MULTI RESISTANT ORGANISM POLICY
Responsible Directorate:
Public Health
Responsible Director:
Dr Judith Hooper
Date Approved:
25 March 2009
Committee:
Governance Committee
NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
Page 1 of 18
Version Control Current versions of all policies can be found on NHS Kirklees internet and intranet. If printing a document, please check internet/intranet for most up-to-date version. Document Title: Document number: Author: Contributors: Version: Date of Production: Review date: Postholder responsible for revision: Primary Circulation List: Web address: Restrictions:
Multi Resistant Organism policy 1 Louise Hodgson 1 February 2009 March 2011 Deputy Director Infection Prevention and Control
Standard for Better Health Map Domain: Core Standard Reference: Performance Indicators:
First domain safety C4, C4a, C4d, C4e 1. To reduce incidence of healthcare associated infections. 2. To reduce incidence from cross infections.
Page 2 of 18
Contents
Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Page
Introduction Associated policies and procedures Aims and objectives Scope of policy Accountabilities and responsibilities Clinical risk assessment Meticillin Resistant Staphylococcus Aureus Management of patients with MRSA Management of patients in the community MRSA screening Decolonisation of MRSA colonisation Transfer of patients with MRSA Multi resistant gram negative bacilli Management of in patients with multi resistant gram 14. negative bacilli 15. Clostridium Difficile Associated Disease Management of in patients with Clostridium Difficile 16. Associated Disease Management of Patients with Clostridium Difficile 17. Associated Disease in the Community 18. Equality Impact Assessment 19. Training Needs Analysis 20. Monitoring Compliance with this policy 21. References Appendices Key Stakeholders consulted/involved in the A development of the policy/procedure B Equality Impact Assessment Tool
Page 3 of 18
4 4 4 4 5 5 5 6 7 9 9 10 11 11 12 13 14 15 15 15 16 17 18
Policy Statement Infection prevention and control is of prime importance within NHS Kirklees and is essential to the safety and confidence of patients, families and carers.
1.
INTRODUCTION
A Healthcare Associated Infection (HCAI) can be defined as an infection that occurs as part of health care treatment. Staff, patients and the public are more aware than ever of the risks of HCAI, including MRSA, the multi-resistant bacteria which are of clinical and public concern. The prevention and control of HCAIs is a national priority. Resistance to anti-microbial agents is a natural evolutionary response of microbes to antimicrobial exposure. The principle of anti-microbial resistance has been described as ‘survival of the fittest’. Where anti-bacterial agents kill susceptible bacteria, resistant organisms survive and multiply and may infect / colonise other patients. Resistance can arise via mutation, gene transfer or by the development of inherently resistant species. Inappropriate antibiotic use promotes the emergence and spread of antibiotic resistance. The importance of these processes varies with the organism, the anti-microbial agent and the clinical setting. 2.
ASSOCIATED POLICIES AND PROCEDURES
This policy must be read in accordance with the following Trust policies, procedures and guidance: • • • • • • • • • 3.
Hand decontamination policy Isolation policy Waste management guidelines Incident reporting Health and safety policies Decontamination, disinfectants and antiseptics policy Standard universal precautions policy Clostridium difficile policy Dress code policy for clinical staff AIMS AND OBJECTIVES
To manage the care of patients with a healthcare associated infection and minimise the risk of cross infection of Meticillin Resistant Staphylococcus aureus (MRSA), gram negative bacilli and Clostridium difficile disease (CDAD) will be covered in this policy. 4.
SCOPE OF THE POLICY
This policy must be followed by all NHS Kirklees employees who are developing policy and procedural documents or developing guidance for colleagues. It must be followed by all staff who work for NHS Kirklees (the PCT), including those on temporary or honorary contracts, bank staff and students. Page 4 of 18
Breaches of this policy may lead to disciplinary action being taken against the individual. Independent contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent contractors are encouraged to seek advice and support at required. 5.
ACCOUNTABILITIES AND RESPONSIBILITIES
The Chief Executive (CE) is accountable for ensuring that effective arrangements for infection prevention and control are in place within NHS Kirklees. The Director of Infection Prevention and Control has responsibility to provide assurance to the Board that infection prevention and control policies are in place and their compliance audited. The Infection Prevention and Control Team will ensure the policy is reviewed as required and work with Heads of Service to implement necessary changes in practice. 6.
CLINICAL RISK ASSESSMENT
As part of the management of patients infected or colonised with multi-resistant organisms a risk assessment is required and is undertaken by a member of the Infection Prevention and Control Team (IPCT) with the clinician / GP / nurse in charge of the patient. The purpose is to assess factors related to the management of the patient. In order to undertake this risk assessment various factors are considered pertaining to: •
The organism, site and / or specimen type.
•
The patient, assessing their inmmunosuppression status, if they have any wounds, invasive devices, are expectorating sputum, receiving health care and if they are colonised or infected.
•
If an inpatient, where they are situated in the ward, including the susceptibility of the surrounding patients.
7.
METICILLIN RESISTANT STAPHYLOCCOCUS AUREUS (MRSA)
Staphylococcus aureus is a gram-positive bacterium that is found in the normal flora of the nose in twenty to thirty percent of healthy people and on the skin. It can be transiently carried on the hands and survives well in the environment in dust. Some strains of Staphylococcus aureus are resistant to some antibiotics including flucloxacillin and all cephalosporins and also resistant to Meticillin, these are referred to as Meticillin Staphylococcus aureus (MRSA). Both MRSA and sensitive Staphylococcus aureus can colonise a person’s skin. MRSA is not more virulent or pathogenic than Meticillin sensitive Staphylococcus aureus, it is however more difficult to treat. MRSA does not pose a risk to healthy health care workers or family members, but can cause serious infection in vulnerable patients.
Page 5 of 18
8.
MANAGEMENT OF IN PATIENTS WITH MRSA
This section refers to in patients at Holme Valley Memorial Hospital. Isolation Patients who are known to be colonised or infected with MRSA should be placed in a side room. If cases exceed side room capacity then cohorting with an emphasis on the importance of cohort nursing is recommended as a strategy for controlling transmission of healthcare associated infection. Patients must not share a room with a person who has chronic open wounds or invasive devices, a risk assessment will be undertaken by a member of the IPCT with the nurse in charge. Due to the nature of the type of patients at HVMH (low risk) and the reason for their stay (rehabilitation and sub acute) patients can leave their side room for meals and rehabilitation, taking care to ensure any patients with chronic wounds and / or invasive devices are not in contact with a colonised / infected patient. However, any activities of daily living and / or dressings etc. must be undertaken in the patients own room. Whilst the patient is in their room the door must be closed. Signage Standard isolation is the type of isolation that is necessary for patients who are known, or suspected of being colonised or infected with, pathogenic micro-organisms. Therefore standard isolation precautions are required and a standard isolation sign must be placed on the outside of the door of all single rooms. Hands Refer to Hand Decontamination Policy. Protective Clothing Refer to Standard Universal Precautions Policy. Waste Refer to Waste Management Guidelines. Linen Linen from MRSA positive patients must be treated as contaminated / infected linen and must be placed immediately into a water-soluble bag (red) and removed from the patient’s bed area as soon as possible. To prevent sodden laundry from dissolving the water-soluble bag, wrap in used linen first. Once ž full the laundry bag must be tied off / fastened and placed in a red nylon laundry bag. Page 6 of 18
Environmental Cleaning The room / bed area requires a thorough clean daily using hot water and detergent, including high-level damp dusting where possible. On the patient’s discharge a thorough clean is required of all surfaces of the room / bed area, mattress, bed frames, call bells, duvets and pillows, with hot water and detergent. Care must be taken when cleaning electrical equipment. The use of disinfectants (Hypochlorite) is required when there is evidence of contamination with blood or body fluids. ‘Haz Tab’ dilution must be made up to 10,000 (parts per million of available chlorine) for blood spillage and 1000 (parts per million of available chlorine) (not containing blood). The use of ‘Chlor-clean’, a disinfectant with detergent action, may be requested by the Infection Prevention and Control Team, for example in an outbreak situation and a terminal clean. Window curtains do not require changing as long as they are visibly clean. Bed space curtains must be changed if visibly dirty and/or if the patient was heavily colonised / infected and / or in the main bed area for more than 48 hours. All curtains must be changed routinely according to local agreement. Equipment Equipment must be ‘single-use’. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids the use of disinfectants (Hypochlorite) are required. ‘Haz Tab’ dilution must be made up to 10,000 p.p.m. for blood spillage and 1000 p.p.m for a body fluid (not containing blood). 9.
