstances visiting may be restricted.

20.2 If visiting is allowed it is usually unnecessary for visitors to wear PPE but they should

be advised to wash/clean their hands when leaving the room. Visitors may need to be shown how to do this effectively.

20.3 Visitors should be advised not to visit other patients but if this is necessary they

should do so before visiting the patient in isolation. They should be advised not to eat or drink whilst in the isolation room.

20.4 Visiting by young children should be discouraged. If visitors insist on bringing young

children they must be informed of any risks.


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21. ROUTINE CLEANING

21.1 Isolation rooms must be cleaned at least as frequently as other patient areas using standard cleaning procedures. Cloths must be disposable. Mop heads must be removed and should be laundered after use or disposable mop heads discarded.

22. TERMINAL CLEANING

22.1 Terminal cleaning of the environment and furniture can be arranged via the housekeeping/domestic supervisor. However, when housekeeping services are not available it is the responsibility of the nursing staff to ensure the room is cleaned before reuse.

22.2 For terminal cleaning of siderooms following C.difficile infection and some

antimicrobial resistant infections, hydrogen peroxide vapour will be used – this must be undertaken by a member of the housekeeping dept.

23. LAST OFFICES

23.1 Following death, the body may remain an infection risk to personnel and therefore isolation precautions must be maintained whilst Last Offices are performed.

23.2 Last Offices are performed in accordance with the Care of the Deceased Patient

Policy.

23.3 All bodies should be sealed in a leak proof cadaver bag.

24. ARCHIVING ARRANGEMENTS The original of this policy will remain with the author, Lead Nurse/Director for Infection Prevention and Control. An electronic copy will be maintained on the Trust Intranet, P – Policies (Trust-wide) – S – Source Isolation. Archived electronic copies will be stored on the Trust's “archived policies” shared drive, and will be held indefinitely. A paper copy (where one exists) will be retained for 10 years.

25. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE PROCEDURES

25.1 In order to monitor compliance with this policy, the auditable standards will be

monitored as follows:

No Minimum Requirements Evidenced by

1.

Patients with suspected or confirmed infectious conditions will be placed appropriately in single rooms in high risk areas or in a bay in lower risk areas with evidence of risk assessment

Annual audit of Patient Placement, isolation facilities and infection risk assessment.

Datix reports of cross infection

25.2 Frequency

In each financial year, the Lead Nurse/Director of Infection Prevention and Control will ensure that results of the auditable standards are included in the annual report of the Joint Directors of Infection Control which is presented to the Board of Directors.




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25.3 Undertaken by Lead Nurse/Director of Infection Prevention and Control 25.4 Dissemination of Results

Results from reporting will be discussed through Divisional Governance Group meetings and at Infection Control and Decontamination Assurance Group meetings, if compliance with the minimum standards not achieved.

25.5 Recommendations/ Action Plans Implementation of the recommendations and action plan if required will be monitored by the Infection Control and Decontamination Assurance Group, which meets quarterly.

25.6 Any barriers to implementation will be risk-assessed and added to the risk register. 25.7 Any changes in practice needed will be highlighted to Trust staff via the Governance

Managers’ cascade system.

26. REFERENCES

Not applicable


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APPENDIX 1: TABLES OF COMMUNICABLE DISEASES AND APPROPRIATE PRECAUTIONS Disease or Organism Mode of transmission

from person to person In the health care setting

Single room

Gloves Apron Other PPE Visitor Restrictions

Duration of

isolation

Comments

Anthrax

Cutaneous Pulmonary

Contact with lesions

Person to person spread unknown. * See comments

Yes

Yes

ALL

ALL

ALL

ALL

See comments

-

Duration of disease

NOTIFIABLE DISEASE Infection Control Team must be informed if anthrax is suspected.

