Infection Prevention and Control

Transcription

1 Document Details Title Trust Ref No Local Ref (optional) Main points the document covers Who is the document aimed at? Author Approval process Who has been consulted in the development of this policy? Approved by (Committee/Director) This policy details guidance for staff on the actions and precautions required when caring for patients with suspected or confirmed influenza to minimise the risk of transmission of the infection between patients, staff and visitors. All staff who work in a clinical environment within Shropshire Community Healthcare NHS Trust. Head of Infection Prevention and Control This policy has been developed by the IPC team in consultation with appropriate clinical services managers, link staff, advisors/specialists (e.g. Medical Advisor, Specialist Nurses, Medicine Management), PHE and IPC Governance Meeting members. Infection Prevention and Control Governance Meeting notified to Quality and Safety Operational Group Approval Date 26 January 2018 Initial Equality Impact Screening Full Equality Impact Assessment Lead Director Category Sub Category Yes N/A Executive Director of Nursing and Operations, DIPC Clinical Infection Prevention and Control Review date January 2021 Distribution Who the policy will be distributed to Method Document Links Required by CQC IPC Governance Meeting Members Electronically to IPC Governance Meeting Members and available to all staff via the Trust website Yes Other Key Words Amendments History No Date Amendment 1 November 2017 Policy reviewed and updated to reflect current guidance and 2017/18 winter flu plan 2 December 2014 Updated following the publication of the winter flu plan 2014/15 Title change

2 Contents Policy on a page Introduction Purpose Definitions Duties The Chief Executive Director of Infection Prevention and Control Infection Prevention and Control Team Managers and Service Leads Staff Committees and Groups Board Quality and Safety Committee Infection Prevention and Control Governance Meeting Overview of Seasonal Influenza Mode of Transmission and Infectivity Large Droplet Transmission Aerosol or Fine Droplet Transmission (during aerosol generating procedures) Direct Contact Transmission Indirect Contact Transmission Incubation Period and Infectious Period Diagnosis of Influenza and Case Definitions Clinical Diagnostic Criteria Case Definitions Presumed Case Confirmed Case Discarded Case Vaccination At Risk Groups Offered Vaccination Treatment Antiviral Medicines Infection Prevention and Control Precautions General Management of Cases Assessment in Minor Injuries Unit (MIU) Patients in Community Hospitals Isolation Practices Checklist Patients Transferred from other Hospitals... 9

3 Inability to Isolate a Patient Appropriately Hand Hygiene Respiratory Hygiene Catch it, bin it, kill it Use of Personal Protective Equipment (PPE) (see Appendix 2) Plastic Aprons Fluid Resistant Gowns Surgical Masks Respiratory Masks Eye/Face protection Gloves Removal of Personal Protective Equipment (see Appendix 3) Environmental Control Environmental Cleaning Patient Care Equipment Furnishings Management of Waste Linen Staff Uniforms Crockery and Utensils Pathology Samples Last Offices Visitors Management of Close Contacts - prophylaxis and contact tracing Specific Settings Dental Surgeries Consultation Approval Process Dissemination and Implementation Advice Training Monitoring Compliance References Associated Documents Appendices Appendix 1 Viral Nose and Throat Swabs Procedure Appendix 2 Personal Protective Equipment (PPE) for Care of Patients with Influenza Appendix 3 Applying and Removing Personal Protective Equipment (PPE)... 20

4 Policy on a page Shropshire Community Health NHS Trust Influenza management for community hospitals Does the patient have a Fever >38 o C or history of fever YES Unlikely influenza for reassessment NO Does the patient have two or more other symptoms? High risk of Influenza Cough Sore throat Runny nose Limb/joint pain (not usual for them) Headache Vomiting and/or diarrhoea YES Isolate patient in a single side room (isolation audit) Refer to clinician for review for antiviral treatment Inform IPCT Swab the patient Ensure correct isolation precautions are in place PPE as usual isolation precautions but add surgical mask if within 1 meter of the patient Patient is required to wear a NB please see Appendix 1 for screening procedure NO At Risk Groups: People aged 65 years or over (including those becoming age 65 years by 31 March) and those aged six months to under 65 years in clinical risk groups All pregnant women (including those becoming pregnant during the flu season) People with a serious medical condition such as: Contacts: Chronic (long-term) respiratory such as asthma Chronic heart disease such as heart failure Chronic kidney disease at stage three, four or five Chronic liver disease Chronic neurological disease, such as Parkinson s or Motor Neurone Disease Diabetes Splenic dysfunction weakened immune system due to treatment/medication Antivirals for high risk group GP to discuss with microbiology Monitor contacts closely for 7 days and isolate if symptoms develop Inform GP if patient becomes symptomatic All contacts to be cohorted Discuss with IPCT or on-call Microbiologist if concerned via the SaTH switchboard on (01743) Page 1 of 19

