Isolation Policy

Reference Number: 627

Yvonne Pritchard
Author & Title: Senior Infection Control Nurse

Responsible Directorate: Infection Control

Review Date: March 2014

Ratified by (committee):
Operational Governance Committee

Date Ratified: March 2011

Version: 4.2

Cleaning Policy for Infected Ward Areas

Hand Decontamination Policy
MRSA Policy
TB Policy
Linen Policy
Related Procedural Documents
Influenza Policy
Clostridium difficile
Universal/Standard Infection Control
Precautions
Patient Access Operational Policy
Index:

1. Introduction _________________________________________________________ 3
2. Purpose of this policy _________________________________________________ 3
3. Duties / Responsibilities _______________________________________________ 3
4. Categories of Isolation ________________________________________________ 5
5. Source Isolation ______________________________________________________ 6
6. Transport of Infected/Infectious Patients _________________________________ 8
7. Visitors/Patients/Carers________________________________________________ 8
8. Post Isolation/Death/Discharge _________________________________________ 8
9. Protective Isolation ___________________________________________________ 9
10. Side room Tool ____________________________________________________ 13
11. Risk Assessment and Isolation of Patients with Infections Caused by Alert
Organisms _____________________________________________________________ 13
12. References _______________________________________________________ 18
Appendix 1: Consultation Schedule______________________________________ 19
Appendix 2: Isolation Sign _____________________________________________ 20
Appendix 3: Guidelines for Ordering, Storing and Dispensing of Patient Medication
in Isolation Rooms _______________________________________________________ 21
Appendix 4: Patients Requiring Negative Pressure Isolation Rooms __________ 21
Equality Impact Assessment Tool __________________________________________ 22
Consultation Checklist ___________________________________________________ 23
Ratification Check List ___________________________________________________ 24

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 2 of 24
1. Introduction
Aim of the policy is to ensure that protective / source isolation procedures are
instigated in order to minimise the risks of cross infection. The correct and timely
placement of infected patients (suspected or proven) into single rooms can be very
effective in reducing the overall numbers of infective patients (DH 2007).

It is also a requirement of the Health Act 2006 (DH) that an evidence based isolation
policy exists incorporating local risk assessment findings and measures. This policy
must include indications and procedures for the infection control management of
isolated patients

2. Purpose of this policy

To identify patients presenting with colonisation, infection or infectious diseases that may be
a risk to others.

To take timely action to prevent the spread of potentially infectious conditions by appropriate
isolation of the source patient and the appropriate use of personal protective equipment.

To ensure that patients at high risk of infections due to immunosuppression or neutropenia

are appropriately isolated and protected to minimise the acquisition of such infections.

To ensure that all staff, departments and any outside agencies likely to be involved in the
care of patients care have a clear understanding of their roles and responsibilities in
preventing the spread of infection.

3. Duties / Responsibilities
CHIEF EXECUTIVE

• To ensure that infection control is a core part of clinical governance and

patient safety programmes
• Promote compliance with infection control policies in order to ensure low
levels of health care associated infections
• Awareness of legal responsibilities to identify, assess and control risk of
infection
• Appoint Director of Infection Prevention and Control

DIRECTOR OF INFECTION PREVENTION AND CONTROL

• Oversee infection control policies and their implementation

• Responsible for infection control team
• Report directly to the Chief Executive and Trust Board
• Challenge inappropriate hygiene practice and antibiotic prescribing
• Assess impact of plans / policies on infection control
• Member of clinical governance and patient safety structures
Document name: Isolation Policy Ref.:627
Issue date: Status: Final
Page 3 of 24
INFECTION CONTROL TEAM

• Review and update Isolation policy

• Give additional advice regarding the management of patients requiring
isolation where required
• Refer to Microbiologist where appropriate
• Include isolation precautions in all induction and update training for clinical
staff
• Promote good practice and challenge poor practice
• Report breaches of isolation through the incident reporting process

MICROBIOLOGISTS

• Provide additional advice outside of office hours

• Alert Infection Control Team and clinical teams of patients requiring
isolation following confirmation of certain infections

