infection prevention

5/20/2018 infection prevention

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GUIDELINES FOR RISK ASSESSMENT OF

PRIORITIZATION OF ISOLATIONFACILITIES/BED MANAGEMENT/MOVEMENT

OF PATIENTS


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Table to Contents

Section1. Introduction

1.1 Background

1.2 Purpose

1.3 Definitions

1.4 Principles

2 Infection Prevention & Control Policy

2.1 Allocation of single rooms

2.2 Infection Prevention & Control Risk Assessment

2.3 Movement of isolated patients between wards and departments

2.4 Inter-healthcare transfer

2.5 Assessment and Care in a Mental Health Setting

2.6 Prevention of MRSA

2.7 Admission to the Orthopaedic ring-fenced wards

2.8 Prevention of outbreaks of viral gastroenteritis

2.9 Communication between the Infection Prevention & Control Team and

Bed Management staff

2.10 The role of the Pre-assessment Units in infection prevention & control/bed

management

3. Implementation/Compliance

4. Audit tool for compliance with Infection Prevention & Control Policy for inter-

healthcare transfer of patients Appendix 5

Appendix 1 Risk assessment to prioritise Isolation Rooms (LPFT)

Appendix 2 Infection Prevention & Control Risk Assessment

Appendix 3 Screening & Assessment of Patients

Appendix 4 - Inter-healthcare infection prevention and control transfer proforma

Appendix 5 Audit Tool


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Infection Prevention and Control Policy for BedManagement and Movement of Patients

1. INTRODUCTION

1.1 Background

The risks of health care associated infection (HCAI) are greatly increased by

extensive movement of patients within the hospital, by very high bed occupancy

and by an absence of suitable isolation facilities (DoH, Winning Ways 2003). The

Department of Healths programme to reduce HCAI, including MRSA, requires areview of the patient journey for emergency and planned patients to identify and

reduce the risks of infection transmission that are associated with movement of

potentially infected patients (DoH, Saving Lives 2005). The need for restricting

movement of infected patients between wards and for rapid isolation of infected

patients has been emphasised in a Healthcare Commission report into outbreaks

ofClostridium difficile(Healthcare Commission 2006).

1.2 Purpose

The policy sets out the infection prevention and control principles that must be

applied to bed management and movement of patients to minimise the risk ofinfection.

1.3 Definitions

This policy applies to all staff involved in patient care and management including

patient placement and should be used in conjunction with other relevant sections

of Infection Control Policies, Procedures and Guidelines in particular:

1.03 Universal (Standard) Infection Control Precautions

1.07 Hospital Isolation & Infection Prevention & Control RelatedPrecautions

1.08 Isolation methods for Communicable Infections1.13 Notifiable Diseases

1.14 Management of patients with diarrhoea caused byClostridium difficile1.15 Management of an outbreak of viral gastroenteritis

1.4 Principles

This policy is based on published evidence, national guidelines and local

experience. Although patient safety is paramount, no patient should be denied

necessary investigation or treatment solely on the grounds of having an infection.


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2. INFECTION PREVENTION AND CONTROL POLICY

2.1 Allocation of single rooms

Allocation of single rooms must be based on a clinical risk assessment with

infection control requirements given priority over bed management/capacity

issues (Healthcare Commission, 2006) See Appendix 1. Delays in transferring A&E patients awaiting a single room on the ward for the

purpose of isolation must be kept to a minimum.

During escalation procedures, patients requiring isolation must not betransferred to temporary in-patient facilities (e.g. Day Surgery Unit).

Patients with a known infection being transferred from other hospitals, mustbe admitted to a single room.

Priority for side rooms should be given to patients with high risks of multi-resistant organisms, including symptomatic Clostridium difficile and diarrhoeaof unknown cause (See Appendix 1).

All patients with acute diarrhoea should be in isolation and assumed to be

infective until symptoms are settled for at least 72 hours or a non infectivecause has been established by the medical team.

Other infections requiring isolation (either suspected or confirmed) eg TB,

chicken pox, measles as well as others are listed in 1.08.

2.2 Infection Prevention and Control Risk Assessment

On admission patients should be assessed for risk factors for multi-resistant

organisms, including MRSA; the risk assessment tool, Appendix 2 can be

utilized for this purpose.

Patients assessed with scores above 6 require isolation.