5 1 Introduction Influenza is a viral infection that affects the lungs and airways. The two main types that infect humans are influenza A and influenza B. In the UK influenza usually occurs in the winter with peaks between January and March. It is common in the community and can spread rapidly in healthcare facilities. 2 Purpose The purpose of this policy is to ensure patients with suspected or confirmed influenza are managed effectively and the risk of spread of infection is reduced to a minimum. The principles contained within this policy reflect best practices and should be adopted by all staff working in a clinical environment. This policy applies to all services directly provided by Shropshire Community Health NHS Trust and all clinical staff should familiarise themselves with the policy. 3 Definitions Term / Abbreviation DH DIPC FFP3 mask GP HEPA IPC JCVI LAIV Pandemic PHE PIR PPE RCA SATH Surgical mask Explanation / Definition Department of Health Director of Infection Prevention and Control A filtering face piece (FFP3) device is a mask which is certified to the PPE Directive. It provides a high level of filtering capability and face fit. It will provide an effective barrier to both droplets and fine aerosols and is the type recommended particularly for people in the healthcare sector dealing with symptomatic patients undergoing treatment where aerosols are likely to be generated. Occasionally may be referred to as a FFP3 respirator. General Practitioner High-efficiency particulate Air is a type of filter that can trap a large amount of very small particles that other vacuum cleaners would simply recirculate back into the air Infection Prevention and Control Joint Committee on Vaccination and Immunisation Live attenuated influenza vaccine An epidemic spreading over a wide area, sometimes worldwide Public Health England Post Infection Review Personal Protective Equipment Root Cause Analysis Shrewsbury and Telford Hospitals Surgical masks are plain masks that cover the nose and mouth and are held in place by straps around the head. In healthcare settings, they are normally worn during medical procedures to protect not only the patient but also the healthcare worker from the transfer of microorganisms, body fluids and particulate matter generated from any splash and splatter. Whilst they will provide a physical barrier to large projected droplets, they do Page 2 of 20

6 not provide full respiratory protection against smaller suspended droplets and aerosols. 4 Duties The Chief Executive The Chief Executive has overall responsibility for ensuring infection prevention and control is a core part of Trust governance and patient safety programmes. Director of Infection Prevention and Control The Director of Infection Prevention and Control (DIPC) is responsible for overseeing the implementation and impact of this policy, make recommendations for change and challenge inappropriate infection prevention and control practice. Infection Prevention and Control Team The Infection Prevention and Control (IPC) team is responsible for providing specialist advice in accordance with this policy, for supporting staff in its implementation, and assisting with risk assessment where complex decisions are required. The IPC team will ensure this policy remains consistent with the evidence-base for safe practice, and review in line with the review date or prior to this in light of new developments. Managers and Service Leads Managers and Service Leads have the responsibility to ensure that their staff including bank and locum staff etc. are aware of this policy, adhere to it at all times and have access to the appropriate resources in order to carry out the necessary procedures. Managers and Service Leads will ensure compliance with this policy is monitored locally and ensure their staff fulfil their IPC mandatory training requirements in accordance with the Trust Training Needs Analysis. To mitigate the impact of service delivery during periods when there are high levels of influenza in circulation, all managers and service leads will maintain business continuity arrangements for not having optimum numbers of staff and also in this context understand the Trust Surge and Capacity plans. See Section 18 associated documents. Staff All staff have a personal and corporate responsibility for ensuring their practice and that of staff they manage or supervise comply with this policy. It is important for healthcare workers to protect themselves against influenza by getting vaccinated, therefore reducing the risk of them passing the virus to vulnerable patients, staff and to family members. Vaccination of staff who have direct patient contact has been shown to significantly lower rates of influenza-like illness, hospitalisation and mortality in the elderly in healthcare settings. Committees and Groups Board The Board has collective responsibility for ensuring assurance that appropriate and effective policies are in place to minimise the risks of healthcare associated infections Quality and Safety Committee Are notified of all IPC incidents. Page 3 of 20

7 4.6.3 Infection Prevention and Control Governance Meeting Is responsible for: Advising and supporting the IPC team Shropshire Community Health NHS Trust Reviewing and monitoring individual serious incidents, claims, complaints, reports, trends and audit programmes Sharing learning and lessons learnt from infection incidents and audit findings Agreeing and escalating key risks/items of concern to the appropriate Directors and/or the Quality and Safety Committee Approval of IPC related policies and guidelines 5 Overview of Seasonal Influenza Influenza is a viral respiratory illness characterised by fever, cough, headache, sore throat, aching joints and muscles. This wide spectrum of symptoms can range from causing minor, self-limiting illness through to pneumonia and death. The most common complications of influenza tend to be bacterial infections e.g. bronchitis and pneumonia. Influenza is transmitted from person to person through close contact with a coughing and/or sneezing infected person. Transmission can occur via multiple routes such as large droplets, direct and indirect contact. Airborne and fine droplet transmission may also occur in certain situations. Influenza viruses are unstable and constantly changing to produce new strains. Vaccines are produced by several manufacturers each year, and provide protection against strains of influenza that the World Health Organisation considers may be most prevalent in the following winter. Pandemics occur when a virus develops that is so different from previously circulating strains that few, if any, people have any immunity to it. This allows the virus to spread widely and rapidly. Unlike seasonal influenza, pandemic influenza can arise at any time of the year. Pandemic Influenza tends to occur every few decades. 6 Mode of Transmission and Infectivity Large Droplet Transmission Large droplets are generated from the source person during coughing or sneezing. Transmission via droplets requires close contact between the source and recipient person because droplets do not remain suspended in the air and only travel short distances (up to 1m). This, along with direct contact transmission, is the commonest route by which influenza is spread. Aerosol or Fine Droplet Transmission (during aerosol generating procedures) Aerosol or fine droplet transmission during aerosol generating procedures involves the residue of evaporated droplets that may remain suspended in the air for long periods of time or dust particles containing the infectious agent. Micro-organisms carried in this manner can be dispersed widely by air currents and be inhaled. This is not a common mode of transmission for influenza in normal circumstances but may arise during procedures carried out in health care e.g. during the performance of cough generating procedures such as intubation, nasopharyngeal aspiration, tracheal suction, tracheostomy care, bronchoscopy, nebuliser therapy, chest physiotherapy. Additional precautions are required during these procedures to reduce transmission (see under Section 9 Infection Prevention and Control Precautions). Aerosols may be generated during the following procedures:- Intubation Page 4 of 20

8 Nasopharyngeal aspiration Tracheostomy care Chest physiotherapy Bronchoscopy Direct Contact Transmission Direct contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonised person. Direct contact transmission can occur between two patients and/or between staff and patients. This is a common mode of spread of influenza. Good hand hygiene is the best defence. Indirect Contact Transmission Indirect contact transmission involves a susceptible host with a contaminated intermediate object, usually inanimate, e.g. used tissues or contaminated surfaces, in the patient s environment. Cleaning of the environment, good hand hygiene and asking the patient to perform good respiratory hygiene and dispose of used tissues carefully help to prevent this. Incubation Period and Infectious Period The incubation period for influenza is usually 2-4 days but can range from 1-7 days. People who are contacts of cases and may be incubating the infection are not considered infectious unless they become symptomatic. They can attend work or school as normal. Adults are considered infectious from when they become symptomatic until their symptoms resolve or until 7 days after the onset of the illness, whichever is shorter. Acutely ill patients requiring intensive care may be infectious for up to 2 weeks. Children are considered infectious from the moment they develop symptoms until their symptoms resolve. They can be infectious for up to 10 days. Severely immunocompromised adults and children may shed virus particles for weeks or even months after the symptoms have ceased. 7 Diagnosis of Influenza and Case Definitions Clinicians are now encouraged to diagnose influenza on the basis of symptoms. However, a nose and throat swab using the red topped virus transport media may be required in certain cases of suspected influenza e.g. the IPC team or Community Hospital General Practitioner (GP) may request a swab on a patient to facilitate best use of a side room for isolation. See Appendix 1 for Viral Nose and Throat Swabs Procedure. 7.1 Clinical Diagnostic Criteria Once seasonal activity with influenza has been confirmed to have reached the national threshold, the following diagnostic criteria apply. Any person with the following: Fever >38 o C or history of fever AND flu-like illness with two or more of the following symptoms: cough sore throat rhinorrhoea, (runny nose) limb/joint pain although this is not common headache Page 5 of 20