MANAGEMENT OF PATIENTS IN THE COMMUNITY (in their own homes)
While the risk of serious infection with MRSA is lower in the community, it still exists. It is increasingly the case that colonisation due to cross contamination with MRSA can occur in community settings. People affected with MRSA do not present a risk to the community at large and should continue their normal lives without restriction. MRSA is not a refusal to admit to a care home or a reason to exclude an affected person from having a home life. In the patient’s own home there should be no restrictions to a normal life and people with MRSA can work and socialise as usual. They do not need to restrict the contact with friends, children or the elderly but encourage hand washing if close contact occurs. If they are admitted to hospital, where the risk of infection is increased, the ward must be informed so the patient is risk assessed, screened on admission and nursed appropriately. Community Health care workers must practice standard infection control precautions as outlined below: Page 7 of 18
Hands Refer to Hand Decontamination Policy. Protective Clothing Refer to Standard Universal Precautions Policy. Waste Refer to Waste Management Guideline. Domestic Waste A small amount (a carrier bag full a week) of healthcare waste containing plasters, small dressings and incontinence products may be placed in the patients / clients domestic waste stream, however, the points below must also be considered if this occurs. •
Only small dressings may be placed in domestic waste bags - no larger than a dressing pad (130mm x 220mm), no antimicrobial dressings.
•
A wound assessment must be undertaken.
•
Packaging may be placed in a domestic waste bag but must be placed in a plastic sack / bag first. It is not appropriate to place yellow / orange coloured bags (those found in dressing packs) in the domestic waste as this indicates that the waste is hazardous. Thin opaque sacks and / or bin liners are appropriate.
•
Small volumes of incontinence products may be placed in the patients / clients own domestic waste stream.
Linen It must be advised that the patient / client or carer uses a pre wash cycle on the washing machine, if the patient / client is bed bound the bed clothes must be washed separately from the other laundry. Environmental Cleaning It is appropriate to clean any areas in the patients home for example, a table top that may have been contaminated or used by the health care worker, before and after use. A detergent wipe, or soap and water are required for this type of clean. The use of disinfectants (Hypochlorite) is required when there is evidence of contamination with blood or body fluids. Spillage kits are advised to be used as they would ensure quick and easy removal of the spillage.
Page 8 of 18
Equipment Equipment must be ‘single-use’. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids use of disinfectants (Hypochlorite) are required 10,000 p.p.m. for blood spillage and 1000 p.p.m for a body fluid (not containing blood). 10.
MRSA SCREENING
The objective of MRSA screening is to reduce the risk of infection for MRSA and ultimately the number of infections by routinely screening elective patients who attend the preassessment clinic at the day surgery unit at Holme Valley Memorial Hospital will be screened during their appointment and they will be counselled about the positive outcomes of this screening. MRSA screening is exempt for the following groups: ● ● ● ● ●
Day case ophthalmology Day case dental Day case endoscopy Minor dermatology procedures, eg, warts or other liquid nitrogen applications Maternity / obstetrics, but include patients for elective caesareans
The screening must take place as near to the procedure as possible, taking into account the five days decolonisation regime if the patient is found to be positive. A full screen comprises of both nasal, groin and axilla swabs. One swab for nostrils, one swab for both groins and one swab for axilla, plus any lesions, or drain sites, a catheter specimen of urine (if catheter present) and a sputum sample if the patient is expectorating. The IPCT will notify the nursing / medical staff if any further sites need to be screened. If a patient is transferred from another hospital to Holme Valley Memorial Hospital it is the responsibility of the nurse in charge of the patient, to ascertain the patients MRSA status prior to transfer. The Infection Prevention and Control Team will advise further screening of MRSA carriers. There is little benefit in taking swabs from patients with chronic lesions and long-term invasive devices, unless there is a clinical indication to do so. 11.