*In the event of a deliberate release of anthrax spores the patient, his/her belongings and the environment may be contaminated. Refer to PHE guidelines

Bronchiolitis Droplet

Yes DCC DCC - Exclude pre-

school children

Clinical Recovery

Brucellosis No person to person spread

No

LSP LSP

Chickenpox

(Varicella zoster) Airborne via respiratory

secretions and vesicle fluid Contact with vesicle

exudate

Yes

DCC DCC - Exclude non immune

1 week after onset or until lesions are dry

Non immune staff must be excluded. Negative pressure isolation room preferred Also refer Varicella Zoster Guidance

Creutzfeldt Jakob Disease (CJD) and

related disorders

Contact via instruments

used for invasive procedures

No LSP LSP - - Duration of hospital stay

Special precautions required for invasive procedures Also refer CJD & other transmissible spongiform encephalopathies policy

Key to table Modes of transmission

ALL = Applies to all persons entering the room Contact – direct (touching, kissing, biting) or indirect via equipment/fomites (includes percutaneous DCC = Required for direct contact or cleaning exposure via used sharps) LSP = Limited to standard precautions Droplet - large respiratory droplets propelled a short distance only N/A = Not applicable Airborne - via droplet nucleii or skin scales – remain suspended in the air for long periods PPE = Personal Protective Equipment AGP = aerosol generating procedure

http://www.hpa.org.uk/

http://www.hpa.org.uk/







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Disease or Organism Mode of transmission


Single room

Gloves Apron Other PPE

Visitor Restrictions

Duration of

isolation

Comments

Croup

Droplet Contact via contaminated hands.

Yes DCC DCC - Exclude pre-school children

Clinical recovery

Cryptococcus neoformans

No person to person spread

No LSP LSP

Cytomegalovirus Contact with saliva, blood,

urine No LSP LSP -

Dengue Fever Contact via contaminated

sharps No LSP LSP Clinical

recovery Always consider other communicable diseases when travelling from abroad. Isolate in s/r until diagnosis is confirmed.

Diarrhoea and/or vomiting (suspected

infective) See Section 5 for individual causes

Contact via faecal oral

route Yes DCC DCC Variable Variable

see Appendix 2

Refer Appendix 2 Also refer C.difficile Policy and Norovirus Guidance if either are suspected

Diphtheria

Respiratory Cutaneous

Droplet

Direct contact with skin

lesions

Yes

Yes

ALL DCC

ALL

DCC

Surgical mask ALL

Exclude non immune

Until swabs are repeatedly negative

NOTIFIABLE DISEASE.

Inform infection control on suspicion.

Encephalitis

(suspected infective)


route Yes LSP LSP NOTIFIABLE DISEASE

Enterovirus

(Echo and Coxsackie)


route Yes for

infants only DCC DCC

Epiglottitis

Droplet Yes DCC DCC Exclude pre-school

48hours of appropriate antibiotic therapy

Immunisation and prophylaxis of close contacts may be necessary

Gas Gangrene No person to person spread

No LSP LSP Infection is usually endogenous


ALL = Applies to all persons entering the room Contact – direct (touching, kissing, biting) or indirect via equipment/fomites (includes percutaneous DCC = Required for direct contact or cleaning exposure via used sharps) LSP = Limited to standard precautions Droplet - large respiratory droplets propelled a short distance only approximately 1 metre N/A = Not applicable Airborne - via droplet nucleii or skin scales – remain suspended in the air for long periods PPE = Personal Protective Equipment AGP = aerosol generating procedure


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Disease or Organism Mode of transmission from person to person

In the health care setting

Single room



Duration of

isolation

Comments

Glandular fever

Contact via saliva (kissing) No LSP LSP

Gastroenteritis

Refer Diarrhoea and/or vomiting

Contact via faecal oral route

Yes DCC DCC Variable Variable see Appendix 2

Refer Appendix 2

Also refer C.difficile Policy and Norovirus Guidance if either are suspected

Gonococcal Infection

Genito-urinary tract Ophthalmia neonatorum

Contact with exudate from

mucous membranes of the genital tract Contact via unwashed

hands

Yes, children

only

Yes

LSP

DCC

LSP

DCC

24 hours of antibiotic therapy

NOTIFIABLE DISEASE

Hepatitis

Undiagnosed

Contact with blood, faeces

and other body fluids (percutaneous expsure)