9 vomiting and/or diarrhoea OR severe or life threatening illness, suggestive of an infectious process Cases fitting the above criteria who are admitted to the community hospitals should be swabbed for Influenza A. NB: Exclude other potential causes of flu-like illness before making the diagnosis of influenza if clinically relevant e.g. common sources of infection such as urinary tract infection causing systemic flu-like symptoms and consider malaria or viral haemorrhagic fever in those with a relevant travel history. 7.2 Case Definitions Presumed Case Any person fitting the clinical diagnostic criteria above Confirmed Case Any person with laboratory confirmation of influenza. NB: Laboratory testing should only be carried out if the patient is hospitalised, to enable differential diagnosis and control of infection in hospital. There may be other unusual circumstances where testing is required in the community. These must be discussed with a Consultant Microbiologist at Shropshire and Telford Hospital Trust (SaTH) on or with Public Health England (PHE) on and choose Option Discarded Case Any suspect case not fulfilling the possible case definition or a possible case if the laboratory result is negative. 8 Vaccination Frontline health and social care workers have a duty of care to protect their patients and service users from infection. It is important for healthcare workers to protect themselves against influenza by getting vaccinated, therefore reducing the risk of them passing the virus to vulnerable patients, staff and to family members. Vaccination of staff who have direct patient contact has been shown to significantly lower rates of influenza-like illness, hospitalisation and mortality in the elderly in healthcare settings. Influenza outbreaks can occur in healthcare settings with both staff and their patients being affected when influenza is circulating in the community. Examples of staff who may be directly involved in delivering care include: Medics, Midwives and Nurses, Paramedics and Ambulance drivers Occupational Therapists, Physiotherapists, Dieticians and Radiographers GPs, Practice Nurses, District Nurses and Health Visitors Health and Social care staff working in care settings Pharmacists, working in community and clinical settings Staff working in direct support of clinical staff with direct patient care Receptionists, Front of House Staff and Domestic Staff Students and trainees in these disciplines and Volunteers who are working with patients should also be included This list is not exhaustive and consultation to provide immunisation should be based on a local assessment of risk and exposure to influenza. Page 6 of 20

10 8.1 At Risk Groups Offered Vaccination Groups eligible for flu vaccination are based on the advice of the Joint Committee on Vaccination and Immunisation (JCVI). JCVI recommended that children are offered a live attenuated influenza vaccine (LAIV), administered as a nasal spray. Seasonal flu vaccinations are currently offered free of charge to the following at-risk groups: People aged 65 years or over (including those becoming age 65 years by 31 March) All pregnant women (including those becoming pregnant during the flu season) All children aged two to eight (but not nine years or older) on 31 August 2017 (with LAIV) All primary school-aged children in former primary school pilot areas (with LAIV) Those aged six months to under 65 years in clinical risk groups People with a serious medical condition such as: Chronic (long-term) respiratory disease, such as asthma, chronic obstructive pulmonary disease or bronchitis Chronic heart disease such as heart failure Chronic kidney disease at stage three, four or five Chronic liver disease Chronic neurological disease, such as Parkinson s or Motor Neurone Disease Diabetes Splenic dysfunction A weakened immune system due to disease or treatment/medication People living in a residential or nursing care home A main carer for an elderly or disabled person whose welfare may be at risk if they fall ill Health and social care workers with direct patient/service user contact This advice may be subject to change each year and up-to-date publications on the DH website should be sourced. 9 Treatment People with suspected flu who are not in the at-risk groups should: Stay at home and rest Drink plenty of fluids Telephone a pharmacist about the best remedy for their symptoms Consider taking the appropriate dose of paracetamol/ibuprofen-based pain relief, if not contra-indicated, or cold remedies to help lower their temperature and relieve their symptoms Avoid visiting GP surgeries and hospitals where they may infect others. In some circumstances, flu can progress from a mild flu-like illness such as fever, cough, sore throat, headache, malaise and muscle and joint pains, to serious symptoms including shortness of breath, chest pain or confusion. These can be signs of pneumonia and/or an exacerbation of an underlying medical condition. These patients will require assessment and treatment in hospital. Bacterial infection can develop secondary to flu; in these cases intravenous antibiotics as well as antiviral medicines will be used. Page 7 of 20

11 9.1 Antiviral Medicines Antiviral medicines prevent the influenza from replicating inside the body. They can lessen symptoms by a couple of days and reduce their severity, and help reduce the likelihood of complications. Please refer to the documents below for information and guidance on the treatment of and treatment for prophylaxis expose to influenza. Use on Amantadine, oseltamivir and zanamivir for the treatment of influenza: and for Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza can be found at 10 Infection Prevention and Control Precautions General Management of Cases Wherever possible, patients with influenza should be managed at home and asked to selfisolate to reduce the risk of spread. If a patient is only mildly unwell they should be asked to phone their GP, or local pharmacist for advice and access to treatment. Patients with symptoms of influenza should be segregated from non-influenza patients as rapidly as possible. If admitted to hospital via a GP, discuss with the GP to ensure patient fits case definition and admission is required, or if further assessment is indicated e.g. chest X-ray. Assessment in Minor Injuries Unit (MIU) Patients being assessed for suspected influenza should be placed in a single room or cohort area with door(s) closed and asked to wear a surgical facemask if clinically appropriate. They do not require en suite facilities or negative pressure ventilation. Staff should wear a surgical facemask, disposable plastic apron and gloves when entering the room for this initial assessment. The number of staff in contact with the patient should be limited as much as possible. If the patient is well enough they can attend the X-ray department, X-ray staff must be notified before patient attends and the patient should be transferred to the department wearing a surgical facemask. They should not be left waiting in the department prior to or after the X-ray. Staff in X-ray must also wear the same Personal Protective Equipment (PPE) when in close contact with the patient. Patients in Community Hospitals Patients who fit the clinical diagnostic criteria for influenza and are still infectious who require hospitalisation should be nursed separately from other patients in a single room using standard airborne precautions and the source isolation sign must be displayed on the door. It is unlikely that there will be numerous patients admitted with influenza but if numbers are high a designated cohort/isolation area may be assigned. Patients will be tested for influenza. If this test comes back positive they are considered a CONFIRMED case. If it is negative they can come out of isolation. Page 8 of 20

