with an ESBL or carbapenem-resistant organism
Stringent adherence to infection control precautions is critical in the prevention of spread of antibiotic-resistant organisms to other patients, and in the case of carbapenem-resistant organisms in particular, it is essential that staff fully understand the implications of cross-infection. There should be an Infection Control Policy in the Infection Control Manual within all healthcare organisations regarding the management of patients with ESBL or carbapenem-resistant organisms.
Isolation: Patients must be isolated in a single room (preferably en-suite where applicable). The decision to discontinue isolation of the patient should be made by a member of the Infection Prevention and Control Team following a clinical risk assessment, and documented in the medical notes. It may be appropriate in some areas to cohort colonised or infected patients with the same ESBL-resistant organism, such as neonates on an Neonatal Intensive Care Unit or Special Care Baby Unit. (See also Chapter 11.) Note: Patients either infected or colonised with a carbapenem-resistant organism must be isolated in a single room for the duration of their hospital stay, with strict adherence to standard precautions and 1:1 nursing (this will have resource implications in terms of staffing).
Hand hygiene: In the event of carbapenem resistance, the HPA (2010) recommend that staff wash their hands with liquid soap and water, rather than decontaminate them with alcohol hand rub, after contact with the patient, with equipment and/or with the patient’s environment. Other- wise, the use of alcohol hand rub or gel is generally acceptable when caring for patients who have ESBL colonisation or infection as long as the patient does not have diarrhoea. (See also Chapter 12.)
Personal protective equipment (PPE): Disposable gloves or aprons must be worn for direct contact with the patient and contaminated equipment and must be changed in between each patient. Following removal of PPE, hands must be washed with liquid soap and water if the patient has a carbapenem-resistant organism. Otherwise, the use of alcohol hand rub and gel following the removal of PPE is generally acceptable when caring for patients who have ESBL colonisation or infection as long as the patient does not have diarrhoea. (See also Chapter 13.) Equipment: Equipment (including a single-use blood pressure cuff and tourniquet) should be
dedicated for use with the patient and not shared with other patients. Only equipment or items essential for the patient’s care on a daily basis should be kept in the room.
Management of invasive devices: As discussed in Chapters 16 and 17, IV devices and urinary catheters can significantly increase the risk of patients developing a bacteraemia if they are not managed appropriately.
Environmental cleanliness: The patients’ side room must be cleaned daily with a chlorine-based solution. In the event of a carbapenem-resistant organism, the frequency of cleaning on the ward should be reviewed and special attention paid to cleaning frequent ‘touch’ areas and equipment, such as computer keyboards, monitors, telephones and door handles. (See also Chapter 15.) Outbreaks: One case of carbapenemase resistance on a ward (i.e. detected on admission screen-
ing from a high-risk patient) should initiate a meeting whereby infection control practice can be reviewed. Isolation of carbapenem resistance from a clinical specimen in a patient who did not meet the criteria for screening, or the detection of a second case on a ward, should trigger
156
an urgent Outbreak Meeting (see Chapter 4) and be reported as a Serious Untoward Incident (SUI). Screening of patient contacts (stools specimens, rectal swabs, and swabs from skin breaks and other sites as requested by the Infection Prevention and Control Team) would be indicated in this situation, as would weekly screening on the ward and screening on discharge.
•
Antimicrobial resistance has been acknowledged to be a major public health threat and a global concern since the late 1990s.•
Resistance is a complex phenomenon, involving the organism, the antimicrobial drug, the environment and the patient.•
Resistance can either be part of the organism’s genetic make-up or be acquired, with spon- taneous genetic mutation and/or genetic recombinations leading to the emergence of an antibiotic-resistant organism.•
Resistance often occurs among normal bacterial flora in patients receiving antibiotics.•
Within the microbial population, there is variation amongst microorganisms and natural selection always ensures that dominant organisms survive.•
Antimicrobial stewardship is central to the control of antimicrobial resistance and the effective treatment of infections, and it is the responsibility of medical, pharmacy and nursing staff.•
Carbapenemase resistance is an increasing public health threat, and at least one in 10 NDM-1 producing strains appears to be pan-resistant.•
Stringent adherence to infection control precautions is critical in the prevention of the spread of antibiotic-resistant organisms to other patients, and it is essential that staff fully understand the implications of cross-infection.Chapter summary: key points
Further resources are available for this book, including interactive multiple choice questions. Visit the companion website at:
www.wiley.com/go/fundamentalsofinfectionprevention
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Part Two
The principles of
infection prevention and control (standard precautions)
Chapter 11 Isolation and cohort nursing 162
Chapter 12 Hand hygiene 174
Chapter 13 Personal protective equipment 192
Chapter 14 The safe handling and disposal of sharps 206
Chapter 15 Cleaning 216
Contents
Fundamentals of Infection Prevention and Control: Theory and Practice, Second Edition. Debbie Weston.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. Companion Website: www.wiley.com/go/fundamentalsofinfectionprevention
Isolation and cohort nursing
11
Compliance with the Health and
Social Care Act 2008 163
Standard precautions 164
EPIC and NICE guidelines 165
The purpose of isolating patients
and different categories of isolation 165 Isolation and risk assessment 167 Infection control precautions
within specialist areas 167
General points regarding the infection control management
of infected and colonised patients 169 Negative-pressure isolation 170 The psychological effects of isolation 171
Care of deceased patients 171
Chapter summary: key points 172
References 173
163
Introduction
Ensuring that patients in hospital who are known or suspected to be infected or colonised with potentially pathogenic microorganisms are ‘isolated’, or barrier nursed, is an important component in preventing and controlling the spread of healthcare-associated infections and communicable diseases. It can, however, be a challenging and sometimes distressing process for patients, their relatives and carers, and healthcare staff, and is not always appropriate, or easily achieved, in other healthcare settings. This chapter looks at implementing patient isolation in the context of infection control standard precautions. Determining the need for isolation and risk assessment is discussed, along with different methods of isolation such as negative-pressure facilities and cohort nursing, and the challenges of isolating patients in different care areas.
After reading this chapter, the reader will: