ISOLATION POLICY
Version
4
Name of responsible (ratifying) committee
Infection Prevention Management Committee
Date ratified
1st March 2013
Document Manager (job title)
Dr Caroline Mitchell (Head of Infection Prevention)
Date issued
1st MARCH 2013
Review date
1st MARCH 2015
Electronic location
Infection Prevention and Control Policies
Related Procedural Documents
Key Words (to aid with searching)
Trust Policies:
Hand Hygiene policy
MRSA/MSSA policy
Standard Precautions policy
Clostridium difficile infection (CDI) management policy
Management of Outbreaks of Viral Diarrhoea &
Vomiting policy
Decontamination policy
Isolation, transmission precautions, source isolation,
protective isolation
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
(Review date 1st MARCH 2015 (unless requirements change)
Page 1 of 10
CONTENTS
1. INTRODUCTION.......................................................................................................................... 3
2. PURPOSE ................................................................................................................................... 3
3. SCOPE ........................................................................................................................................ 3
4. DEFINITIONS .............................................................................................................................. 3
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 3
6. PROCESS ................................................................................................................................... 4
7. TRAINING REQUIREMENTS ...................................................................................................... 9
8. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 9
9. EQUALITY IMPACT STATEMENT .............................................................................................. 9
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................ 10
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
(Review date 1st MARCH 2015 (unless requirements change)
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1. INTRODUCTION
Isolation refers to the use of a single room as a physical barrier to help prevent the
transmission of potentially infectious organisms. Isolation has been shown to be effective in
reducing onwards spread of infection but is only one element of a successful infection
prevention strategy. Other measures, such as environmental and equipment cleaning, the
correct use of personal protective equipment (PPE) and above all hand hygiene are equally or
more important.
2. PURPOSE
The aim of this policy is to ensure appropriate use of isolation facilities based on local risk
assessment in accordance with the Health & Social Care Act (DH 2010).
This policy should be used with reference to the:
 Hand Hygiene policy
 MRSA/MSSA policy
 Standard Precautions policy
 Clostridium difficile infection (CDI) management policy
 Management of Outbreaks of Viral Diarrhoea & Vomiting policy
 Decontamination policy
3. SCOPE
This policy applies to all PHT Healthcare workers (HCW), including agency, bank and locum
staff, Carillion staff including porters and house keepers and visiting HCW’s from other
organisations.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Nil
5. DUTIES AND RESPONSIBILITIES
Infection Prevention Team:
 Review and update Isolation policy
 Give additional advice regarding the management of patients requiring isolation where
required
 Include isolation precautions in all induction and update training for clinical staff
 Promote good practice and challenge poor practice
 Conduct audit and inspection of isolation practice with feedback to clinical staff
Microbiologists:
 Alert Infection Prevention Team and clinical teams of patients requiring
isolation following confirmation of certain infections
Patient Flow / Duty Hospital Managers:
 Facilitate placement of patients with potential or known infections into appropriate
isolation rooms as soon as possible
 Escalate difficulties in isolation to the Infection Prevention Team
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
(Review date 1st MARCH 2015 (unless requirements change)
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Report breaches of isolation to Infection Prevention Team and by incident reporting
Matrons / Ward Managers:
 Must establish a cleanliness culture across their units and promote compliance with
infection prevention guidelines
 Promote good practice and challenge poor practice
Medical Staff:
 Ensure compliance with infection prevention policies
 Follow advice from the Infection Prevention Team relating to isolation of patients
 Review the need for isolation on a daily basis
All Healthcare Staff:
 Must be familiar with and adhere to the relevant infection prevention policies to reduce the
risk of cross infection of patients
 Must adhere to the full terms and conditions of isolation documented in this policy
 Must use the risk assessment process to identify the isolation priorities of individual
patients
 Promote good practice and challenge poor practice
 Refer to the infection prevention 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
6. PROCESS
Principles of Isolation:
 Isolation is one aspect of effective infection prevention policy and standard precautions
should be applied to all patients without exception
 Isolation must never compromise the safety or clinical care of a patient
 The benefits of isolation should be weighed against the potential risks (patient’s mental
state, severity of illness etc) and patients should receive preparatory and ongoing
information relating to their condition, treatment and rationale behind isolation
 Infection risk should be constantly assessed as part of the ongoing clinical patient
assessment and managed accordingly.
 Isolation must be discontinued as soon as the risk of onwards transmission of infection
has diminished or resolved
Source Isolation:
Refers to the physical isolation of a patient with suspected or confirmed transmissible infection
in a single room in order to prevent or reduce the risk of onwards transmission by blocking the
route of spread.
Source isolation of infectious patients should occur in:
 A neutral pressure single room with ante room OR
 A negative pressure single room with ante room OR
 A standard single room
 The room should be cleaned after all other ward cleaning has been carried out
Protective Isolation:
Refers to the physical isolation of a susceptible patient in a single room in order to reduce the
risk of exposure to potentially harmful micro-organisms.