DECOLONISATION OF MRSA COLONISATION ● Pre-assessed patients who are positively colonised will be notified by the preassessment clinic via a letter that their result is positive; information leaflets will also be sent to the patient. The pre assessment clinic will arrange for the patient to collect the decolonisation treatment. The patients GP must also be informed. ● Positive patients who have recently been discharged from the hospital (CHFT and / or MYHT) prior to receiving MRSA decolonisation treatment will be prescribed the Page 9 of 18
treatment in the community. The results of these patients will be communicated from the IPCT in the hospital to the NHS Kirklees IPCT who will then inform the patients GP who will prescribe the patients treatment. The treatment must be commenced as soon as possible. Treatment consists of: ● Nasal carriage: apply a small amount of mupirocin 2% (Bactroban) nasal cream to both nostrils three times a day for five days only. Massage round with the cream until it can be felt at the back of the nose. ● Skin carriers: Chlorhexidine gluconate 4% wash (hydrex handwash) or Octenidine (Octenisan wash lotion) instead of soap and hair shampoo, applying it directly onto wet skin (preferably with a single use wet cloth), concentrating on the groins, axilla and perineal areas. To be used daily for five days in the shower, bath or when bed bathing. ● Wound / lesion carriers: Keep wound occluded. Refer to the tissue viability nurses if the wound is deteriorating. ● The use of emollients is advisable in patients with skin problems or the elderly. On completion of the decolonisation regime repeat screening is not necessary unless advised by the Infection Prevention and Control Team. The decolonisation regime may not completely remove MRSA colonisation but will reduce the risk of infection. 12.
TRANSFER OF PATIENTS WITH MRSA
If a patient with MRSA is transferred to another healthcare setting (inpatient), the receiving clinical staff must be informed. This allows the receiving institution to take necessary measures to protect vulnerable patients. In general MRSA does not present a risk to the general public. Booking of Patients for Ambulance Transport Most carriers of MRSA can be transported with other patients with no extra precautions. Arrangements must be made for patients to travel alone if any of the following pertain: ●
Immuno-compromised;
●
Open wounds such as skin grafts, or exudating wounds, that cannot be covered by an impermeable dressing;
●
Excessively expectorating sputum and may not be able to effectively dispose of / manage with tissues.
If in doubt seek advice from the Infection Prevention and Control Team.
Page 10 of 18
Patient Assessment prior to travelling in the ambulance / patient transport ●
Catheters are emptied before discharge.
●
Wounds are covered with an impermeable dressing and the wound checked for visible exudate.
●
If patients are expectorating sputum then staff must ensure that clean tissues are transported with the patient; consider lone transportation if the patient cannot effectively dispose of / manage tissues themselves.
13.
MULTI-RESISTANT GRAM NEGATIVE BACILLI (GNB)
Species of this type of bacteria most commonly seen include, Escherichia Coli (E. Coli), Klebsiella, Proteus, Pseudomonas, Enterobacter, Citrobacter and Acinetobacter spp. Collectively these bacteria may be referred to as Gram-Negative Bacilli (GNBs). ●
GNBs are commonly found in the gastro-intestinal tract, in water and soil. Colonisation of hospitalised patients with a GNB is common.
●
Multi-resistant bacteria are seen more frequently in areas that have high usage of broad-spectrum antibiotics and where patients are immuno-compromised e.g. Critical Care and Oncology Units.
●
GNBs commonly achieve antibiotic resistance by producing enzymes called extendedspectrum B-lactamases (ESBLs) that destroy and confer resistance to antibiotics.
●
GNBs have been implicated in outbreaks of infection in Intensive Care, Neonatal and Oncology Units. They can cause urinary tract infections, pneumonia, surgical site infections and meningitis.
14.
MANAGEMENT OF IN PATIENTS WITH MULTI-RESISTANT GRAM NEGATIVE BACILLI (GNB)
In general GNB does not present a risk to the general public or to patients in low risk areas such as community hospitals and residential or nursing homes. Isolation It is not routinely advised that patient with a GNB are placed in a single room. Hands Refer to Hand Decontamination Policy. Protective Clothing Refer to Standard Universal Precautions Policy.