PATIENT ACCESS TEAM

• To ensure that patients with potential or known infections are isolated as soon
as possible, referring to the risk assessment
• To manage the side room tool in liaison with the Infection Control Team
• Report breaches of isolation to Infection Control Team and by incident
reporting

MATRONS

• Must establish a cleanliness culture across their units and promote

compliance with infection control guidelines
• Lead Root Cause Analysis of MRSA bacteraemia ensuring that it is completed
within 5 working days of identification
• Ensure that nursing staff perform MRSA screening as per guidance and that
results are appropriately followed up

MEDICAL STAFF

• Ensure compliance with infection control policies

• Follow advice of microbiologists and Infection Control Team relating to
isolation of patients

ALL HEALTHCARE STAFF

• Must be familiar with and adhere to the relevant infection control policies to
reduce the risk of cross infection of patients
• Must use the risk assessment process to identify the isolation priorities of
individual patients
• Promote good practice and challenge poor practice
Document name: Isolation Policy Ref.:627
Issue date: Status: Final
Page 4 of 24
 • Refer to the infection control team if unable to follow the policy guidelines
• Keep their patient informed of their infection status and provide information as
necessary
• Must ensure that patients who are isolated have access to investigations and
rehabilitation

4. Categories of Isolation
Isolation must not compromise the clinical care of the patient
There are two categories of isolation (Ayliffe 2001):

Source isolation: when a patient poses an infection risk to others

Protective isolation: when a patient is at risk from others

Source isolation
Source isolation is the physical separation of one patient from another, in order to
prevent the spread of infection. Single room isolation will not by itself prevent the
transmission of organisms, but is part of universal infection control precautions which
must be observed at all times with all patients, including those in isolation to
minimise the risk of transmission. Additional precautions may need to be
implemented dependant on the source and mode of spread.

All hospitals providing in-patient care must ensure that they are able to provide or
secure the provision of adequate isolation facilities for patients sufficient to prevent
or minimise the spread of Healthcare Associated Infection (DOH 2000) Hospital
Trusts have a responsibility to ensure that the policy includes the potential risk of
infection and the use of effective protective measures and equipment (DOH 2006)

Protective Isolation
Protective isolation is the physical separation of patients who are immuno-
compromised/immunosuppressed in order to prevent the acquisition of infection
from other patients, staff or visitors.

In both categories

• The decision to isolate a patient should be based on the infection risk to other
patients, staff and visitors.
• An appropriate isolation notice is required and must be placed on the outside
of the door, outlining the precautions required (see appendix 1)
• In order to minimize the risks of anxiety and depression that are often
experienced by many isolated patients, a full explanation of the nature of
infection, including the symptoms, treatment and the rationale for the control
measures should be given to the patient.

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 5 of 24
 • Daily assessment and evaluation of the need for ongoing isolation
precautions must take place.
• The infection control team is available for advice and guidance.

5. Source Isolation
Source Isolation is indicated for conditions such as MRSA, Clostridium difficile,
patients with ESBLs (extended spectrum β lactamase producers), Chicken Pox,
GRE and VRE (Glycopeptide resistant enterococci including Vancomycin resistant
organisms), pulmonary tuberculosis, patients with diarrhoea and or vomiting,
influenza and fevers from the tropics in which an infectious cause cannot be ruled
out (refer to table and specific policies for further information).

Please note that this list is not exhaustive. If you think that a patient may have an
infectious condition that will put others at risk, please discuss with the clinical team in
the first instance, and consider discussion with the infection control team or
microbiologist if indicated.

Ideally a single room should be allocated to patients with these conditions, but given
the limited availability of side rooms a risk assessment needs to be undertaken. The
risk assessment must be carried out within 6 hours of admission and will include
consideration of the risk factors of the other patients in isolation and the patients in
the bays.

Alternatives to side rooms include barrier nursing the patient on the general bay or
cohorting of patients with the same condition. However please note that not all
patients with similar symptoms e.g. diarrhoea, have the same aetiology, and
cohorting should only be done following discussion with the infection control team/or
consultant microbiologist. (Out of hours number may be obtained via the RUH
switchboard).