12 Isolation Practices Checklist Shropshire Community Health NHS Trust On commencement of isolation the senior nurse or a deputy must undertake the Isolation Practices Checklist and a copy to the IPC team at Shropcom.IPCTeam@nhs.net This Checklist is available from the IPC page of the Trust s website under Self-Audit Tools and Checklists here or copy and paste this website address This tool is to be used as a checklist to give assurance that all precautions are in place to minimise the risk of cross infection Patients Transferred from other Hospitals Patients with Suspected or Influenza Positive and are still infectious should be nursed separately from other patients in a single room using standard airborne precautions and the source isolation sign must be displayed on the door. Patients who have been exposed to influenza and those who have been prescribed prophylactic doses of antivirals should also be nursed separately from other patients in a single room using standard airborne precautions and the source isolation sign must be displayed on the door Please refer to Section 5.5 for Incubation Period and Infectious Period An Isolation Practices Checklist must be completed (see para above) Inability to Isolate a Patient Appropriately The risk assessment will assist in determining the priority for use of the single room. However, it may still mean that it is not possible to isolate all patients who ought to be isolated for infection control reasons. In this instance an incident form using Datix must be completed and the IPC team informed Hand Hygiene Effective hand hygiene is essential to reduce the transmission of infection in healthcare settings and is a critical element of standard infection control precautions. Hands must be cleaned immediately before every episode of direct care or contact with patients and after any activity or contact that potentially results in hands becoming contaminated, including the removal of protective clothing (including gloves), cleaning of equipment and handling of waste. Hands should be cleaned between caring for different patients and between different care activities for the same patient, even if gloves have been worn. Hand hygiene includes hand washing with soap and water and thorough drying, and/or the use of alcohol-based products (e.g. alcohol hand rub) that do not require the use of water. If hands are visibly soiled or contaminated, then they should be washed with soap and water and dried; if not visibly soiled, an alcohol hand rub can be used. Touching the face with gloved hands or hands should be avoided. All staff, patients and visitors should clean their hands when entering and leaving areas where care is delivered. Patients should have access to hand hygiene products at the bedside e.g. hand wipes Respiratory Hygiene Catch it, bin it, kill it Patients, staff and visitors should be encouraged to minimise potential influenza transmission through good respiratory hygiene measures: Page 9 of 20

13 Hands should be kept away from the eyes, mouth and nose. Disposable, single-use tissues should be used to cover the nose and mouth when sneezing, coughing or wiping and blowing noses. Used tissues should be disposed of promptly in the appropriate waste bin. Tissues, waste bins (preferably lidded and foot operated) and hand hygiene facilities should be available for patients, visitors and staff. Hands should be cleaned (using soap and water if possible, otherwise using alcohol hand rub) after coughing, sneezing, using tissues or after any contact with respiratory secretions and contaminated objects. Encourage patient to use hand gel or moist skin wipes. Assist those who need help with this. Some patients (e.g. older people and children) may need assistance with containment of respiratory secretions; those who are immobile will need a container (e.g. a plastic bag, paper bag on locker) readily at hand for immediate disposal of tissues. In communal waiting areas or during transport, symptomatic patients should wear a surgical mask to minimise the dispersal of respiratory secretions and reduce environmental contamination Use of Personal Protective Equipment (PPE) (see Appendix 2) Plastic Aprons Disposable plastic single use aprons should be worn for patient contact and when there is a risk of contamination of clothing or uniform with respiratory secretions. The apron must be changed between patients Fluid Resistant Gowns Consider for situations where cross contamination of clothing is anticipated e.g. in paediatric setting or during intubation. They must be worn during aerosol generating procedures (see definition in section 5.2) Surgical Masks Surgical masks are plain masks that cover the nose and mouth. They protect the health care worker from large droplets that are generated from the patient during coughing, sneezing or talking. They do not provide protection against fine droplets. Surgical masks should be worn by health care workers for close patient contact (within 1m) and administration of pressurised humidified oxygen and administration of medication via nebulisation. The mask should cover both the nose and mouth and not be allowed to dangle around the neck after usage. Do not touch the mask once applied. Masks are a single use item. Mask should be worn for a maximum of four hours only and then changed. Mask should be changed immediately if they become moist. It may be practical for staff working in cohorted areas to wear a surgical mask on entry and wear it for the duration of the activity in this area. Decontaminate hands after removing mask Respiratory Masks Respiratory masks provide the highest protection (EN149:2001 FFP3) from fine droplets and should be worn by health care workers when performing patient procedures where Page 10 of 20