Protective isolation of immunocompromised/susceptible patients should occur in:
 A positive pressure single room with ante room
 A neutral pressure single room OR
 The room should be cleaned before any ward cleaning is carried out
Cohorting:
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
(Review date 1st MARCH 2015 (unless requirements change)
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An alternative of last resort to single room isolation is the cohorting of patients together with the
same condition. However, not all patients with similar symptoms e.g. diarrhoea, have the same
aetiology and many patients with the same organism e.g. C.difficile will have different strains.
Cohorting should only be undertaken following discussion with and approval by the infection
prevention team.
Escalation Strategy:
 Potentially infectious patients should be isolated within 2 hours of first suspicion
 Where no suitable single room is available in the immediate clinical area, staff should
escalate to:
i. Specialty flow coordinator (then)
ii. Duty hospital manager (then)
iii. (On-call) Infection Prevention Team
Asset List:
The Trust currently has:
 10 positive pressure single rooms with ante room (protective isolation) F6 ward
 4 neutral pressure single rooms with ante room (source or protective) E5 ICU
 12 neutral pressure single rooms with ante room (source or protective) G5 ward
(emergency use only)
 2 adjustable positive/neutral pressure single rooms with ante room F5 ward
 >220 standard single rooms across all wards
Common Principles of Isolation:
 The need for isolation should be clearly communicated to the patient, family members (if
appropriate) and clinical staff
 The need for isolation should be reviewed on a daily basis. Discuss specific cases with
the Infection Prevention Team
 An isolation sign should be prominently displayed on the room door which provides
sufficient information to instruct and protect contacts without breaching confidentiality
(appendix 1)
 Ensure that the door remains closed, especially when airborne infections are
suspected/confirmed e.g. pulmonary TB, influenza
Hand Hygiene & PPE:
 Hand hygiene facilities should be easily accessible inside and outside of the single room
 Clinical staff and visitors must decontaminate hands on entry and exit of the room
 Patients should be strongly encouraged to clean hands regularly, either with soap and
water, or cleansing wipes, particularly after using the toilet and before eating
 PPE (gloves, aprons/gowns, face masks/visors (where appropriate)) should be
prominently available outside the room entrance
 Protective equipment should only be worn by relatives carrying out direct ‘hands on
care’ and not for routine social visiting
 Limit and restrict the number of staff and visitors who come into contact with the patient
to reduce the potential to spread or introduce infection. Where immunity to a condition
occurs e.g. Chicken Pox, staff and visitors should be restricted to those who are nonsusceptible
Cleaning, Linen & Waste:
 The room must be cleaned at least once daily with dedicated cleaning equipment using
a suitable agent (hypochlorite e.g. Actichlor plus or chlorine dioxide e.g. Difficil-S)
 Carillion are responsible for cleaning the clinical environment, clinical staff are
responsible for cleaning clinical equipment
 Ensure that the room is kept clean and uncluttered, with flat surfaces clear of
unnecessary items
 Only stock that is required should be taken into the room
 Clinical equipment inside the room must be dedicated to the patients until the patient is
discharged or no longer deemed to be infectious. The equipment must then be
appropriately decontaminated before being used on other patients. If equipment cannot
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be restricted to a single patient then equipment must receive a thorough clean with a
chlorine agent before leaving the room
Charts and notes should be kept outside the room to reduce the risk of contamination
Clinical waste bin with either a yellow/black ‘tigerstripe’ bag (non-infectious offensive
waste for protective isolation) or orange (infectious offensive waste for source isolation)
should be kept in the room as appropriate
All linen should be bagged at the bedside as infectious linen in appropriate coloured
bags
Transport of Infectious Patients:
 Movement of infectious or potentially infectious patients should be kept to a minimum.
When it is necessary to transfer patients to other wards or departments, precautions to
minimise the risk of transmission, based on the route of spread, must continue
 If it is possible to delay an investigation without adversely affecting the patients
management this should be considered. However, infectious disease should not
compromise urgent clinical investigations
 The receiving area must be informed prior to transfer to ensure appropriate precautions
are in place and that suitable segregation facilities are available
 Patients with known or suspected infections should not be placed in waiting areas and
adequate time for post procedure cleaning should be built into clinic/theatre schedules
Terminal Room Cleaning:
All rooms must be thoroughly cleaned with hypochlorite e.g. Actichlor plus or chlorine dioxide
e.g. Difficil-S when vacated. This includes between patients with the same organism.