If there are no side rooms available in the immediate vicinity, consult the site team
for availability on another ward if appropriate.

Where a patient is nursed in a general bay all appropriate precautions must be

implemented. The infected patient should be nursed away from other patients at risk
and an appropriate sign must be displayed above the patient’s bed.

All isolation rooms must be cleaned daily as per cleaning policy to reduce the
environmental contamination.

Once the risk assessment has identified that the patient requires isolation the
following precautions must be considered:-

• Nurse patient in a single room with the appropriate facilities available e.g. if
the patient’s source of infection is diarrhoea an en –suite facility would be
ideal but if not available a dedicated commode will be required for the
patient’s sole use.
Document name: Isolation Policy Ref.:627
Issue date: Status: Final
Page 6 of 24
 • Explain to patient, relatives and carers why isolation is required and provide
them with any relevant information e.g. specific leaflets available on the
intranet or from the Infection Control Team

• Check whether isolation is still necessary on a daily basis e.g. have

symptoms resolved, are screening results negative?

• Ensure that the isolation door remains closed especially when airborne
infections have been isolated e.g. TB

• Display isolation sign on the door of the room, these are available on all
wards. The sign can be reversed if the room is not used for isolation. Do not
label the patient as being infectious and maintain confidentiality.

• Limit and restrict the number of staff and visitors who come into contact with
the patient to reduce the risk of spread. Where immunity to the condition
occurs e.g. chicken pox, staff and visitors should be restricted to those who
are non-susceptible to the condition

• Personal protective equipment must be worn according to the condition and

mode of spread. This should be available outside the isolation room and a
small supply of gloves should also be held within the room.

• Protective clothing should only be worn by relatives as appropriate e.g. when

carrying out ‘hands on care’ (see individual policies or contact infection
control).

• The room must be cleaned daily with dedicated cleaning equipment using a
chlorine based agent will be required e.g. Actichlor Plus.

• Where possible use dedicated equipment for isolated patients. Where this is
not possible all equipment must be cleaned between each patient use.

• Only stock that is required should be taken into the room.

• Keep charts and notes outside of the room to reduce the risk of
contamination.

• Clinical waste bin should be kept inside the room.

• Sharps bin as appropriate to be kept inside the patient’s room.

• Infected linen bags as appropriate to be kept inside the patient’s room and all
linen bagged at the bedside.

• Strict and thorough hand washing (see Hand Decontamination Policy)

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 7 of 24
 • Encourage the patient to wash hands before and after entering the
ward/room, after using the toilet and before eating.

• Visitors should be instructed to decontaminate their hands on entry and

leaving the ward/room.

6. Transport of Infected/Infectious Patients

1. Movement of infectious or potentially infectious patients should be kept to a
minimum. When it is necessary to transport patients to other wards or
departments, precautions to minimize the risks of transmission must continue.

2. If it is possible to delay an investigation without adversely affecting the

patients management this should be considered. However the presence of an
infectious disease should not delay urgent clinical investigations.
3. The receiving area must be informed prior to transfer to ensure that they have
the appropriate precautions in place and that appropriate facilities are
available.

4. Patients with known or suspected infections must as far as possible be seen

at the end of the list and not be left in the waiting areas. This will allow
adequate cleaning of the environment and equipment following the
appointment and reduce the risks to other patients.

5. Check specific infection control policies for advice and guidance. Consult the
infection control team for any further advice or guidance.

7. Visitors/Patients/Carers
• Explain the precautions required whilst maintaining the patient’s
confidentiality.

• Advice on the appropriate hand washing and /or other precautions required.

• Discourage visitors from having contact with other patients in the ward or
hospital.

• Check with specific policies regarding specific diseases to ascertain whether

visitors should be excluded due to particular susceptibility.

• Assess the need for isolation on a daily basis and stop when there is no
longer a risk to others.

8. Post Isolation/Death/Discharge
New patients must not be admitted to the room until it has
undergone a special clean.
Document name: Isolation Policy Ref.:627
Issue date: Status: Final
Page 8 of 24
 1. Make sure that the room is cleaned thoroughly once the room is vacated.