Patients should be re-assessed as their condition changes and at regular

intervals.

2.3 Movement of isolation patients between wards and department

Assess the need to move the patient. If an inter-ward transfer can be

postponed, or an investigation/procedure can be postponed until the patient is

no longer in isolation, without compromising the patients care and

management, then it should be delayed.

Communication between wards and departments regarding the isolation

status or a patient is essential and enables the receiving department to put

its local procedure in place.

A patient being nursed in isolation should only be transferred between wardsfor that individuals clinical needs, and if this occurs an inter-healthcaretransfer form (Appendix 4) must be completed, see 2.4 below.

Once vacated, an isolation room must be terminally deep cleaned.

2.4 Inter-healthcare transfer

The inter-healthcare infection control transfer form (Appendix 4) has beendesigned by the Department of Health (2007) to improve communication ofinfection risks between healthcare providers.

An inter-healthcare infection control transfer form should be completed andaccompany patients requiring transferring between wards or to otherhospitals.


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An inter-health case infection control transfer form should be completed andaccompany patients discharged to other healthcare settings, includingnursing and residential homes.

2.4 Risk Assessment and Management in Mental Health Settings

The decision to isolate / barrier nurse a patient in an inpatient environment mustnot be taken lightly and should always be made after assessing the risk to theindividual, other residents and staff. To isolate / barrier nurse a confused ordistressed patient may be detrimental to their well-being or safety.

Advice should be sought from the Infection Control Team on the appropriatenessof isolating / barrier nursing patients. In the absence of the Infection ControlTeam during out of hours, at weekends and bank holidays, the Health Protection

Agency (HPA) can be contacted. The Infection Control Team should becontacted as soon as is possible afterwards.

Before deciding to isolate / barrier nurse a patient, careful consideration must be

given to: Emotional well-being of the patient e.g. mental health or patient safety

Mode of transmission of the infection e.g. air-borne, faecal-oral route etc

The availability of facilities

The risk of spread to other service users /healthcare workers

Most patients affected will be physically unwell and will be compliant with thearrangements for isolation.

If the individual is resistant to isolation due to mental state or lack ofunderstanding, all efforts should be made to inform the patient of thecircumstances of why isolation is necessary and of the consequences tothemselves and others should they not be isolated.

All patients should have the risk of contaminating others recorded on their riskassessment, until the risk has passed.

In the event of an infectious patient being identified outside of Hospital (an AWOLpatient or a patient who is on leave from the hospital), the Manager on-call arealso to be informed as well as the Health Protection Agency (if appropriate).

Patients should be informed why isolation is necessary and why affected patientswill not be able to leave the ward whilst displaying symptoms of infectious illness,

regardless of legal status under the Mental Health Act.

If at any time the patient request to go on leave from the ward, all effort should bemade to ensure they are symptom free and informed that they may not be able toreturn to the ward.

Patients relatives or carers should be informed that the patient is leaving theward that is currently closed due to an outbreak of an infection. They should beaware of any symptoms to look out for and inform the ward if they develop.

If symptoms to develop, the patient should remain on leave to prevent furtherpotential spread of infection.


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Only if there is deterioration in the infected patients mental state, which preventsthem from staying on leave, should the patient return to the infected ward.

If the patient is symptom free and needs to return to the ward, all efforts are to bemade that they are treated in a non- affected area if at all possible.

Care plan for the provision of mental healthcare for isolated patients will bedevised on an individual basis, taking into account the presentation of physicalillness. Activity for isolated patients is encouraged to reduce sense of isolationand loneliness.

Consideration should be given to the potential deterioration of mental state duringa period of isolation. All steps to be taken to ensure individuals mental wellbeingis maintained.

All isolated patients should be subject to a minimum of level 3 observations underthe safe and supportive observation policy (OPR), and be subject to food andfluid charts to minimise risks of dehydration and malnutrition.

Patients who are bed bound should be reminded to reposition themselves (orwith assistance) to reduce the likelihood of pressure sores.

Staff should be wearing gloves if there is a need for physical intervention. Facemasks should be worn if there is a splash risk.

If staff members are spat at by an infected patient or suspected infected patient,then first aid should be given to the affected member of staff and they should bereferred to the Occupational Health Department.