14 aerosol may be generated e.g. intubation, nasopharyngeal aspiration, tracheostomy care, chest physiotherapy, some dental procedures. Fit testing of face filtering piece (FFP3) respiratory masks should be provided for staff in high-risk clinical areas undertaking aerosol generating procedures e.g. Dentistry. The fit testing must be repeated every two years or earlier if required e.g. changes in the shape of the face, and alternative brands of masks are required Certain other procedures/equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include: administration of pressurised humidified oxygen administration of medication via nebulisation During nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of the aerosol. Respiratory mask should be replaced after each use If the respiratory mask becomes damaged or distorted or contaminated by body fluids it should be changed immediately Decontaminate hands after removing or changing mask Eye/Face protection Gloves Disposable eye and face protection (goggles or face visors) must be worn when there is a risk of contamination of the eyes by splashes and droplets and during aerosol generating procedures (see definition in section 5.2) The appropriate sterile or non-sterile disposable soft vinyl gloves should be worn for procedures where contact with respiratory secretions is likely, including aerosol generating procedures. Hands must be decontaminated after removing gloves. Please refer to Trust s Standard Precautions including Surgical Hand Scrub, Gowning and Gloving Policy for glove selection Removal of Personal Protective Equipment (see Appendix 3) 11 Environmental Control 11.1 Environmental Cleaning Influenza viruses can survive on environmental surfaces for varying periods, depending on the type of surface. Detectable virus (by culture) can survive on hard surfaces for up to 48 hours and on porous surfaces for up to 12 hours. Measurable quantities of viable virus can be transferred to hands from hard, non-porous surfaces for up to 24 hours after contamination. Undertake routine cleaning with freshly prepared neutral detergent and hot water Detergent solution or detergent wipes should be used on frequently touched surfaces e.g. bed tables, medical equipment, door handles Vacuums must only be used on carpeted areas provided they have a High-efficiency particulate Air (HEPA) filter Page 11 of 20

15 Spillages and contamination should be dealt with in line with local policy Domestic staff should be allocated to specific areas and not moved between influenza and non-influenza areas Domestic staff should wear a surgical mask, apron and gloves in the immediate patient environment in cohorted areas and in single rooms Neutral detergent and hot water should be used for terminal cleaning Privacy bed curtains must be changed as part of the terminal clean. A Bed Space Terminal Cleaning Tool should be completed which are available from the IPC page of the Trust s website, under Self-Audit Tools and Checklists here Patient Care Equipment Keep equipment to a minimum. Standard practices for handling and decontaminating used and soiled patient care equipment, including re-usable medical devices, should be followed. Non-critical patient equipment should be dedicated for use by influenza patients only. Equipment that recirculates air must NOT be used e.g. fans. Furnishings Remove soft furnishings. The remaining furniture should be easy to clean and impervious to bodily fluids. Management of Waste General waste into black/clear bag Clinical waste into orange infectious waste bag PPE and tissues used in healthcare setting should be disposed of as infectious clinical waste. PPE and tissues used within patients own home should be disposed of as general waste. Linen No special precautions beyond those required to conform with standard and infection precautions are recommended. Treat linen that is contaminated with respiratory secretions as infected wet linen Refer to Trust s Linen and Laundry Policy. Staff Uniforms Wash separately from other linen at the highest temperature permitted for the item then iron or tumble dry for at least thirty minutes. Theatre scrubs should be available for staff with patient contact who normally wear their own clothes e.g. doctors. Crockery and Utensils Normal handling procedures apply. Pathology Samples Handled as normal. Page 12 of 20