2. Dispose of any unused disposable items which may be contaminated.

3. Clean all equipment and belongings before the patient comes out of isolation
or prior to further use.

4. The appropriate cleaning method for the room and the equipment will be
determined by the organism. If a deep clean is required contact the cleaning
supervisor.

5. Nurses to allocate responsibilities to clean the equipment prior to deep

cleaning.
6. In the case of death follow the guidance in universal infection control
precautions policy.

9. Protective Isolation
Immunocompromised patients vary in their susceptibility to infections, depending on
the severity and type of immunosuppression. The measures that follow are in
addition to standard infection control precautions.

Protective isolation is intended to prevent a more susceptible patient acquiring

infection.

A single room is required for neutropenic patients (neutropenia refers to a neutrophil

count of <0.5) to prevent the acquisition of infection by immunocompromised
patients. A room with positive pressure ventilation is desirable for patients who are
estimated to have prolonged neutropenia i.e. > 7 days provided the patient does not
have any evidence of a transmissible infection e.g. Meticillin resistant
staphylococcus aureus (MRSA) or active TB. Five ‘positive pressure’ rooms are
available in William Budd Ward Annex. Patients who are likely to be neutropenic and
are suspected of having one of the above may be nursed in a general side room
with the door closed.

If a single room is not available then a risk assessment must be undertaken (For
further advice check the table at the end of policy) Neutropenic patients are high
priority and full protective isolation precautions must be implemented at all times.

9.1 Preparation of room prior to admitting a neutropenic patient

1. Side room must be cleaned before the patient is admitted including clean
mop head. (designated equipment for the use of cleaning protective
isolation rooms e.g. white bucket and mop handles available in William
Budd)

2. Ensure that the hand basin is stocked with appropriate hand hygiene
products e.g. liquid soap, alcohol gels and paper towels.
Document name: Isolation Policy Ref.:627
Issue date: Status: Final
Page 9 of 24
 3. Ensure that there are plastic aprons and non sterile gloves available
outside the patient’s room.

4. Remove any unnecessary equipment and furniture from the room to

facilitate on-going cleaning during patients stay.

5. Equipment in the isolation room must, as far as possible, be dedicated for

the use of that patient.

6. All equipment must be cleaned thoroughly prior to and following use.

7. If an en-suite toilet is not available, then an adjacent toilet or commode

must be thoroughly cleaned and placed for the dedicated use of the
neutropenic patient.
8. Place ‘Isolation’ sign on the outside of the door (Appendix 1)

9. Discourage the patient from keeping unnecessary belongings in the room to

enable effective cleaning to take place, balancing this with the patient’s
psychological needs.

10. Patient’s records must be kept outside the room to reduce the risk of
contamination.

11. Keep the door of the room closed, apart from the necessary entrances and
exits balancing the psychological care of the patient and the need for
protective isolation.

9.2 Care of the Patient in Protective Isolation

General precautions

• Hand decontamination: always wash hands with soap and water or

alcohol gel prior to entering and on leaving the isolation room.

• White plastic aprons must be worn by staff and visitors if they are
performing clinical care or assisting the patient with hygiene activities
(not required for social visiting). Aprons must be disposed of as clinical
waste in the room, except when transporting blood or body fluids for
disposal in the sluice.

• Gloves are not necessary except for aseptic procedures (sterile and
non-sterile) and for contact with blood or body fluids as per universal
precautions.
Staff
• Ensure all staff are aware of the necessary precautions

• Limit the number of staff entering the isolation room

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 10 of 24
 • Staff with infections should not be working in the environment

• Staff who are nursing patients with infections i.e. source isolation
should avoid nursing patients in protective isolation during the same
shift.

Patient psychological care

• Patients in protective isolation must receive psychological support and

reassurance regularly throughout each shift.

• Involve specialist nurses and psychologists as deemed necessary –

ensuring patient has given consent for referral
• Ensure patient has contact with outside world where possible by
facilitating access to services should as “Patient line” cards and
newspapers

Visitors

• Reduce the risk of cross infection by limiting the number of visitors.