Page 11 of 18
Waste Refer to Waste Management Guidelines. Linen Linen from patients with a GNB must be treated as contaminated / infected linen and must be placed immediately into a water-soluble bag (red) and removed from the patient’s bed area as soon as possible. To prevent sodden laundry from dissolving the water-soluble bag, wrap in used linen first. Once ¾ full the laundry bag must be tied off / fastened and placed in a red nylon laundry bag. Environmental Cleaning The room / bed area requires a thorough clean daily using hot water and detergent, including high-level damp dusting where possible. On the patient’s discharge a thorough clean is required of all surfaces of the room / bed area, mattress, bed frames, call bells, duvets and pillows, with hot water and detergent. Care must be taken when cleaning electrical equipment. The use of disinfectants (Hypochlorite) is required when there is evidence of contamination with blood or body fluids. ‘Haz Tab’ dilution must be made up to 10,000 p.p.m. for blood spillage and 1000 p.p.m for a body fluid (not containing blood). The use of ‘Chlor-clean’, a disinfectant with detergent action, may be requested by the Infection Prevention and Control Team, for example in an outbreak situation and a terminal clean. Window curtains do not require changing as long as they are visibly clean. Bed space curtains must be changed if visibly dirty and / or if the patient was heavily colonised / infected and / or in the main bed area for more than 48 hours. All curtains must be changed routinely according to local agreement. Equipment Equipment must be ‘single-use’. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids the use of disinfectants (Hypochlorite) are required. ‘Haz Tab’ dilution must be made up to 10,000 p.p.m. for blood spillage and 1000 p.p.m for a body fluid (not containing blood). 15.
CLOSTRIDIUM DIFFICILE ASSOCIATED DISEASE (CDAD)
Clostridium difficile is an anaerobic bacterium that is present in the gut of 3% of healthy adults and 66% of infants. However, Clostridium difficile rarely causes problems in children or healthy adults, as it is kept in check by the normal bacterial population of the intestine. When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins, which cause illness. The symptoms can vary from mild diarrhoea Page 12 of 18
to severe life threatening conditions. Clostridium difficile is transmitted by clostridial spores, which are shed in large numbers by infected patients and are capable of surviving for long periods in the environment. 16.
MANAGEMENT OF IN PATIENTS WITH CDAD
Stool sample A sample of the patient’s diarrhoea stool must be taken and sent to laboratory as soon as possible (aim for the sample to be tested in the laboratory within 18 hours of taking it). The laboratory form must be fully completed ensuring any antibiotic history is noted. The member of staff obtaining sample must adhere to the standard precautions policy ensuring they are wearing protective clothing and decontaminating their hands thoroughly. Stool Chart The patient’s frequency and type of stool using the Bristol stool chart must be completed to allow an accurate assessment of the patients systems. Isolation It is always advised that patients with diarrhoea are placed in a single room until they are 48 hours symptom free (last 5, 6, 7 type stool was 48 hours previous). Signage Standard isolation is the type of isolation that is necessary for patients who are known, or suspected of Clostridium difficile infection. Therefore standard isolation precautions are required and a standard isolation sign must be placed on the outside of the door of all single rooms. Hands Refer to Hand Decontamination Policy. Alcohol gel is not recommended to be used as there is no evidence to support that alcohol is effective in killing Clostridium difficile spores. Protective Clothing Refer to Standard Universal Precautions Policy. Waste Refer to Waste Management Guidelines.
Page 13 of 18
Linen Contaminated linen must be placed immediately into a water-soluble bag (red) and removed from the patient’s bed area as soon as possible. To prevent sodden laundry from dissolving the water-soluble bag, wrap in used linen first. Environmental Cleaning Clostridium difficile spores can survive in the environment, to prevent further spread a thorough environmental cleaning on a daily basis must be undertaken. Increase the cleaning of horizontal surfaces to twice daily with chlorine containing cleaning agents (at least a thousand ppm available chlorine). As special cleaning arrangements are required the domestic must be informed of the infection risk (not of the patient’s diagnosis) and of any protective measures necessary for the domestic staff member. Once the patient has been free from diarrhoea for 48 hours the room should be terminally cleaned with chlorine containing cleaning agents at least a thousand ppm available chlorine and cubicle curtains changed. This should take place even if the patient is not moving from the single room. Terminal cleaning of the patient’s room must also be carried out at the discharge of the patient / before admitting another patient. Equipment Equipment must be ‘single-use’. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids the use of disinfectants (Hypochlorite) are required. ‘Haz Tab’ dilution must be made up to 10,000 ppm for blood spillage and 1000 ppm for a body fluid (not containing blood). Transfer of patients with CDAD Where possible patients must not be transferred to other health care settings (in patient or day / out patient) whilst they are symptomatic with diarrhoea and / or until they are 48 hours symptom free (last 5, 6, 7 type stool was 48 hours previous). 17.