16 Last Offices When performing last offices for deceased patients a surgical mask and eye protection should be considered if there is a risk of splashes of secretions onto the facial mucosa. Portering staff do not require PPE when transporting patient to the mortuary. Visitors Visitors should be restricted and may be advised to wear a mask if their visit to an affected patient is necessary. Please consult with IPC team. Visitors with influenza symptoms should not enter the healthcare facility and should be encouraged to return home. 12 Management of Close Contacts - prophylaxis and contact tracing Close contacts are considered to be family, friends or health care workers who lived with, or who had direct contact with respiratory secretions, body fluids and/or excretions of a symptomatic case. The clinical management of contacts in the community is the responsibility of their GP. Those in high risk groups should seek advice from their GP. PHE will provide advice to clinical staff as required and will be informed if an outbreak is declared. Telephone and choose Option 2. Within hospital, ward contacts of non-isolated patients may be considered close contacts. If in a high risk group for severe influenza and it is less than 48 hours since their last contact with an infected case, they may require prophylaxis. Please refer to Section 7.1 High Risk Groups Advice should be sought from a Consultant Microbiologist via SaTH switchboard on (01743) In addition, ward contacts should be monitored for 7 days after their last contact with an infectious case to look for early signs of influenza, such as pyrexia. If the patient develops any symptoms or signs which may indicate influenza they should be isolated and a viral throat and nose swab taken and sent to the laboratory. Patients deemed to be low risk may be admitted to wards were patients who have been in contact with patients who have developed influenza are being nursed. Patients can only be admitted or moved if the symptomatic patients are being nursed in a side room and the bay/room has been terminally cleaned. 13 Specific Settings 13.1 Dental Surgeries Only urgent dental treatment should be carried out on patients with symptoms of influenza. Patients with influenza symptoms should be identified rapidly and triaged to determine whether urgent treatment (i.e. treatment prior to resolution of symptoms) is required. Patients with suspected influenza symptoms should be segregated from other patients. This is likely to involve seeing such patients at the end of surgery with appropriate cleaning afterwards. PPE as appropriate for infectious aerosol-generating procedures should be worn for dental treatment of patients with symptoms of influenza. 14 Consultation This policy has been developed by the IPC team in consultation with appropriate clinical services managers, Heads of Nursing and Quality, Medicine Management, PHE and IPC Governance Meeting members. Page 13 of 20

17 A total of three weeks consultation period was allowed and comments incorporated as appropriate Approval Process The IPC Governance Meeting members will approve this policy and its approval will be notified to the Quality and Safety Committee. 15 Dissemination and Implementation This policy will be disseminated by the following methods: Managers informed via Datix who then confirm they have disseminated to staff as appropriate Staff - via Team Brief and Inform Awareness raising by the IPC team Published to the Staff Zone of the Trust website The web version of this policy is the only version that is maintained. Any printed copies should therefore be viewed as 'uncontrolled' and as such, may not necessarily contain the latest updates and amendments. When superseded by another version, it will be archived for evidence in the electronic document library Advice Individual Services IPC Link staff act as a resource, role model and are a link between the IPC team and their own clinical area and should be contacted in the first instance if appropriate. Further advice is readily available from the IPC team or the Consultant Microbiologist via the SaTH switchboard on (01743) Training Managers and service leads must ensure that all staff are familiar with this policy through IPC induction and update undertaken in their area of practice. In accordance with the Trust s mandatory training policy and procedure the IPC team will support/deliver training associated with this policy. IPC training detailed in the core mandatory training programme includes standard precautions and details regarding key IPC policies. Other staff may require additional role specific essential IPC training, as identified between staff, their managers and / or the IPC team as appropriate. The systems for planning, advertising and ensuring staff undertake training are detailed in the Mandatory Training Policy and procedure. Staff who fail to undertake training will be followed up according to the policy. Further training needs may be identified through other management routes, including Root Cause Analysis (RCA) and Post Infection review (PIR), following an incident/infection outbreak or following audit findings. Additional ad hoc targeted training sessions may be provided by the IPC team. 16 Monitoring Compliance Compliance with this policy will be monitored as follows: Hand hygiene will be audited in accordance with the Hand Hygiene Policy and via peer Hand Washing Assessments Cleaning standards within Community Hospitals will be monitored in accordance with the Publicly Available Specification (PAS) 5748 framework Page 14 of 20

18 Environmental and patient equipment cleaning will be monitored as part of local routine cleanliness audits Audited locally using the HCAI Prevention audits undertaken by the IPC team and by staff as Self- audits as part of the IPC audit programme Additional periodic auditing and self-audits by clinical teams The IPC Governance Meeting will monitor compliance of the cleanliness audit scores and the IPC team audit programme Numbers of staff undertaking IPC training, which includes Standard Precautions will be monitored by the Organisational Development and Workforce Department As appropriate the IPC team will support Services Leads to undertake IPC RCAs/PIRs. Managers and Services Leads will monitor subsequent service improvement plans and report to the IPC Governance Meeting. Knowledge gained from RCA/PIR and IPC audits will be shared with relevant staff groups using a variety of methods such as reports, posters, group sessions and individual feedback. The IPC team will monitor IPC related incidents reported on the Trust incident reporting system and, liaising with the Risk Manager, advise on appropriate remedial actions to be taken. 17 References Department of Health (2017) The national flu immunisation programme 2017/18. DH. London. Department of Health and Public Health England (2017) Annual Flu Programme to 2018 flu season. DH, London. Department of Health (2010) Health and Social Care Act 2008: Code of Practice care on the prevention of and control of infections and related guidance (updated 2015). London Department of Health (2008) Pandemic influenza: Guidance for dental practices. DH, London. NHS England (2013) Pandemic Influenza - NHS Guidance on current and future preparedness in support of an outbreak. NHS England, Leeds. Public Health England (2017) PHE guidance on the use of antiviral agents for the treatment of and prophylaxis of seasonal influenza, (Version 8.0). PHE, London, Public Health England (2016) Infection control precautions to minimise transmission of acute respiratory tract infections in healthcare settings, (Version 2), PHE, London, Public Health England (2014) Pandemic Influenza Response Plan DH. London 18 Associated Documents This policy should be read in conjunction with: Cleaning and Disinfection policy Hand Hygiene policy Isolation policy Linen and Laundry policy Outbreak Management and Significant Incident Policy - Incorporating Bed and Ward Closure Standard Precautions including Surgical Hand Scrub, Gowning and Gloving Policy Page 15 of 20

