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«Policy Number IC01 Policy Title INFECTION PREVENTION AND CONTROL POLICY Accountable Director Director of Infection Prevention and Control Author Lead ...»

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Please refer to the Royal Marsden Clinical Procedures 8th edition, for details of the last office procedures. http://www.royalmarsdenmanual.com/online/toc.asp All staff performing last offices should practice standard Infection Prevention and Control precautions, as not all cases of infection have been identified before death.

Precautions include hand washing, wearing of personal protective equipment such as disposable gloves and aprons. If there is a risk of splashing bodily fluids then protective eyewear in the form of visors/goggles may be necessary.

If there are any wounds on the body that are leaking they must be sealed using waterproof dressings.

The death of a patient who is potentially infectious does not always require a body bag, the use of a body bag is recommended for the safe transport of the body.

Infections/ Specific Conditions which require the use of body bags or embalming.

(Information for undertakers)

–  –  –

The funeral directors should be informed of the infection status of the patient by the Doctor who certifies/ verifies the death or by the member of staff who is responsible for handing over the body to the funeral director.

–  –  –

An Infection Prevention and Control notification sheet must be completed (HSE

2004) see Appendix 7 The form should not state the patient’s diagnosis, this remains confidential information.

A copy of the form needs to be attached to the outside covering of the body;

also a copy will need to be inserted into the deceased patient’s medical notes/windip.

6.11 Immunisation of Staff and Service users Immunisation is an important way of avoiding infection amongst staff and service users. Vaccines however are not available against all infections and efficacy can vary depending on the vaccine and the individual.

Please see Immunisation against infectious disease- Green Book and Occupational Health Policy for further details.

Chickenpox/Varicella Varicella immunisation is recommended for non-immune health care workers who work directly with service users.

Diphtheria Polio Tetanus (Td/IPV) This triple vaccine is recommended for staff who may be exposed to specific hazards (such as puncture wounds or soil) during the course of their work Hepatitis A and B This is recommended for service users who are diagnosed as carriers of Hepatitis C. and staff who work in high risk environments.

Hepatitis B Immunisation against hepatitis B is recommended for: all staff who have patient contact

• all staff who handle patient laundry

• all staff who handle patient property

• staff involved in collecting clinical waste

• all service users in high risk groups for BBVs Influenza This vaccine is recommended for front line healthcare workers, and at risk service users.

Measles Mumps Rubella (MMR) The vaccine is recommended for all

–  –  –

Tuberculosis Occupational Health will carry out a pre-employment check and if Vaccination is advised, it will be offered.

6.12 Infectious Diseases In this section information is given regarding the infections, and advice on how to prevent the spread of infection. Staff are required to inform the Infection Prevention and Control Team of any patient who has been diagnosed as having an infectious illness. Staff infections should in the first instance be reported to occupational health.

A to Z listing of infections and conditions This section will only give guidance on certain healthcare associated infections that the Department of Health requires the trust to include within policy.

Information on all other relevant infectious diseases is now located on the trust website.

6.12.1 Clostridium difficile Clostridium difficile infection (CDI) also known as ' C. difficile' or 'C. diff' are gram-positive anaerobic spore forming bacilli that can produce toxins.

C. difficile rarely causes problems in children or healthy adults, as it is kept in check by the normal bacterial flora of the intestine. However broad spectrum antibiotics prescribed to treat other conditions or used prophylactically can reduce the normal bacterial flora in the gut allowing C. difficile to multiply unchecked, these bacteria may then produce toxins which attack the intestines, causing mild to severe disease, sometimes even resulting in death.

Service users may become symptomatic up to eight weeks after receiving antibiotic therapy.

C.difficile infection does pose a difficult problem in healthcare environments as it produces large numbers of resilient spores, which are not killed by routine cleaning products and can survive for long periods in the environment.

Prevention and control of C. difficile infection requires that cases are identified and reported early and isolation of symptomatic service users who are suspected to be infected with C. difficile is carried out promptly.

Symptoms

• Diarrhoea (foul smelling and ranging from mild to severe)

• Abdominal Pain

• Fever

• Dehydration and Electrolyte Imbalance

• Colitis All symptoms must be monitored and recorded accurately.

–  –  –

Clinicians (doctors and nurses) should apply the following mnemonic protocol (SIGHT) when managing suspected potentially infectious diarrhoea:





Suspect that a case may be infective where there is no clear S alternative cause for diarrhoea Isolate the service user and consult with the Infection Prevention I and Control team while determining the cause of the diarrhoea.

Gloves and aprons must be used for all contacts with the service G user and their environment Hand washing with soap and water should be carried out before and H after each contact with the service user and the service user’s environment T Test the stool for toxin, by sending a specimen immediately Transmission is via the faecal oral route

• Direct service user to service user contact.

• Contact with contaminated environment.

• Infection from the hands of health care workers.

Risk factors

• Service users over 65 years of age

• Service users who are Immunocompromised

• Service users receiving antibiotics (especially those receiving broad spectrum or several different antibiotics)

• Service users admitted from areas where a case of C. difficile. has been identified

• Service users recently transferred from an acute trust or where they have recently received antibiotics

• Service users who have received Proton Pump Inhibitors (PPI)

• Service users who have had bowel surgery Prevention strategies Several strategies are in place within Mersey Care NHS Trust that support the prevention of cases of C. difficile infection occurring

• Antibiotic stewardship which includes quarterly audit and monitoring of compliance of prescribing practice against trust approved antimicrobial guidelines are undertaken by the Mersey Care NHS Trust pharmacy team.

• Point prevalence surveillance of antimicrobials utilised within the trust is carried out by the IPCT.