Yes

LSP

LSP

NOTIFIABLE DISEASE

Hepatitis A Contact (faecal-oral) Yes LSP LSP 7 days after onset of jaundice

NOTIFIABLE DISEASE

Hepatitis B, C & δ Contact with blood and

body fluids (usually percutaneous exposure via used sharps)

Not usually*

LSP LSP LSP NOTIFIABLE DISEASE (if acute)

*Single room required only if bleeding uncontrollably or has large open wounds or receiving haemodialysis.

Herpes simplex Type

I and II

Contact with lesions and

via shared towels etc. Droplet

Not usually*

LSP

LSP All lesions scabbed

* Single room may be required if patient has extensive lesions Also refer Herpes Simplex information on Hub

Herpes zoster

Refer Shingles


ALL = Applies to all persons entering the room Contact – direct (touching, kissing, biting) or indirect via equipment/fomites (includes percutaneous DCC = Required for direct contact or cleaning exposure via used sharps) LSP = Limited to standard precautions Droplet - large respiratory droplets propelled a short distance only approximately 1 metre N/A = Not applicable Airborne - via droplet nucleii or skin scales – remain suspended in the air for long periods AGP = aerosol generating procedure PPE = Personal Protective Equipment




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Disease or Organism Mode of transmission from person to person In health care setting

Single room



Duration of

isolation

Comments

Human Immunodeficiency Virus

Direct or indirect contact

with blood and body fluids (usually percutaneous exposure via used sharps)

No LSP LSP LSP

Patients with AIDS may have infectious conditions that require isolation

Impetigo Refer streptococcal infection

Infestations

Human Fleas Cat/dog fleas

Contact with patient and

bedding and clothing N/A

Yes

No

ALL ALL Gowns DCC

Recommend limiting visitors to those who have already had contact until treated

Until patient, bedding and clothing are treated.

Human fleas are extremely uncommon. Treat animals and environment

Lice (Body) Contact with patients,

clothing, bedding, towels etc

Yes ALL ALL Gowns DCC

Recommend limiting visitors to those who have already had contact until treated

Until patient, bedding and clothing are treated

Body lice live in the seams of clothing.

Lice (Head) Contact (head to head)

and via shared combs, head wear, pillows

Yes DCC DCC Advise visitors to avoid head to head contact

Until treated

Lice (Pubic) Contact (usually sexual) No LSP LSP Until treated

As this is usually STD consider referral to GUM clinic for screening




th January 2017




Single room



Duration of

isolation

Comments

Infestations continued

Scabies Crusted/atypical scabies

Contact with skin

(prolonged skin contact usually required) Contact with skin, bedding, clothing etc

Yes

Yes

DCC

DCC

DCC

Gown DCC

None until treated

Until treated As advised by the ICT

Itching may continue for several days/weeks Close contacts will need treatment Refer to dermatologist Contacts will need treatment. Also refer Scabies guidance

Worms


route

No

LSP

LSP

Until treated

Family contacts or equivalent may need treatment

Influenza, Seasonal Droplets Yes LSP LSP Surgical mask DCC FFP3 respirator for AGPs

Advise against visiting particularly if not immunised.

7 days after onset of symptoms

Alert ICT if more than one case on same ward. Also refer Influenza - Guidance on the Management of Seasonal

Legionnaires’ Disease


No LSP LSP N/A Microbiologist MUST be contacted to arrange for rapid diagnostic methods to be set up. NOTIFIABLE DISEASE

Leptospirosis

(Weil’s Disease)

Contact with blood and

urine No LSP LSP N/A NOTIFIABLE DISEASE

Lice

Refer Infestations

Listeriosis

Mother to baby in utero and during delivery Contact (faecal oral)

although very rare.