• Discourage visitors with symptoms of infections or known exposure to

infections e.g. chicken pox.

• Discourage visitors with small children

• Visitors must sit on the chairs provided for visitors

• Educate visitors on hand hygiene + / - apron use depending upon

activities

• Ensure awareness of visiting restrictions – max of 2 people at a time,

limit children etc

• Ensure awareness of restriction of gifts for patient:

Note neutropenic food guidelines

No flowers or plants as they may be a source of aspergillus or other

fungal spores. Cut flowers also provide a reservoir for gram positive
organisms.

Linen and Clothing

• Sheets and pillowcases must be changed daily

• Blankets must be changed if visibly soiled or on alternate days.

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 11 of 24
 • Curtains in patient room must be changed on patient discharge.

• Linen will be placed in white bags unless they are contaminated with
bodily fluids in which case they will be placed in red alginate bags prior
to being placed in an outer red bag

• Patients must be encouraged to change clothing daily

Patient Hygiene

• Patients must receive education on good hygiene practices. This must

include washing hands before eating and after toileting

• Disposable single use wipes / cloths should be provided for washing

• Face cloths / flannels must not be used unless they are sent home
daily for laundering

• Skin must be kept clean by daily bathing or washing

Patients may use the baths in the ward providing they are cleaned
thoroughly before each patient use. No sharing of toiletries /
equipment.
Showers are contraindicated where the water source is at risk of
contamination. Contact infection control for advice if in any doubt.

• Oral hygiene must be performed as prescribed using prescribed

mouthwashes

Diet

• Patients must be provided with sterile drinking water

• Patients must not be given ice from ice machines

• Patients must be educated on ‘Neutropenic food guidance’ – involve

the dietician and diet chef as necessary to ensure that the patient is
receiving adequate nutrition

• Patient menu cards have the word @neutropenic placed in the

right hand corner of the menu card to alert the kitchen of dietary
restrictions

• Patients should receive a clean diet which is cooked / provided by the

hospital to protect from food borne organisms.

9.3 Cleaning of patients room

• The protective isolation room must be cleaned daily using clean mop head.

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 12 of 24
 • Water and mop head must be changed between each protective isolation
room.

• All horizontal surfaces and furniture must be damp dusted daily using single
use cleaning cloths and neutral detergents.

• Single use gloves must be worn when cleaning the protective isolation rooms
and hands washed on leaving the room.

• When the patient is discharged the room must be given a terminal clean
before being re-occupied.

9.4 Patients requiring investigations whilst in protective isolation

• Ideally investigations / procedures should be performed in the isolation room

• Visits to other departments should only occur with permission from medical
staff or senior nursing staff who are familiar with the patient’s current
treatment plan.

• Within the RUH portable x-rays are ordered for neutropenic patients.

• Should permission be given for the patient to visit another department for
investigations e.g. CT scan the receiving department should be aware of the
neutropenic status and ensure that the patient does not come into contact
with patients or staff with known or suspected infection?

• Patients should go directly to the department and return immediately the

investigation is complete – waiting in the department or the corridors must be
avoided.

10. Side room Tool

If patients cannot be isolated within their own ward the Patient Access Team should
be contacted. They have access to the side room tool which is updated daily by the
Patient Access Team with the names and details of all patients requiring isolation.

The side room tool should provide the Patient Access Team and the Infection
Control Team with an accurate picture of where patients can be isolated.

11. Risk Assessment and Isolation of Patients with

Infections Caused by Alert Organisms
Always check individual policies relating to the specific organism to ensure
correct precautions are in place.

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 13 of 24
Any patient suspected or known to be colonized or infected with an infectious agent
that may pose a risk to others must be isolated in line with this policy. Due to the
lack of isolation facilities it is recognized that at times single rooms will need to be
prioritised.

The following information will help in this risk assessment process.