• Medical staff receive specific training on induction to the trust that refers to antibiotic prescribing practice.

• Mersey Care NHS Trust utilises an Antimicrobial formulary which provides guidance on the management of common infections. Incorporating strategies to optimise prescribing of antimicrobials

Page 35 of 94 Infection Prevention and Control Policy

• Pharmacy is represented on the Infection Prevention and Control Committee (ICC)

• Infection Prevention and Control Nurses are members of the Drugs and Therapeutics Committee

• The IPCT offer additional training to clinical areas on C.difficile as required.

• Each clinical area has a designated Infection Prevention and Control Link Practitioner (IPCLP) who is required to attend regular IPCLP training sessions.

• Prevention and Management of enteric infections including C.difficile is a regular topic at IPCLP training sessions

• ICLPs are required to cascade information back to their clinical area after every training session

• Service users Led Assessment of the Care Environment (PLACE) inspections are carried out of all inpatient areas annually. Ensuring that wards are kept clean and acceptable to service users.

• Annual IPC training for facilities staff is carried out. This includes guidance on the use and efficacy of different cleaning products, used to decontaminate after a case of C.difficile infection.

• Monthly Environmental audits and Annual Infection Prevention and Control audits are carried out to ensure clinical areas are clean and in a good state of repair.

Period of Infectivity Lasts until diarrhoea has stopped (and for at least a further 48 hours) and normal bowel action has occurred.

Clinical definitions

The Infection Prevention and Control Team (IPCT) should:

Adhere to the following definitions for use in identifying and managing incidents of C. difficile C. difficile infection: one episode of diarrhoea, defined either as stool loose enough to take the shape of a container used to sample it or as Bristol Stool Chart types 5-7 (Appendix 2), that is not attributable to any other cause, (e.g.

inflammatory colitis, overflow) including therapy (e.g. laxatives and enteral feeding) and that occurs at the same time as a positive test result for the organism with a positive toxin assay (with or without a positive C.difficile culture)

Define increase of cases/outbreaks as follows:

A Period of Increased Incidence (PII) of C. difficile two or more new cases (occurring 48 hours post admission, not relapses) in a 28-day period on a ward.

–  –  –

An outbreak of C. difficile infection: two or more cases caused by the same strain related in time and place over a defined period that is based on the date of onset of the first case.

In the event of any of a PII or outbreak an incident meeting would be convened.

Also in the event of any sudden increases in the number and/or severity of cases detected in a ward or across several units within the trust typing of specimens would be requested.

Severity of Disease Mild disease: 3 or fewer type 5-7 stools on Bristol Chart per day and a normal white cell count (WCC) Moderate disease: 3 to 5 stools of type 5-7 per day and a raised WCC ( but less than 15) Severe disease: WCC greater than15, OR a temperature greater than 38.5, OR an acutely rising serum creatinine (e.g. greater than 50% increase above baseline) with evidence of severe colitis (abdominal, endoscopic or radiological signs). (The number of stools may be a less reliable indicator of severity) Life threatening disease: complete ileus or toxic megacolon with a systemic inflammatory response or septic shock Infection Prevention and Control Guidelines Service users who are symptomatic and suspected of having C. difficile must be reported to the IPCT immediately (out of hours contact Silver on Call) and isolated as soon as possible. (within 4 hours) Stool specimens must be collected and sent for Culture and Sensitivity (C&S) and C. difficile testing (please list complete antibiotic history from last 8 weeks on lab request form and record in clinical notes) following onset of symptoms or admission of symptomatic service user.

Service users must be monitored closely by ward staff and also reviewed daily (or more frequently if any concerns arise) by a doctor to ensure no deterioration in condition. A stool chart should be maintained and all details recorded as per the chart Doctors should consider C. difficile infection as a diagnosis in its own right, grading each confirmed case for severity, treating accordingly and reviewing each service user daily (including medication, including stop dates), monitoring

–  –  –

bowel function against the Bristol Stool Chart (Appendix 1). Service user review should be undertaken in conjunction with the infection prevention and control team. The team should review all C. difficile infection service users, where possible daily to ensure that the infection is optimally treated and the service user is receiving all necessary supportive care.

Antibiotic history must be checked, and if antibiotics are currently being administered, this should be discussed by the Doctor with the trust Infection Prevention and Control Doctor/ Consultant Medical Microbiologist. and strict adherence to the trust’s Antimicrobial Guidelines: Management of Common Infections must be applied and monitored.

Precautions

• Encourage strict and thorough hand washing with soap and water, after every contact with the service user, or the service user’s environment. Do not use alcohol gel.

• Staff must utilise, Personal Protective Equipment (PPE) wear gloves and an apron which should be changed between delivery of different care tasks for the service user.

• Orange stream infectious waste bags must be used for all waste connected with the case including used PPE, incontinence pads or any other items which may have become contaminated.

• Isolation of service user in a single room with en-suite facilities or single room with named single person commode, or single room next to an identified toilet for sole use of infected service user.

If no single room is available every effort must be made to provide a room on the ward including consideration of moving a non infectious service user to another ward to provide one.

In the event of an outbreak of C. difficile and insufficient single rooms are available then cohorting of infected service users in a bay may be advised.

• Furnishings and equipment in room must be kept to a minimum. All decorative items must be removed.

• Visitors are to be asked to wash hands prior to leaving the isolation area.

• Service user hand hygiene must be adhered to, encourage service users to wash hands after using toilet and before meals, if service users are too ill, moist hand wipes should be offered, assist service user as required.

• Service user must be washed after each episode of diarrhoea and the integrity of the skin is to be checked if skin is breaking down further advice should be sought.



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