2.5 Prevention of MRSA (see also Section 2.2 and 2.17 Glycopeptide-resistantEnterococcus and other antimicrobial-resistant micro-organisms)

2.6 Admission to the Orthopaedic Ring-fenced Wards

The aim is to prevent MRSA being introduced to the elective orthopaedic wards,particularly in joint replacement surgery where the incidence of MRSA is low butthe effect of MRSA infection can be devastating.

The ring-fenced wards need to maintain a strict admission criterion that givespriority admission to patients undergoing joint replacement surgery.

Only patients with an MRSA screen negative result should be admitted to thering-fenced wards.

2.7 Prevention of Outbreaks of Viral Gastroenteritis

All patients requiring admission should be asked questions about viralgastroenteritis symptoms using the flow chart found in Appendix 3.

Patients admitted with a history of diarrhoea and vomiting should NOT beadmitted on EAU but directly into an isolation room on a ward.

Patients with acute diarrhoea should be isolated and not transferred until 72hours symptom free or unless there is a strong clinical indication for the move(e.g. transfer to ICU).


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2.8 Communication between Infection Control Team and Bed ManagementStaff

During office hours, close liaison between the Infection Control Team and theBed Manager is essential.

Out of office hours a Consultant Microbiologist can be contacted via the

hospital switchboard The Bed Manager (or representative) must always attend Infection

Outbreak/Incident Meetings when the outbreak/incident impacts on bedavailability.

An Infection Control Team representative will provide regular feedback onrelevant issues to all bed management staff.

2.9 The Role of the Pre-assessment Unit in Infection Prevention andControl/Bed Management

Certain patients may have infection risks (e.g. MRSA carriers; Public Health riskof CJD) and their notes should be clearly marked as such. In addition:

Patients known to be MRSA carriers must be screened at pre-assessment asper ULHT MRSA policy. In the event of positive screening results, pre-assessment staff to ensure ward and theatre staff are aware.

The Infection Control Team must be contacted by pre-assessment staffregarding patients who present a public health risk of CJD, see Guidelines2.7 Management of Patients with Transmissible SpongiformEncephalopathies with regard to Infection Control.

Pre-assessment staff must inform theatre and ward staff of patients withblood borne viruses.

3. IMPLEMENTATION/COMPLIANCE

All Trust Managers are responsible for ensuring that staff are aware of the location of thispolicy, for ensuring that staff read this policy and implement it in practice.

References

1. Coia J E Duckworth C J Edwards D I et al (2006) Guidelines for the control and

prevention of Methicillin resistant Staphylococcus aureus (MRSA) in healthcare

facilities. Journal of Hospital Infection Vol 63S P51-5442. Department of Health (2005) Saving Lives: A delivery programme to reduce

healthcare associated infection including MRSA.3. Department of Health (2003) Winning Ways: Working together to reduce

healthcare associated infection in England.4. Healthcare Commission (2006) Investigation into outbreaks ofClostridium difficile

at Stoke Mandeville Hospital, Buckinghamshire Hospital NHS Trust.5. Department of Health (2007). Saving Lives: reducing infection, delivering clean

and safe care. Isolating patients with healthcare associated infection Asummary of best practice.

6. Department of Health (2008) Board to Ward.


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APPENDIX 1

RISK ASSESSMENT TO PRIORITISE ISOLATION ROOMS (LPFT)

Isolation facilities across the Trust are limited and are generally side rooms with or

without en-suite facilities.

The Trust does not have negative-pressure isolation facilities.

Isolation facilities across Lincolnshire Partnership NHS Foundation Trust are limited. TheTrust does not have negative or positive pressure ventilation facilities and thereforepatients/service users who require this form of isolation may require transfer to a hospitalwith these specialist facilities. The infection control team/on call microbiologist willadvise.

The isolation rooms within LPFT are generally side rooms with or without bathroom

facilities. The number of side rooms varies according to the location of the facility.

If a suitable isolation room is not immediately available on a ward, liaison must takeplace between the ward manager or modern matron and the Infection Control team toenable the rationalisation of isolation needs. This may involve the transfer of otherpatients/service users out of side rooms to accommodate those with higher needs.

An sentinel form must be completed if a patient cannot be suitably isolated, so thereasons for this can be identified and appropriate action taken.

Occasionally cohort isolation care will be recommended by the infection control team.The same principles apply. In order to make optimal use of the limited facilities an

isolation risk assessment may be helpful to prioritise whether the need for isolation ishigh, medium or low.