19 Waste Management policy Business Continuity Guidance Annex 8.2 Surge and Escalation Plan 19 Appendices Page 16 of 20

20 Appendix 1 Viral Nose and Throat Swabs Procedure Equipment Completed Microbiology Laboratory Request Form- request respiratory viral screen Personal Protective Equipment (PPE) Surgical Face Mask, Eye Protection (if required) Disposable Apron and Non Sterile Vinyl Gloves Viral Swab Kit containing 2 swabs and specimen container with transport medium Wooden Spatula Nose swab collection: 1. Position patient by an appropriate light source 2. Decontaminate hands 3. Put on PPE 1st APRON 2nd MASK 3rd EYE PROTECTION 4th GLOVES 4. Swab inside the back of the nose - the area each side of the nasal septum using the stainless steel shaft swab 5. Rotate the swab slightly several times 6. Immediately put swab into specimen container Page 17 of 20

21 Throat swab collection: 1. Using the wooden spatula depress patients tongue 2. Quickly but gently rub the plastic shaft swab over the pillars of the fauces (area between uvula and in front of the tonsils) 3. Avoid touching any other area of the mouth or tongue 4. After the procedure place swab immediately into specimen container and into the pre-completed laboratory request form 5. Remove PPE - 1st GLOVES 2nd APRON (WASH HANDS) 3rd EYE PROTECTION 4th MASK 6. Dispose of PPE into foot operated pedal waste bin 7. Immediately decontaminate hands Page 18 of 20

22 Appendix 2 Personal Protective Equipment (PPE) for Care of Patients with Influenza Entry into cohorted area but no patient contact Close patient contact (within one metre) a Aerosol generating procedures b Hand Hygiene Gloves X c d Plastic Apron X X Gown X X e, f f Surgical Mask g X FFP 3 Respirator Mask X X Eye Protection h X Risk Assessment Key X PPE required PPE not required a h Refer to statements below a) PPE for close patient contact (within one metre) also applies to the collection of nasal or throat swabs. b) Wherever possible, aerosol-generating procedures should be performed in side rooms or other closed single patient areas with only essential staff present (see section 5.2 for examples of aerosol generating procedures). c) Gloves and an apron should be worn during environmental cleaning procedures. d) Gloves should be worn in accordance with standard infection control precautions. e) Consider a gown in place of an apron if extensive soiling of clothing or contact of skin with blood and other body fluids is anticipated (for example, during intubation or caring for babies). f) If non-fluid repellent gowns are used, a plastic apron should be worn underneath. g) Surgical masks are recommended for use at all times in cohorted areas for practical purposes. h) Eye protection is required to be worn as part of standard infection control precautions when there is a risk of blood, body fluids, excretions or secretions splashing into the eyes. Surgical masks with integrated visors are an option for eye protection. Page 19 of 20

23 Appendix 3 Applying and Removing Personal Protective Equipment (PPE) The order for applying PPE is:- 1. Apron 2. Face Mask 3. Eye Protection 4. Gloves The order for removing PPE is:- PPE should be removed in an order that minimises the potential for cross-contamination. Always assume that the outside of the PPE is contaminated and remove it before leaving patient care area. Guidance on the order and technique of removal of PPE is as follows: 1. Gloves Grasp the outside of the glove with the opposite gloved hand; peel off Hold the removed glove in gloved hand Slide the fingers of the un-gloved hand under the remaining glove at the wrist Peel the second glove off over the first glove and discard appropriately 2. Gown or Apron Unfasten or break ties Pull gown or apron away from the neck and shoulders, touching the inside of the gown only Turn the gown or apron inside out, fold or roll into a bundle and discard appropriately 3. Decontaminate Hands 4. Eye Protection To remove, handle by headband or earpieces and discard or decontaminate as appropriate 5. Face Mask Untie or break bottom ties, followed by top ties or elastic, and remove by handling ties only and discard appropriately 6. Decontaminate Hands Page 20 of 20