Yes in neonatal

unit only

LSP LSP Clinical recovery

Microbiologists should be informed as potentially food borne








th January 2017




Single room



Duration of

isolation

Comments

Malaria Contact via contaminated

sharps No LSP LSP NOTIFIABLE DISEASE

Always consider the possibility of other tropical infections which may be infectious. Therefore until diagnosis confirmed a single room is advisable.

Measles Airborne Yes ALL ALL FFP3 respirator ALL

Exclude non -immune

4 days after rash appears

NOTIFIABLE DISEASE. Also refer Measles information &

guidance

Meningitis

Undiagnosed

? Droplet transmission ? Indirect contact (faecal

oral)

Yes

DCC

DCC

Surgical masks

Variable depending on cause

NOTIFIABLE DISEASE

Masks for airway management and close prolonged contact

Bacterial

Meningococcal (Neisseria meningitidis)

Droplet Yes DCC DCC As above 48 hours of appropriate antibiotics

NOTIFIABLE DISEASE Antibiotic prophylaxis may be required for household and mouth kissing contacts. CCDC or Health Protection Nurse will advise. Refer Appendix 1.

Other bacterial causes

No person to person transmission

No LSP LSP

e.g. pneumococcal, haemophilus influenzae

Viral Contact (faecal oral) +/- Droplet

Yes DCC DCC Clinical recovery

NOTIFIABLE DISEASE

Commonly caused by enterovirus


ALL = Applies to all persons entering the room Contact – direct (touching, kissing, biting) or indirect via equipment/fomites (includes percutaneous DCC = Required for direct contact or cleaning exposure via used sharps) LSP = Limited to standard precautions Droplet - large respiratory droplets propelled a short distance only approximately 1 metre N/A = Not applicable Airborne - via droplet nucleii or skin scales – remain suspended in the air for long periods PPE – Personal Protective Equipment AGP = aerosol generating procedure




th January 2017




Single room



Duration of

isolation

Comments

Meningococcal Septicaemia – See Meningococcal Meningitis

MRSA Contact via unwashed hands most significant route unless patient has an exfoliating skin condition when the airborne route becomes important

Refer MRSA Policy

DCC DCC On the advice of the Infection Control Team

Always start topical suppression treatment to reduce risk of transmission to other patients - refer MRSA policy

Multi-Resistant Gram Negative Organisms

Depends on site of colonisation and organism. Contact via unwashed

hands and contaminated equipment most significant route of transmission.

Depends on

organism and

setting. Seek

advice.

DCC DCC Gown may be required - depends on organism

On the advice of the Infection Control Team

For ESBL and AMP C producing bacteria and Carbapenamase producing organisms refer to Multi-Drug Resistant Organism Policy

Mumps Droplet Contact with urine/saliva

Yes DCC DCC Surgical mask for close contact /airway management

Exclude non immune

9 days after onset

NOTIFIABLE DISEASE

Mycoplasma pneumonia

Droplet Yes

LSP LSP Surgical mask for close contact /airway management

10 days after onset

Patients are usually no longer infectious by the time the diagnosis is confirmed.


ALL = Applies to all persons entering the room Contact – direct (touching, kissing, biting) or indirect via equipment/fomites (includes percutaneous DCC = Required for direct contact or cleaning exposure via used sharps) LSP = Limited to standard precautions Droplet - large respiratory droplets propelled a short distance only approximately 1 metre N/A = Not applicable Airborne – via droplet uclei or skin scales – remain suspended in the air for long periods PPE = Personal Protective Equipment AGP = aerosol generating procedure







th January 2017




Single room

Gloves Apron Other PPE Visitor Restrictions

Duration of

isolation

Comments

Norovirus Contact and droplets Yes ALL ALL Exclude unless already exposed

48 hours symptom free

Norovius is highly transmissible and causes outbreaks in hospital. Strict adherence to use of PPE and hand hygiene is essential

Parvo virus (human)

(Slapped Cheek)

Droplet Yes

LSP LSP Exclude pregnant women

Usually once rash appears but see comments.