Code
3 High priority for an isolation room. Discuss with site team or infection
control if a single room is not available.
2 Single room required. Assess patients currently in side rooms. If side
room still unavailable nurse in a main bay away from other vulnerable
patients e.g. patients with open wounds, or invasive devices,
immunocompromised patients etc. Move to a single room as soon as
possible. Discuss further with infection control if required.
1 Low risk. Single room or cohort bay required, but may be nursed in a bay
providing other patients in the bay are not vulnerable.
* Contact tracing may be required for these patients.

This is not an exhaustive list please discuss with the infection control team or
the microbiologist on call if there are any major concerns regarding individual
patients.

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 14 of 24
 Alert Organism Risk Factors Level Isolation Requirement
Assess the Isolate until the patient has been on antibiotics for at least 24-48
Abscesses e.g. quinsy 3
patient hours. Discuss with Infection Control Team.
Blood borne virus e.g. Assess the Isolation not required unless there is a high risk of blood or blood
0
HIV, Hepatitis B,C patient. stained body fluid splash.
Symptomatic with diarrhoea and C diff toxin positive or suspicion
Clostridium difficile Diarrhoea 3
of C diff.
Once symptom free for 48 hours the patient no longer requires
Asymptomatic 0
isolation, but watch carefully for recurrence of symptoms.
See CJD policy for advice re surgical procedures.
CJD 0 Inform microbiologist on call immediately if diagnosis is suspected
to ensure safe handling of specimens.
Rash
developed
Only staff with a history of Chicken pox (or serologically confirmed
Chicken Pox within the 3*
immunity) should have contact with this patient
previous 10
days
Rash present
but has not 3* As above
crusted over.
All lesions
crusted and at
0 Isolation not required
least 5 days
since onset
Extended Spectrum Beta-
Catheterised,
Lactamase Encourage good hand and personal hygiene.
incontinent 3
(ESBL) producing Dedicated commode (or lavatory) cleaned between each use.
patient
organisms in urine
Continent Encourage good hand and personal hygiene, clean toilet after use.
2
patient If possible use a dedicated toilet.
Assess
Encourage good hand hygiene and personal hygiene.
ESBL producing individual risks
3 If possible use a dedicated toilet.
organisms in other sites. e.g. weeping
Discuss with IC team if required.
wounds etc.
Document name: Isolation Policy Ref.:627
Issue date: Status: Final
Page 15 of 24
 Lesions dry. 1
Assess
GRE Glycopeptide individual risks Encourage good hand hygiene and personal hygiene.
resistant enterococci e.g. 3* Dedicated toilet if patient has diarrhoea
(including VRE) incontinence, Discuss with IC team if required.
diarrhoea
Up to 7 days after onset in children and immunosuppressed
Influenza (including Avian individuals until 5 days clear of symptoms.
3*
flu and H1N1) For avian influenza inform microbiologist on call immediately if
diagnosis is suspected.
Measles 3* Until 5 days after onset of rash
Suspected meningitis- Until 24 hours of antibiotics. Inform occupational health if in direct
3*
meningococcal contact with respiratory secretions e.g. during resuscitation.
Sputum
Positive with
Meticilin Resistant productive
Isolation in high risk areas advised although the clinical needs of
Staphylococcus aureus cough, flaking
3 the patient must be paramount.
(MRSA) skin condition,
Discuss with infection control if necessary.
wet wounds
with break
through.
Skin
colonisation 2
only
Mumps 3* Until 9 days after onset of rash
Isolate infants until clinical recovery occurs. Cohort nursing may
RSV 3*
be considered in certain circumstances.
Rash in an
exposed area Only staff with a history of Chicken pox (or serologically confirmed
Shingles 3*
with wet immunity) should have contact with this patient.
lesions.
Confirmed
Tuberculosis pulmonary with 3* Until 14 days continuous treatment
a productive
Document name: Isolation Policy Ref.:627
Issue date: Status: Final
Page 16 of 24
 cough.
Suspected TB 3* Isolate until 3 negative sputum specimens on microscopy.
Suspected/
Discuss with TB nurse specialist and Infection Control. Will require
Confirmed drug 3*
isolation in a negative pressure side room (see Appendix 3).
resistant TB
Unless aerosolising procedures are being under taken or draining
Non Pulmonary
0 wounds etc or undergoing surgery.
TB
Often affects
immuno-
Norwegian Scabies 3* Until course of treatment has been completed
compromised
patients
Awaiting
Classical scabies 2 Discuss with Infection Control Team
diagnosis
Group A Streptococcus 3 Until 48 hours of appropriate antibiotics.
SARS Inform Infection Control or Microbiologist on call immediately if
3*
diagnosis is suspected.
Vancomycin resistant Assess Encourage good hand hygiene and personal hygiene.
enterococci (VRE) individual risks Dedicated toilet if patient has diarrhoea
e.g. 3* Discuss with IC team if required.
incontinence,
diarrhoea
Viral Hemorrhagic Fever Inform Infection Control or Microbiologist on call immediately if
3* diagnosis is suspected. Will require isolation in a negative
pressure side room (see Appendix 3)

