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Source isolation

Definition

Source isolation is used for patients who are infected with, or are colonized by, infectious agents that require additional precautions over and above the standard precautions used with every patient (Siegal et al. [110]) in order to minimize the risk of transmission to other vulnerable persons. The exact precautions needed will depend on the mode of transmission of the organism and are known as ‘transmission‐based precautions’. Patients requiring source isolation are normally cared for in a single room, although during an outbreak it may be necessary for patients affected by the same infection to be nursed in a ‘cohort’.

Related theory

A single‐occupancy room will physically separate patients who present a risk from others who may be at risk, and will act as a reminder to any staff dealing with patients who present a risk of the need for additional infection control precautions. Single‐occupancy rooms used for source isolation should have en suite toilet and bathroom facilities wherever possible, and should contain all items required to meet the patient's nursing needs during the period of isolation (e.g. instruments to assess vital signs). Ideally, these should remain inside the room throughout the period of isolation. However, if this is not possible because insufficient equipment is available on the ward, any items taken from the room must be thoroughly cleaned and disinfected (with locally approved disinfectant) before being used with any other patient (Health Protection Scotland [55]). Conversely, it is important not to have unnecessary equipment in the room that may have to be discarded when the patient leaves.
The air pressure in a source isolation room should be negative or neutral in relation to the air pressure in the rest of the ward (note that some airborne infections will require a negative pressure room) (Siegal et al. [110]). A lobby will provide an additional degree of security and space for donning and removing PPE and performing hand hygiene. Some facilities have lobbies that are ventilated to have positive pressure with respect to both the rest of the ward and the single‐occupancy room; this allows the room to be used for both source and protective isolation (DH [27]).
Where insufficient single rooms are available for source isolation, they should be allocated to those patients who pose the greatest risk to others. As a general rule, patients with highly multiresistant organisms and/or enteric symptoms (such as diarrhoea and vomiting) or serious airborne infections (such as tuberculosis) have the highest priority for single‐occupancy rooms (Jeanes et al. [64]). If a patient cannot be isolated, this should be escalated to the site manager and flagged as a risk. While the patient is waiting for an appropriate room, contact precautions will be required in the open ward.
Patients should receive a clear explanation of why they are being isolated and how this is prioritized, or they may be concerned about inconsistency. It is important that the patient's other nursing and medical needs are always taken into account, and infection control precautions may need to be modified accordingly as isolation can have adverse psychological effects (Guilley‐Lerondeau et al. [49]).

Evidence‐based approaches

Principles of care

Attending to a patient in isolation

Meals

Meals should be served on normal crockery and the patient provided with normal cutlery. Cutlery and crockery should be washed in a dishwasher able to thermally disinfect items – that is, with a final rinse of 80°C for 1 minute or 71°C for 3 minutes. Disposables and uneaten food should be discarded in the appropriate bag. Contaminated crockery is a potential vector for infectious agents, particularly those that cause enteric disease, but thermal disinfection will minimize this risk (Fraise and Bradley [41]).

Urine and faeces

Wherever possible, a toilet should be kept solely for the patient's use. If this is not feasible, the patient should be offered a commode. If there is sufficient stock, the commode should be kept in the patient's room; it should be emptied promptly and cleaned between each use with an appropriate disinfectant. Gloves and apron must be worn by staff when dealing with body fluids. Bedpans and urinals should be covered and taken directly to the sluice for disposal. They should not be emptied before being placed in the bedpan washer or macerator unless the volume of the contents needs to be measured for a fluid balance or stool chart. Weighing scales are recommended for recording volume for fluid balance (1 ml = 1 gram). Gloves and aprons worn in the room should be kept on until the body waste has been disposed of and then removed (gloves first) and discarded as offensive waste.

Spillages

As elsewhere, any spillage must be mopped up immediately to remove the risk of anyone slipping. Blood or body fluids should be cleaned up using a locally approved disinfectant with demonstrable activity against target pathogens, following the manufacturer's instructions and local guidance.

Bathing

Ideally an en suite bathroom or patient specific bathroom should be used. If this is not possible, the patient should use the ward bathroom, which should be thoroughly cleaned after use to minimize the risk of cross‐infection to other patients.

Linen

Follow local procedure and place linen in an infected linen bag. This is usually a red water‐soluble alginate polythene bag, which must be secured tightly before being put into a red fabric bag. These bags should await the laundry collection in the area designated for this. Placing infected linen into the appropriate bags confines harmful organisms and allows laundry staff to recognize the potential hazard and avoid handling the linen (DH [26]).