Patients in aplastic crisis may be infectious for 1 week after onset. Exclude pregnant members of staff.

Plague

Bubonic Pneumonic

Contact with pus from

buboes Droplet

Yes

Yes

ALL

ALL

ALL

ALL

Surgical Mask, Gown ALL

Exclude unless already exposed

Duration of disease

NOTIFIABLE DISEASE Contact Infection Control Team immediately on suspicion. Person to person transmission is rare but the patient should be transferred to high security infectious disease unit.

Polio


route Droplet

Yes LSP LSP

Exclude non immune

7 days from onset of symptoms

NOTIFIABLE DISEASE

Psittacosis

Person to person spread very rare

No LSP LSP N/A

Pyrexia of Unknown Origin with recent

travel abroad

As cause is unknown all modes of transmission must be considered

Yes

ALL

ALL

Limited to previous contacts and close family

Variable – clinical recovery if cause not confirmed

Malaria, typhoid and Hepatitis A are the commonest causes of PUO in returned travellers BUT always consider possibility of Viral Haemmorhagic Fever.

Also refer VHF guidance.

Q-fever


No LSP LSP

ALL = Applies to all persons entering the room Contact – direct (touching, kissing, biting) or indirect via equipment/fomites (includes percutaneous DCC = Required for direct contact or cleaning exposure via used sharps) LSP = Limited to standard precautions Droplet - large respiratory droplets propelled a short distance only N/A = Not applicable Airborne – via droplet nuclei or skin scales – remain suspended in the air for long periods PPE = Personal Protective Equipment AGP = aerosol generating procedure



th January 2017


PPE = Personal Protective Equipment Disease or Organism

Mode of transmission from person to person

In the health care setting

Single room



Duration of

isolation

Comments

Rabies

Person to person transmission rare; transmission via corneal, tissue and organ transplants has been reported

Yes LSP LSP Masks and eye protection if coughing

Limited Clinical recovery

NOTIFIABLE DISEASE Contact Microbiologist and Infection Control Team if suspected.

Person to person transmission is only a theoretical risk but because of the implications of acquisition single room accommodation is required

Ringworm (extensive)

Contact with skin scales,

nail and hair and via associated equipment e.g.hair clippers, shavers

No DCC DCC Variable Own bath shower facilities desirable.

Rubella

Droplet Yes DCC DCC Surgical mask for close contact

Exclude non immune

4 days after onset of rash.

NOTIFIABLE DISEASE

Scarlet Fever Refer Streptococcal infection

Smallpox Contact with vesicles Airborne via respiratory droplet nucleii

Yes ALL ALL FFP3 respirators gowns and eye protection ALL

Exclude unless already exposed

Until informed

by the Infection Control Team

NOTIFIABLE DISEASE CONTACT MICROBIOLOGIST AND INFECTION CONTROL IMMEDIATELY ON SUSPICION Implement Emergency Preparedness Plan



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th January 2017




Single room



Duration of

isolation

Comments

Shingles Contact with exudate Airborne via vesicle fluid

(in disseminated shingles only)

Yes

DCC

DCC

Exclude if non immune to chickenpox

1 week after onset or until lesions are dry

Exclude staff non-immune to chicken pox

Also refer Varicella zoster virus

(VZ),chickenpox and shingles information

Streptococcal (Group A) Infection

Including sore throat scarlet fever, impetigo, erysipelas, wound Infection, toxic shock syndrome, puerperal fever.

Contact with lesions Droplets

Yes

DCC

DCC

Surgical face mask for close contact

Recommend excluding children and any visitor with a wound.