The risk assessment system (designed by Dr Gopal Rao, Infection Control Consultant,Lewisham GDH London) is based on the causative organism, its resistance profile, risk

and mode of spread and patient characteristics. It should help in making pragmaticdecisions about isolation by ascribing a score to each of the following factors:

- Advisory Committee on Dangerous Pathogens (ACDP) classification.

- Route of transmission and dispersal characteristics of patient.

- Evidence for transmission.

- Prevalence of infection in the hospital.- Antibiotic resistance.- Susceptibility of other patients.

See Table 1 and Table 2 for details of the prioritisation system and method for

calculating the score.

Step 1 Identify infection or disease.

Step 2 Use Table 1 and Table 2 to score ACDP classification, routeof transmission, evidence for transmission. Assess prevalence ofinfection

in the hospital and score, determine antibiotic resistance and score,


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assess susceptibility of other patients and score, assessdispersal characteristics of patient and score.

Step 3 Add all scores and compare total to chart to determine priorityfor isolation.(Annette Jeanes & Gopal Rao 10/99)

The Wards and departments are contacted and informed of any alert organisms on a

daily basis by the infection control team at which time a risk assessment is completed if

isolation facilities are not available.

In the absence of sufficient single isolation rooms, cohort of affected patients will need

to be considered.


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Table 1 SCORE GRID

PATIENTS HOSPITALIZED ABROAD PRIOR TO ADMISSION SHOULD BE ISOLATED IN A

SINGLE ROOM PRIOR TO RESULTS OF SCREENING

Criteria Classification Score Comments Infection Infection

1 2ACDP 2 5

3 10

4 40

Route Air-borne 25

Droplet 10 Add 10 for cough ortracheostomy.

Contact 5 Includes faeco-oral.NBAdd 10 fordiarrhoea or skin

shedder.

Blood-borne 0

Evidence of Published or strongtransmission Consensus or 10

Moderate 5Poor 0

Nil -10

Significant Yes 5 Such as MRSA, VREresistance or No 0 etc.limited treatment

options.

High susceptibility Yes 10 Specific for variousof other patients No 0 infections and patientwith serious populations.consequences

Prevalence Sporadic - 0 This reflects theeg C.difficile single case burden of infection in

Endemic the hospital and

-5 cohort measures mayeg MRSA clusters

be more applicable.

Epidemic -5 See above.

TOTAL SCORE

Score Category of priority for isolation:

Score Priority

0 20 Low

25 35 Med

40 50 High


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Table 2

Condition or ACDP Mode of Evidence for Specific guidance & risk factorscatInfection Transmission nosocomial pt

to pt spread

Acute viral 2 Faeco-oral / Poorencephalitis incl. contact

Herpes simplex.AIDS 3 Blood borne Nil AIDS patients with specific infections

see specific guidance.

Body lice 2 Contact Strong Bedding and clothing should also betreated.

Campylobacter 2 Faeco-oral Poor

Chickenpox 2 Air borne Strong More infectious than shingles. Usually(Varicella) infectious for up to five days following

first crop of vesicles longer in the

immunocompromised.

Clostridium difficile 2 Faeco-oral Strong Isolate only in the presence of diarrhoea and until there has been no

diarrhoea for 72 hours.Cryptococcus 2 Nil Nil

Diarrhoea and / or 2 Faeco-oral / Strong All patients with diarrhoea should bevomiting including droplet isolated until proven to be non-dysentery. infectious aetiology.

Gentamicin resistant, 2 Contact. Strong Dependant on site of body and whereextended spectrum patient is sited in the hospital.beta-lactamase External site eg catheter is more likelyresistant and to spread.quinolone-resistant Greater risk of spread in IntensiveGram-negative rods Care.& other multiply-resistant bacteria.

Head lice 2 Contact Poor Transmission is difficult unless there ishead to head contact. Some lice areresistant to treatment and these casesshould be isolated.

Hepatitis 2 or 3 Faeco-oral / Poor Only Hepatitis A requires isolation -(undiagnosed) blood low infectivity after onset of jaundice.

Hepatitis B & C 3 Blood borne Nil

Hepatitis A & E 2 or 3 Faeco-oral Poor Low infectivity after onset of jaundice.