 Curtains must be removed and sent to the laundry as infected linen
 All disposable equipment should be discarded into orange clinical waste bags
 All clinical equipment, including bed frames should be thoroughly cleaned by clinical
staff
 All areas of the room should be cleaned using dispoable clothes with particular attention
paid to touch points and horizontal surfaces e.g. door handles, taps, dispensers, nurse
call system, toilet areas, bed frame, tables, lockers, chairs
Very High Risk Patients:
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 single room as soon as possible.
As QAH does not have these facilities the patient should be transferred to Southampton
University Hospitals Trust or the Royal Free Hospital London which has appropriate
facilities for the management of these patients.
Alternative arrangements can be sourced through the local Health Protection Unit.
Hampshire and Isle of Wight Health Protection Unit
Unit 8, Fulcrum 2,
Solent Way, Whiteley
Fareham, Hampshire
PO15 7FN
Tel: 0845 055 2022
Fax: 0845 504 0448
Notification of Infectious Diseases:
It is the responsibility of the attending registered medical practitioner to notify infectious
diseases. Notification forms can be obtained via the HPA website at
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/NotificationsOfInfectiousDisease
s/ReportingProcedures/
Diseases notifiable (to Local Authority Proper Officers) under the Health Protection
(Notification) Regulations 2010:
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Acute encephalitis
Acute infectious hepatitis
Acute meningitis
Acute poliomyelitis
Anthrax
Botulism
Brucellosis
Cholera
Diphtheria
Enteric fever (typhoid or paratyphoid fever)
Food poisoning
Haemolytic uraemic syndrome (HUS)
Infectious bloody diarrhoea
Invasive group A streptococcal disease
Legionnaires’ Disease
Leprosy
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Malaria
Measles
Meningococcal septicaemia
Mumps
Plague
Rabies
Rubella
SARS
Scarlet fever
Smallpox
Tetanus
Tuberculosis
Typhus
Viral haemorrhagic fever (VHF)
Whooping cough
Yellow fever
As of April 2010, it is no longer a requirement to notify the following diseases: Dysentery,
Leptospirosis, Ophthalmia neonatorum, Relapsing fever and Viral hepatitis. These and other
diseases that may present significant risk to human health may be reported under Other
significant disease category.
Alert Organisms:
The following list is provided as guidance and is not exhaustive. For complicated presentations,
please contact the Infection Prevention Team.
Alert Organism
Abscesses e.g.
quinsy
Blood borne virus e.g.
HIV, Hepatitis B,C
Risk Factors
Assess the patient
Campylobacter
Immunocompromise
Chicken Pox
Rash developed within
the previous 10 days or
vesicles not crusted over
Clostridium difficile
Toxin positive
Assess the patient
Carriage
CJD
Cryptosporidium
immunocompromise
Diarrhoea (infectious)
Exclude overflow,
laxitives, ng feeds,
crohns/colitis etc
Incontinent patient
Extended Spectrum
Beta-Lactamase
(ESBL) producing
organisms in urine
Catheterised or fully
continent patient
ESBL producing
organisms in other
Assess individual risks
e.g. weeping wounds etc.
Isolation Requirement
Isolate until 24-48 hours of appropriate antibiotics. Discuss
with the Infection Prevention Team
Isolation not required unless there is a high risk of blood or
blood stained body fluid splash. Additional precautions may
be required within the renal dialysis unit
Isolate whilst acutely symptomatic (80-90% of cases
resolve by day 7) but excretion in stools may continue for
2-7 weeks
Immediate isolation required. Only staff with a history of
Chicken pox (or serologically confirmed immunity) should
have contact with this patient. Patient can be removed from
isolation once vesicles fully crusted
Isolate for duration of hospital admission, regardless of
symptoms. Isolate if readmitted within 6 months of original
diagnosis
Isolate for duration of hospital admission, regardless of
symptoms Isolate if readmitted within 6 months of original
diagnosis
Isolation not required. See CJD policy for advice re surgical
procedures. Inform microbiologist on call immediately if
diagnosis is suspected to ensure safe handling of
specimens
Isolate whilst symptomatic (2 days to 4 weeks),
immunocompromised patients will take longer to clear
infection
Immediate isolation, preferably within 2 hours of onset of
symptoms until full resolution of diarrhoea and formed stool
Isolation required. Encourage good hand and personal
hygiene. Dedicated commode (or lavatory) cleaned
between each use
Isolation preferable. Encourage good hand and personal
hygiene. Dedicated commode (or lavatory) cleaned
between each use
Isolation required. Encourage good hand hygiene and
personal hygiene. If possible use a dedicated toilet.
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
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sites
GRE Glycopeptide
resistant enterococci
(including VRE)
Discuss with Infection Prevention Team if required
Isolate for duration of hospital admission, regardless of
symptoms. Isolate if readmitted. Patient will have longterm skin and intestinal carriage. Dedicated bathroom
facilities. Encourage good hand hygiene and personal
hygiene
Isolate until patient has completed course of antivirals and
is symptom free. FFP3 face masks to be worn for aerosol
generating procedures. FFP1 face masks to be worn during
non aerosol generating close contact.