MANAGEMENT OF PATIENTS WITH CDAD IN THE COMMUNITY
Where possible community staff visiting patients with CDAD should visit the patients last so that infection is not transmitted to reduce the risk of transmission. Hands Refer to Hand Decontamination Policy. Alcohol gel is not recommended to be used as there is no evidence to support that alcohol is effective in killing Clostridium difficile spores. Protective Clothing Refer to Standard Universal Precautions Policy. Page 14 of 18
Waste Refer to Waste Management Guidelines. Linen Fouled linen must be placed in the washing machine with care and the carers / health care workers must wear disposable plastic aprons and gloves when handling it. It must be advised that the patient / client or carer uses a pre wash cycle on the washing machine and the contaminated linen must be washed separately from the other laundry, the washing machine must be set at the highest temperature the laundry allows. Equipment Equipment must be ‘single-use’. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids use of disinfectants (Hypochlorite) are required 10,000 p.p.m. for blood spillage and 1000 p.p.m for a body fluid (not containing blood). 18.
EQUALITY IMPACT ASSESSMENT
This Policy was found to be compliant with this philosophy (see appendix B). 19.
TRAINING NEEDS ANALYSIS
The PCT is committed to the training and continuing development of all staff including independent contractors on all relevant issues surrounding infection prevention and control. All induction programmes and infection prevention and control mandatory training will include MRSA and Clostridium difficile infections. 20.
MONITORING COMPLIANCE WITH THIS POLICY
The Trust will have key indicators for the monitoring of Infection Prevention and Control: ●
Essential Steps audits to ensure key infection prevention and control policies are being implemented
●
Percentage of clinical and non-clinical staff at HVMH undertaking mandatory annual Infection Control training.
●
Quality indicators will be part of normal performance monitoring against a set of local, regional and national standards.
●
Healthcare associated infection identified after completion of root cause analysis investigations.
Page 15 of 18
21.
REFERENCES
1.
Centres for Disease Control (1996) Guideline for Isolation Precautions in Hospitals. American Journal of Infection Control. 24, pp 24-52.
2.
Department of Health, Health Act 2006, Code of Practice for the Prevention and Control of Healthcare Associated Infections (revised January 2008).
3.
Department of Health and Standard Advisory Committee (2000) The path of least resistance. DH, London
4.
Department of Health and PHLS (1995) Clostridium Difficile Infection Prevention and Management. DH, London
5.
Department of Health (2005) Saving Lives: a delivery programme to reduce Healthcare Associated Infection MRSA. DH Publications, London.
6.
Department of Health (2006) Safe Management of Healthcare Waste. HTM 07-01. The Stationary Office, London.
7.
Department of Health (2006) Infection Control for Care Homes. DH, London.
8.
Health Protection Agency (2005) Glycopeptide – Resistant Enterococci. http://www.hpa.org.uk/infections/topics-az/enterococci/GRE-QandAs.htm. Accessed 05/07/06
9.
Joint BSAC/HIS/ICNA Working Party (2001) Review of Hospital Isolation and Infection Control Related Precautions.
10. Joint BSAC/HIS/ICNA Working Party on MRSA (2006) Guidelines for the control, and prevention of Meticillin-resistant Staphylococcus aureas (MRSA) in healthcare facilities. The Journal of Hospital Infection. Volume 63, supplement 1. ISSN 0195-6701 11. Department of Health 2008 – A Guide to Best Practice: Isolation of patients DH, London
Page 16 of 18
A. Key stakeholders consulted/involved in the development of the policy/procedure Key Participant Yes/No
Feedback requested Yes/No
Feedback accepted Yes/No
Caroline Summer and Kath Barraclough
No
Yes
Yes
Infection Prevention and Control Team
Yes
Yes
Yes
Kirklees Infection Prevention and Control Committee
No
Yes
Yes
NHS Kirklees Policy Development Group
No
Yes
Yes
Stakeholders name and designation
Page 17 of 18
B. Equality Impact Assessment Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favorably than another on the basis of: • Race
No
• Ethnic origins (including gypsies and travellers)
No
• Nationality
No
• Gender
No
• Culture
No
• Religion or belief
No
• Sexual orientation including lesbian, gay and bisexual people
No
• Age
No
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
2.
Is there any evidence that some groups are affected differently?
No
3.
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
No
4.
Is the impact of the policy/guidance likely to be negative?
No
5.
If so can the impact be avoided?
n/a
6.
What alternatives are there to achieving the policy/guidance without the impact?
n/a
7.
Can we reduce the impact by taking different action?
n/a
Page 18 of 18
Comments