HIV 2 Blood borne Nil Without other infections.

Infectious 2 Droplet Poor mononucleosis(glandular fever)

Influenza (clinical 2 Droplet Strong Not usually practicable to isolatediagnosis) during epidemics.

Intestinal parasites 2 Faeco-oral Poor

(incl. protozoans)

Legionellosis 2 Airborne Nil(legionnairesdisease)

Measles 2 Droplet Strong

Meningitis 2 or 3 Droplet/faeco- Moderate All meningitis cases should be isolatedundiagnosed (viral or oral until cause is established.bacterial) Meningococcal meningitis requires

isolation until patient has received 48

hours of treatment.


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Condition or ACDP Mode of Evidence for Specific guidance & risk factorscatInfection Transmission nosocomial pt

to pt spread

Meningococcal 2 Droplet Moderate Remain in isolation until 48 hours of

septicaemia treatment given.

Meticillin-resistant 2 Contact Strong * See Major dispersers ie. dry or flak y skin,

Staphylococcus Appendix 1 leaking wounds, expectoratingaureus infected sputum = high risk.

Surgical orthopaedic, ITU, SCBU,Oncology/haematology = high risk.Nasal carriage only and commencedon treatment = low risk.Wound colonisation only covered =low risk

Mumps 2 Droplet Poor

Norovirus 2 Faeco-oral / Strongdroplet

Penicillin-resistant 2 Droplet StrongStreptococcuspneumoniae

Pubic lice 2 Contact Poor

Respiratory syncytial 2 Droplet Strongvirus

Rotavirus 2 Faeco-oral / Strong

droplet

Rubella 2 Droplet Moderate

Salmonella or 2 Faeco-oral Strong

Shigella

Scabies (confirmed) 2 Contact Strong

Scarlet fever 2 Droplet Mod

Shingles (Herpes 2 Contact Mod Less infectious than chickenpoxzoster)

Streptococcus 2 Droplet/contact Strong For 24 hours following treatment

pyogenes

TB open pulmonary 3 Air-borne Strong Isolated for period of 10 14 daysfollowing commencement oftreatment. HIV positive/suspectedMDRTB patients should remain in anegative-pressure isolation singleroom which will therefore result intransfer of patient to another Trust.

TB closed pulmonary 3 Air Nil

or non pulmonary borne/contactAtypical 3 Air borne WeakMycobacteria (MAI,

M. kansasii etc.,)

Typhoid fever 3 Faeco-oral Weak

Vancomycin- 2 Contact Strongresistant

enterococcus

Verotoxin producing 2 or 3 Faeco-oral Poorstrains of Eschericiacoli 0157

Viral Haemorrhagic 4 Blood borne Refer Blood and body fluids are highlyimmediately toFever infectious.InfectionDiseases Centre


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APPENDIX 2

Infection Prevention and Control Risk Assessment(This tool does not apply to day treatment areas, theatre and outpatients departments)

Risk assessment for in-patients who are known to be MRSA positive

Screening sites: Nose, groin, lesions, wounds and indwelling devices

Attach patient label here

Assess and score patient either at pre-admission or if there is a change in patients risk factor

or location.

Score 5 or less Score 6 or 7 = Medium RiskDoes not need Screen and preferably isolate

nursing in patient

isolation orscreening

Score 8 or above = HIGHRISK Nurse patient in isolation

and screen

More than one factor can be

selected from the list below -

place cumulative score in total

box. No risk factors = score 0

Score 1st 2nd 3rd 4th Please enter the date of assessments,Assessment Assessment Assessment Assessment the ward and if applicable the sites

swabbed (see overleaf)

RISK FACTORS: History of hospitalization 8abroad prior to admission (until

screening results obtained)

Infected wounds/lesions/ 1st

Assessment

other e.g. chest infection with Date of assessment:productive cough, infected 5line site, excessive skin Ward:

shedding, cellulitisSite swabbed:

No obvious infectionBUT has tracheostomy tube, Date of swabs:central venous access/dialysis line, non healed 2 Nurses signature:(exudating) wounds e.g.

leg ulcers

Long term urinary2

NDAssessmentcatheters/other invasive 2

device Date of assessment:

Healthcare employees 1 Ward:

Previous in-patient Site swabbed:admissions within t he past 1

6 months Date of swabs:

Other signs of infection Nurses signature

Not mentioned above 1

Previous history of MRSA

or other resistant organism 6


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ADMITTED FROM/AND INTERNAL & EXTERNAL TRANSFERS:

Overseas healthcare setting 4 3r

Assessment

Cardiothoracic surgery unit 4

Date of assessment:

Ward:

Renal/neurosurgical unit 4Site swabbed:

ICU/HDU 4Date of swabs:

Other surgical areas andmedical ward (as in-patient 48 Nurses signature:

hours & over) 2

Rehabilitation ward/unit 2

Nursing homes 2 4th

Assessment

Residential care home 1

Date of assessment:

Ward:INBOUND HOSPITAL WARD:

(see overleaf) Site swabbed:

High Risk Areas A 4 Date of swabs:

Moderate Risk Areas B 2 Nurses signature:

Low Risk Areas C 1

Total scores

WARDS

High Risk Areas A

ICU

Elective & Trauma OrthopaedicsVascularNeonatal Intensive CareOncology

Medium Risk Areas B

Obstetrics/GynaecologyCardiologyUrology/General SurgeryMedical/ElderlyDermatologyAccident & EmergencyMedical Assessment Unit

Surgical Assessment Unit

Low Risk Areas C

OphthalmologyDay AssessmentRehabilitationEndoscopy UnitDay Surgery


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APPENDIX 3

Screening and Assessment of Patients to Aid Early Recognition of

Viral Gastroenteritis of Patients Admitted to Hospital

CLINICAL Is there a history of diarrhoea, vomiting and abdominal cramps now or in the last72 hours?

(There may be one or more of these symptoms present).

Yes No

Duration of thesymptoms, are they

less than 3 days?

Yes No

Has the patient May not be viralbeen in contact gastroenteritis -with others with treat as suspectedsimilar symptoms? infective gastroenteritis.

Obtain stool specimenand isolate in a

sideroom.

Yes

Possible viral

gastroenteritis.

Do not admit to EAU.

Must have sideroom,preferably with ensuite.

Obtain stool specimen.

Inform Infection Control.

Inform HPA if patientis from a care home.(Health Protection Nurse

contact no. 01476 514699)

Has the patient been incontact with someone

with diarrhoea and/or

vomiting in the last 3 days?

No Yes

Proceed May be incubatingas normal viral gastroenteritis.

Advisable to placein sideroom for a

minimum of 48hours.


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APPENDIX 4Inter-healthcare Infection Control Transfer Form

Patient/client details:

(Insert label if available)Name:

Address:

NHS number:

Date of birth:

Receiving facility hospital, ward,

care home, district nurse Contact no:

Is the ICT/ambulance service

aware of transfer?

Consultant:

GP:

Current patient/client location:

Transferring facility hospital, ward,

care home, other:

Contact no:

Is the ICT aware of transfer? Yes/No

Is this patient/client an infection risk?

(Please tick most appropriate box and give

confirmed or suspected organism)

Confirmed riskOrganism:

Confirmed riskOrganism:

Suspected riskOrganism:

No known risk

Patient/client exposed to others with Infectione.g. D&V Yes/No

If patient/client has diarrhoeal illness, please indicate bowel history for last week:

(based on Bristol stool form scale)

Is the diarrhoea thought to be of an infectious nature? Yes/No

Relevant specimen results (including admission screens

MRSA, glycopeptides-resistant enterococcus,C.difficile, multi-resistant Acinetobacter) andTreatment information, including antimicrobial therapy:

Specimen:

Date:Result:

Treatment information:

Other information:

Is the patient/client aware of their diagnosis/risk of infection Yes/No

Does the patient/client require isolation? Yes/No

Should the patient/client require isolation, please phone the receiving unit in advance.

Name of staff member completing form: .......

Print name:Contact no.:


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APPENDIX 5

AUDIT OF MOVEMENT OF PATIENTS WITH SUSPECTED AND/OR CONFIRMED

INFECTIONS

Patient No. Patient

Ward/Dept Ward/Dept Comments %nursed in 1 2 eg if patient compliancesingle room moved was

isolation the transferfollowing supported

riskby clinical

assessmentrisk

YES/NOassessment

1

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infection prevention

Documents

infection hcai

prevention of outbreaks

prevention of mrsa2

management of patients

control principles

movement of isolated

planned patients

infected patients doh