Waste

Hazardous waste bags should be kept in the isolation room for disposal of clinical waste generated in the room. The top of the bag should be sealed and labelled with the name of the ward or department before it is removed from the room.

Cleaning an isolation room

The following principles should be adhered to regarding the cleaning of an isolation room:
  • Domestic or environmental services staff must be instructed on the correct procedure to use when cleaning an isolation room; however, they must not be given any confidential patient information.
  • They should understand what disinfectants should be used and if necessary how to make them up (dilution) as well as the correct colour coding for cleaning materials. This will reduce the risk of mistakes and ensure that appropriate precautions are maintained (Curran et al. [16], DH [33]). Cleaning cloths may be reusable microfibre or disposable, depending on the organization's local policy.
  • Separate cleaning equipment must be used for isolation rooms. Cross‐infection may result from shared cleaning equipment (Wilson [129]).
  • Domestic or environmental services staff must wear gloves and plastic aprons while cleaning isolation rooms to minimize the risk of contaminating hands or clothing. Some PPE may also be required for the safe use of some cleaning solutions.
  • Isolation rooms should be cleaned last, to reduce the risk of the transmission of contamination to ‘clean’ areas (NICE [85]).
  • Daily cleaning will reduce the number of bacteria in the environment. Organisms, especially gram‐negative bacteria, multiply quickly in the presence of moisture and on equipment (Wilson [129]).
  • Furniture and fittings should be damp‐dusted daily (by nursing or cleaning staff) using a disposable cloth and a detergent or disinfectant solution, as dictated by local protocol. This is to remove dirt and a proportion of any organisms contaminating the environment (Wilson [129]).
  • The toilet, shower and bathroom areas must be cleaned at least once a day and, if they become contaminated, using a non‐abrasive hypochlorite powder, cream or solution. Non‐abrasive powders and creams preserve the integrity of the surfaces.
  • Floors must be washed daily with a disinfectant as appropriate. All excess water must be removed and disposed of in a dedicated disposal sink. Floors should have a hard surface: carpeted rooms should not be used in patient care areas.
  • Cleaning solutions must be freshly made up each day and the container emptied and cleaned daily after use. This is because disinfectants may lose their effectiveness over time and cleaning solutions can easily become contaminated (Weber et al. [123]).
  • After use, the bucket must be cleaned and dried. Contaminated cleaning equipment and solutions will spread bacteria over surfaces being cleaned (Weber et al. [123]).
  • Mop heads and reusable cloths should be laundered daily as they become contaminated easily (Wilson [129]). Current methods for decontamination of reusable mops and cloths include ozone or laundry in water above 71°C (minimum 3 minutes). The exact methods will be dictated by local contract arrangements.

Post‐procedural considerations

Discharging a patient from isolation

If the patient no longer requires isolation but is still to be a patient on the ward, inform them of this and the reasons why isolation is no longer required before moving them out of the room. Also inform them if there is any reason why they may need to be returned to isolation, for example if diarrhoea returns.
If the patient is to be discharged home or to another health or social care setting, ensure that the discharge documentation includes details of their condition, the infection control precautions taken while they were in hospital, and any precautions or other actions that will need to be taken following discharge. Accurate information on infections must be supplied to any person involved with providing further support or nursing/medical care in a timely fashion (DH [30]).

Cleaning an isolation room after a patient has been discharged

The following principles should be adhered to regarding the cleaning of an isolation room after a patient has been discharged:
  • The room should be stripped. All bed linen and other textiles must be changed and curtains changed (reusable curtains must be laundered and disposable curtains discarded as offensive waste). Dispose of any unused disposable items. Curtains and other fabrics readily become colonized with bacteria (Shek et al. [109]), and paper packets cannot easily be cleaned.
  • Impervious surfaces (e.g. locker, bedframe, mattress cover, chairs, floor, blinds and soap dispenser) should be washed with soap and water, or a sporicidal disinfectant if activity against spores is required, and dried. Relatively inaccessible places, for example ceilings, may be omitted, as inaccessible areas are not generally relevant to any infection risk (Wilson [129]). Wiping of surfaces is the most effective way of removing contaminants. Spores from some sources (e.g. C. difficile) will persist indefinitely in the environment unless destroyed by an effective disinfectant, and bacteria will thrive more readily in damp conditions.
  • The room can be reused as soon as it has been thoroughly cleaned and restocked. Effective cleaning will have removed infectious agents that may pose a risk to the next patient.
  • For some high‐risk infections, such as C. difficile or multiresistant gram‐negative bacteria, it may be helpful to use additional automated room disinfection technology such as hydrogen peroxide vapour or ultraviolet‐C light. However, these are not available in all settings; if they are available, they must only be used by specifically trained staff.
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