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 17 of 24
12. References
Ayliffe, G.A.J, Babb, J.R, Taylor, L.Z (2001) Hospital Acquired Infection, Principles and
Prevention. Third Edition, Arnold Page 99

Department of Health (2006) The health Act 2006 Code of Practice for the prevention and
Control of Health Care Associated Infections London DH, 2006

Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care.
London DH, 2007

Department of Health (2003) Winning Ways: Working together to reduce healthcare

associated infections in England. London: DH, 2003

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 18 of 24
Appendix 1: Consultation Schedule
Name and Title of Individual Date Consulted
Tracey Halladay, Senior Infection Control Nurse November 2007

Yvonne Pritchard, Senior Infection Control Nurse August 2008

Francesca Thompson, Director of Nursing/Director November 2008
of Infection Prevention and Control
Dr Sarah Meisner, Consultant November 2008
Microbiologist/Infection Control Doctor
Caroline Gilleece, Clinical Nurse Manager July 2007
Oncology and Haematology
Dr John Waldron, Medical Director November 2008
Alex Massey, Patient Access Manager February 2009

Name of Committee Date of Committee

Medical Division August 2007, October 2008
Surgical Division August 2007, October 2008
Specialty Division August 2007, October 2008
Saving Lives Implementation Committee August 2007, October 2008
Infection Prevention and Control Committee November 2008
Clinical Governance Committee November 2007
Francesca Thompson March 2009

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 19 of 24
Appendix 2: Isolation Sign

ISOLATION ROOM

Please see nurse before entering

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 20 of 24
Appendix 3: Guidelines for Ordering, Storing and
Dispensing of Patient Medication in Isolation Rooms
There has been much discussion and concern regarding the patient medication inside
isolation rooms. Following discussion at SLIC it has been agreed that the best way forward
is as follows:

1. Medication of isolated patients will be dispensed from the medicine trolley (where
available). Medicines for patients in isolation rooms to be stored in the medicine
trolley until patient no longer in isolation.
2. If no medicine trolley is available, and the only alternative is the pod inside the room
then only a week’s supply should be issued/stored in the pod in the room. Wards
should consider the possibility of moving pods to the outside of rooms where possible
to minimise wastage of unused drugs. In the case of medicines not routinely stocked
at the RUH and for inhalers, insulin devices etc, the patient’s own medicines should
be used until supply available.
3. The medication in the pod inside isolation rooms will be replaced with a fresh supply
when patient comes out of isolation wherever possible.
4. The pod should be cleaned and decontaminated once the patient is no longer an
infection control risk and on discharge.
5. IV medication must be prepared in the treatment room and everything required to
administer the drug should be taken into the room, and administered at the bedside,
and sharps disposed of at point of use.

Appendix 4: Patients Requiring Negative Pressure

Isolation Rooms
Adults and children with suspected or known infectious Multi Drug Resistant (MDR
TB) and Extensively Drug Resistant TB (XDR-TB) must be admitted to a negative
pressure room.

Clinicians caring for a patient with recent foreign travel with suspected Viral
Haemorrhagic Fevers must immediately contact the Microbiologist on call for
advice on where to refer the patient. The patient must be isolated in a Negative
Pressure Side Room as soon as possible.