For avian influenza inform microbiologist on call
immediately if diagnosis is suspected
Not transmitted between individuals, no isolation required
Influenza (including
Avian flu and H1N1)
Legionella
(legionnaires disease)
Malaria
Confirmed
Suspected
Measles
Suspected
meningitismeningococcal
Meticilin Resistant
Staphylococcus
aureus
(MRSA)
Sputum Positive with
productive cough, flaking
skin condition, wet
wounds with break
through
Skin colonisation only
Mumps
Norovirus
Salmonella (inc. typhi
(typhoid fever))
Shigella
Shingles
Tuberculosis
Rash in an exposed area
with wet lesions
Rash in a covered area
with wet/drying lesions
Confirmed pulmonary TB
with a productive
cough
Suspected pulmonary TB
AFB negative pulmonary
TB/ TB closed site
Suspected/ Confirmed
drug resistant TB
Norwegian Scabies
Often affects immunocompromised patients
Classical scabies
Group A
Streptococcus
SARS
Awaiting diagnosis
Vancomycin resistant
enterococci (VRE)
Viral Hemorrhagic
Fever
See GRE
Not transmitted between individuals, no isolation required
Febrile illness with a history of travel to tropical/subtropical
area should be managed as high risk until malaria
diagnosis confirmed
Isolate until 5 days after onset of rash
Isolate until 24 hours of antibiotics. FFP1 face mask to be
worn during any procedure likely to generate respiratory
droplets. Inform occupational health if in direct contact with
respiratory secretions e.g. during resuscitation
Immediate isolation required.
Discuss with the Infection Prevention Team
If no single room available, may be treated in a main bay if
located next to a hand washing sink with full transmission
precautions
Isolate until 9 days after onset of rash
Isolate immediately on first episode of projectile vomiting or
diarrhoea, until 48 hours after complete cessation of
symptoms
Isolate infants until clinical recovery occurs. Cohort nursing
may be considered in certain circumstances if all patients
RSV status known
Isolate immediately (excretion may continue for 2 days to 2
months, median 5 days)
Isolate whilst acutely symptomatic (excretion may continue
for 2-4 weeks post acute illness)
Isolate until lesions are fully dried. Only staff with a history
of Chicken pox (or serologically confirmed immunity)
should have contact with this patient
May be treated in a main bay provided no
immunocompromised patients are in the room
Isolate until 14 days continuous, compliant treatment. Use
FFP 2 or 3 facemask for contact
Isolate until 3 negative sputum specimens on microscopy
No requirement to isolate
Discuss with TB nurse specialist and Infection Prevention
Team. Will require isolation in a negative pressure side
room and transfer to alternative site
Highly transmissible, isolate until full course of treatment
has been completed (minimum 2 treatments)
Discuss with Infection Prevention Team
Isolate until 48 hours of appropriate antibiotics
Immediate isolation required. Inform Infection Prevention or
Microbiologist on call immediately if diagnosis is suspected
Discuss with Infection Prevention Team or Microbiologist
on call immediately if diagnosis is suspected. Will require
isolation in a negative pressure side room and transfer to
alternative site
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
(Review date 1st MARCH 2015 (unless requirements change)
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7. TRAINING REQUIREMENTS
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Clinical and non-clinical staff to receive practical hand hygiene training on induction and
every 2 years thereafter (Infection Prevention Team)
Clinical and non-clinical staff to receive face-to-face induction training on aspects of
infection prevention & isolation (Infection Prevention Team)
Update training to be delivered as part of Patient Safety & Quality Days, departmental
and drop in days, Link Advisor days and Senior Doctors Training (Infection Prevention
Team)
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Ayliffe, G.A.J, Babb, J.R, Taylor, L.Z (2001) Hospital Acquired Infection, Principles and
Prevention. Third Edition, Arnold Page
Department of Health (2010) The Health Act 2008 Code of Practice for the Prevention and
Control of Health Care Associated Infections London DH, 2010
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement to be
monitored
Lead
Time to isolation for patients
with suspected infectious
diarrhoea
IPCT
Quality of Isolation (PPE,
Clutter, Signage, Chlorine
Cleaning)
IPCT
Tool
Frequency of
Report of
Compliance
Infection
Prevention
Dashboard
Weekly for all areas
Infection
Prevention
Dashboard
Weekly for all areas
Reporting arrangements
Policy audit report to:

.
Isolation Policy: Version 4 Issue Date: 1st MARCH 2013
(Review date 1st MARCH 2015 (unless requirements change)
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HoN
HoN, MM, Consultants, Ward
Managers, IPMC
Policy audit report to:
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Lead(s) for acting on
Recommendations
HoN, MM, Consultants, Ward
Managers, IPCM
HoN