48 hrs from commen-cing appropriate antibiotics

Scarlet Fever – NOTIFIABLE DISEASE

Staff with sore throats should seek advice from Occupational Health

Also refer Group A Streptococcal Infections –Prevention & Control Policy

Streptococcal Group B (Neonatal)

Contact via faeces, skin sites

No

LSP

LSP

N/A

Syphyllis

Early congenital Primary Secondary

Contact with lesions, secretions, blood

No LSP LSP 24 hrs of effective therapy

Latent & Late No person to person spread

No LSP LSP N/A

Tetanus No person to person spread

No LSP LSP N/A NOTIFIABLE DISEASE










th January 2017




Single room



Duration of

isolation

Comments

Toxoplasmosis No person to person spread

No LSP LSP N/A

Tuberculosis

NOTIFIABLE DISEASE Also Refer TB guidance

Pulmonary (open) ie sputum smear positive

Airborne via resp droplet

nuclei

Yes

LSP

LSP

FFP3 respirator for AEP

Limit to household/ family contacts

Usually 2 weeks treatment

Negative pressure ventilation preferable. MDRTB must be nursed in negative pressure isolation and FFP respirators worn at all times.

Pulmonary (closed)

No spread

No

LSP

LSP

N/A

Extrapulmonary No spread

No

LSP LSP N/A

Typhoid & Paratyphoid

Indirect contact - faecal/urine/oral spread

Yes, with en-suite facilities

DCC

DCC

Advise

visitors not to eat or drink in the isolation

room

Variable

NOTIFIABLE DISEASE

Ensure blood cultures and stools are labelled with risk of infection stickers

Typhus

Indirect contact via inoculation injury

No

Yes

LSP

LSP

Until any

infestation is treated

NOTIFIABLE DISEASE

Ensure patient is free of infestation.





th January 2017


Disease or Organism Mode of transmission from person to person In the health care setting

Single room



Duration of isolation

Comments

Vancomycin Resistant Enterococcus (VRE)

Contact with colonised/infected sites

Yes

DCC

DCC

-

-

Until informed by Infection Control

Also Refer VRE/GRE Guidance

Varicella Zoster Refer

Chicken pox or Shingles

Viral Haemorrhagic Fever (eg Lassa, Ebola, Marburg)

Contact - percutaneous

exposure to blood and body fluids ?Droplet - pharyngeal

secretions

Yes ALL FFP3 respirator Visors Gown Boots ALL

Immediate family/partner Exclude children.

As advised by

Infection Control Team

NOTIFIABLE DISEASE CONTACT INFECTION CONTROL IMMEDIATELY ON SUSPICION

Also refer VHF guidance

Whooping Cough Droplet - respiratory

secretions Yes DCC DCC Surgical

face masks for close contact

Exclude non immune

5 days after antibiotics started

NOTIFIABLE DISEASE

Yellow Fever Contact - percutaneous

exposure Yes LSP LSP 5 days

after onset

NOTIFIABLE DISEASE






th January 2017


APPENDIX 2: TABLE OF SPECIFIC GASTROINTESTINAL INFECTIONS

Organism Risk Group Source Person to Person Spread

Incubation Period

Period of Excretion

Specific Therapy Single Room Duration of Isolation

Notes

Adenovirus Mainly pre school children

Human ++ ? 2-5 days No Yes Duration of disease

Amoebic Dysentery Foreign Travellers

Human + ? May be prolonged

Variable Metronidazole Yes Duration of disease

NOTIFIABLE DISEASE

Astrovirus Pre school children

Human ++ ? 2-7 days No Yes Duration of disease

Bacillus cereus All ages Food esp. Chinese takeaway

- 1-6 hours N/A No No N/A NOTIFIABLE DISEASE as food poisoning

Calicivirus All ages Human ++ 24-48 hours 2-3 days No Yes Duration of disease

Campylobacter All ages Food Raw milk Water

+ 2-7 days Variable Possibly Erythromycin or Ciprofloxacin

If possible Duration of disease

NOTIFIABLE DISEASE as food poisoning

Clostridium botulinum

All ages Food - 12-36 hours N/A Specific Anti-toxin No N/A NOTIFIABLE DISEASE as food poisoning