As the RUH does not have a negative pressure side room the patient should be
transferred to University Hospital Bristol NHS Foundation Trust which has
appropriate facilities for the management of these patients. The clinician responsible
for the patients care must refer the patient to an appropriate Consultant at the
University Hospitals Bristol NHS Foundation Trust.

Alternative arrangements can be sourced through the local Health Protection Unit.
Please see the contact details below

South West (North) Health Protection Unit :

Tel: 0845 5048668

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 21 of 24
Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval

Initial Screening

Policy, service, strategy, procedure or function: Isolation Policy

Lead (e.g. Director, Manager, Clinician): Francesca Thompson
Person responsible for the assessment:
Name: Yvonne Pritchard
Job Title: Senior Infection Prevention and Control Nurse
Is this a new or existing policy, service strategy, procedure or function?
Existing
Who is the policy/service strategy, procedure or function aimed at?
• Staff

Are any of the following groups adversely affected by the policy?

If yes is this high, medium or low impact (see attached notes):
Group Affected? Impact
Disabled people: No High / Medium /Low
Race, ethnicity & nationality No High / Medium /Low
Male/Female/transgender: No High / Medium /Low
Age, young or older people: No High / Medium /Low
Sexual orientation: No High / Medium /Low
Religion, belief and faith: No High / Medium /Low

If the answer is yes to any of these proceed to full assessment.

This applies whether the impact assessment is high, medium or low.

If the answer is no to all categories, the assessment is now complete

1. Does the policy, service strategy, procedure or function No / Yes

include measures which promote equality?

2. If yes, what are these measures?

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 22 of 24
Consultation Checklist
Author; attach this to each copy of the policy being sent to a meeting for comment.
Dear Chairman
Please would you disseminate this document for comment at your next meeting and return
any amendments/comments to:
Title of meeting: Saving Lives Implementation Committee
Date of meeting: 1 August 2007
Policy Title and Reference: Isolation Policy 627
Name of author: Tracey Halliday

Are there any elements of this policy which present

No
operational issues that require further discussion?
If yes, please provide a contact name for the author.
Does the document include a training plan? N/A
Does the document include relevant references? Yes
Are up to date National Guidelines included? Yes
If you are the appropriate forum, have the necessary
N/A
resources been agreed to implement this document?
Is there a plan for policy implementation? N/A
Does your meeting recommend further consultation with
No
groups or staff other than listed in the document?
Other comments from meeting.

What are the cost implications of implementing this document?

Equipment £ N/A
Staffing (additional) £ N/A
Training £ N/A
Other £ N/A

Are there any other department affected? No

Document endorsed without further comment? Yes

Further amendments to document suggested? No

Name of Chair: Sharon Preston

Signature: ____________________________________ Date: __________________

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 23 of 24
Ratification Check List
Author; attach this to each copy of the policy being sent to a meeting for comment.
Dear Chairman
Please would you review this document for comment at your next meeting and agree final
approval and organisation ratification.
Title of meeting: : Saving Lives Implementation Committee
Date of meeting: 22 October 2008
Policy Title and Reference: Isolation Policy 627
Name of author: Yvonne Pritchard

Are there any elements of this policy which present

No
operational issues that require further discussion?
If yes, please provide a contact name for the author.

Is the policy referenced? Yes

Are up to date National Guidelines included? Yes

If you are the appropriate forum, have the necessary

N/A
resources been agreed to implement this document?

Is there a plan for policy implementation? N/A

Does your meeting recommend further consultation with

No
groups or staff other than listed at the front of the policy?

Is the policy referenced? Yes

What are the cost implications of implementing this document?

Equipment £ N/A
Staffing (additional) £ N/A
Training £ N/A
Other £ N/A

Document endorsed without further comment? Yes

Further amendments to document suggested? No

Name of Chair: Francesca Thompson

Signature: ____________________________________ Date: __________________

Document name: Isolation Policy Ref.:627

Issue date: Status: Final
Page 24 of 24