Clostridium difficile

Refer C.difficile Policy

Human. Contaminated environment

++ Variable Variable Refer C.difficile Policy

Yes 48 hours after symptoms resolved with return to normal bowel action

Inform Infection Control Nurses

Also refer C.difficile Policy








th January 2017


Organisms Risk Group Source Person to Person Spread

Incubation Period

Period of Excretion

Specific Therapy

Single Room

Duration of Isolation

Notes

Clostridium perfringens

All ages Food esp. cooked meats


Cryptosporidium Mainly children Human Water Animal contact

+ 2-14 days 1-3 weeks No Yes Duration of disease


E. Coli 0157 All ages Contact with cattle Contaminated food.

++ Variable If severe Yes 48 hours after resolution of symptoms


Enteropathogenic E.coli

Children under 3 years

Human ++ 12-72 hours Variable Not usually Yes Duration of disease


Giardia lamblia All ages Human Water

++ 1-4 weeks Variable Metronidazole

If possible

Duration of disease


Norovirus

All ages Human ++++++ 24-48 hours Variable No Yes Min 48 hours resolution of symptoms


Also refer viral gastroenteritis guidance

Rotavirus Mainly pre school children

Human ++ 1-4 days 2-5 days No Yes Min 48 hours resolution of symptoms





th January 2017


Organisms Risk Group Source Person to Person Spread

Incubation Period

Period of Excretion

Specific Therapy

Single Room

Duration of Isolation

Notes

Salmonella sp.(non typhi)

All ages Food Human cases + 12-72 hours Variable Severe cases only

Yes Duration of disease


Salmonella typhi & paratyphi

All ages esp. after foreign travel

Human Food ++ 1-3 weeks Variable Yes Yes Period of hospitalisation

NOTIFIABLE DISEASE

Shigella sp Young children Following foreign travel

Human ++ 1-7 days Variable If severe Yes Period of hospitalisation


Staph aureus All ages Food esp. cooked meats


Vibrio cholerae Travel abroad Human Water Food

+ 1-5 days Variable Yes Tetracycline

Yes Period of hospitalisation

NOTIFIABLE DISEASE

Yersinia sp Mainly children Food + 3-7 days Variable If severe Yes Duration of disease


Source Isolation Procedures of 33 Ratified by: Infection Control & Decontamination Assurance Group: 24

th January 2017


APPENDIX 3: MANAGEMENT OF THE CONTACTS OF PATIENTS WITH PROBABLE MENINGOCOCCAL DISEASE

Action by ward doctor On which ever ward the patient is admitted, the ward doctor will prescribe and dispense from stock ciprofloxacin or rifampicin or ceftriaxone as appropriate to contacts. Drug stock and patient leaflets held in ED pharmacy cupboard. The name of each contact, their date of birth, GP, the drug and dose must be recorded in medical notes of the index case. Action by EXOHS

Keep records of 1) all staff contacts 2) all staff antibiotic prescriptions

Staff contacts needing prophylaxis, as agreed with duty HPU doctor

Action by HPU doctor Make a record of

1) all contacts 2) all antibiotic prescriptions

All other contacts needing prophylaxis

- not present in hospital

Close/ family contacts needing prophylaxis, as agreed with duty HPU doctor, who are - present in hospital

Action by GP/DDOC Duty GP/DDOC phoned and faxed to prescribe appropriate antibiotic

MANAGEMENT OF THE CONTACTS OF PATIENTS WITH PROBABLE MENINGOCOCCAL DISEASE

The object of this flowchart is to identify contacts at risk of meningococcal infection, and to prescribe them appropriate antimicrobial prophylaxis within 12 hours

Action by medical/nursing member of team, at the earliest opportunity Telephone the Health Protection Unit (HPU) 0844 225 3557 and ask for the Doctor/Nurse on duty for Public Health. Out of normal working hours ask RD+E switchboard for the Devon, Cornwall and Somerset Health Protection Unit Contact Rota 1st on.

1) Have the patient’s details to hand 2) If possible have a relative / partner / friend accompanying the patient available

Action by duty HPU Doctor HPU doctor will draw up lists of contacts, either by visiting or talking on ‘phone to hospital staff or persons who have accompanied the patient to hospital. An assessment is made of which contacts need prophylaxis, this includes hospital and ambulance staff as well as family / community contacts Copy list of staff contacts to Exeter Occupational Health Service (EXOHS)

Patient with probable meningococcal disease in the Royal Devon and Exeter Hospital

Action ED doctor as appropriate depending on where staff contacts work. Doctor will prescribe and dispense from stock ciprofloxacin or rifampicin or ceftriaxone as appropriate to staff contacts. Copy of prescription to go to EXOHS and HPU.

For hospital staff contacts

ED/and SWAST contacts


th January 2017


APPENDIX 4: COMMUNICATION PLAN

COMMUNICATION PLAN

The following action plan will be enacted once the document has gone live.

Staff groups that need to have knowledge of the strategy/policy

All clinical staff

The key changes if a revised policy/strategy

Adapted to take updated guidance on PPE into consideration and greater clarity within the section on definitions

The key objectives The purpose of this policy is to: provide the information required to determine appropriate isolation precautions based on the route of transmission.

How new staff will be made aware of the policy and manager action

Induction

Specific Issues to be raised with staff Draw attention to the Index of infections which is the most useful tool for determining the required precautions

Training available to staff Induction and infection control updates

Any other requirements N/A

Issues following Equality Impact Assessment (if any)

No negative impacts

Location of hard / electronic copy of the document etc.

Infection Control Team Office and Site Management Office


th January 2017


APPENDIX 5: EQUALITY IMPACT ASSESSMENT TOOL

Name of document Source Isolation Policy

Division/Directorate and service area Specialist Services, Infection Control

Name, job title and contact details of

person completing the assessment

Judy Potter

Lead Nurse/Joint Director for Infection

Prevention and Control

Date completed: 20/10/2016

The purpose of this tool is to: identify the equality issues related to a policy, procedure or strategy summarise the work done during the development of the document to reduce

negative impacts or to maximise benefit highlight unresolved issues with the policy/procedure/strategy which cannot be

removed but which will be monitored, and set out how this will be done.

1. What is the main purpose of this document?

The purpose of this policy is to: Provide the information required to determine appropriate isolation precautions based on the route of transmission.

2. Who does it mainly affect? (Please insert an “x” as appropriate:)

Carers ☐ Staff X Patients X Other (please specify)

3. Who might the policy have a ‘differential’ effect on, considering the “protected

characteristics” below? (By differential we mean, for example that a policy may have a noticeably more positive or negative impact on a particular group e.g. it may be more beneficial for women than for men)

Please insert an “x” in the appropriate box (x)

Protected characteristic Relevant Not relevant

Age ☐ X

Disability ☐ X

Sex - including: Transgender,

and Pregnancy / Maternity X X

Race ☐ X

Religion / belief ☐ X

Sexual orientation – including:

Marriage / Civil Partnership ☐ X


th January 2017


4. Apart from those with protected characteristics, which other groups in society might this document be particularly relevant to… (e.g. those affected by homelessness, bariatric patients, end of life patients, those with carers etc.)?

N/A

5. Do you think the document meets our human rights obligations? X

Yes

6. Looking back at questions 3, 4 and 5, can you summarise what has been done during the production of this document and your consultation process to support our equality / human rights / inclusion commitments?

The content of this policy is not new but has had some anomalies regarding use of PPE corrected. Previous discussions with the Equality and Diversity Manager did not identified any issues relating to equality, diversity and inclusion commitments The policy has been circulated to all members of the Infection Control which includes Specialist Nurses and Medical Microbiologists for consultation, including those working in the community setting, and has been considered by the Infection Control Operational Group which includes widespread representation from clinical, managerial and support staff.

7. If you have noted any ‘missed opportunities’, or perhaps noted that there remains some concern about a potentially negative impact please note this below and how this will be monitored/addressed.

“Protected

characteristic”: N/A

Issue:

How is this going to be

monitored/ addressed

in the future:

Group that will be

responsible for

ensuring this carried

out: