SOP FOR ISOLATION ROOM

The decision to isolate a patient or a clinical area should always be taken after assessing the risk to the individual, other patients and staff with
the support & advice from the Infection Prevention & Control Team. When isolation precautions are required they should be tailored to meet the
needs of each patient and reflected in their care plans. Once the decision has been made to isolate a patient or a clinical area, the necessary
precautions must be commenced promptly so as not to put other patients, visitors or staff at risk.While it is acknowledged that strict
implementation of isolation precautions in the mental health & learning disability environments may be difficult for reasons such as poor
patient understanding and compliance and the need to maintain as ‘normal’ a lifestyle as possible, it remains important that the principles of
good infection control practice are not compromised and in all cases the care plans must include any specific precautions required.In order
that patients who are isolated in a single room do not feel ostracised, the reason for isolation should be explained to the patient asbest as
possible and to their close family contacts and carers.

Aims

To prevent the transmission of infective organisms from an infected patient to others.

To give psychological support and reassurance to the patients whilst he/she is in isolation.

To ensure all staff (including housekeeping staffs) are aware of the correct precautions to take.

To protect vulnerable patients and staff.

Definitions

Source Isolation - Used for patients who are sources of pathogenic microorganisms which may spread from them and infect other patients
and/or staff, isolating the source patient to prevent transfer of infection

Protective Isolation -Used for patients who are rendered highly susceptible to infection by disease or therapy, isolating vulnerable patients to
prevent acquisition of infection

Cohort nursing - Grouping of infectious patients and nursing them within an area of a hospital ward as a strategy for controlling infection

Types of Isolation

Strict Isolation -For highly transmissible or dangerous diseases. It is envisaged that strict isolation would only be provided as a short-term
temporary measure while transfer to an appropriate isolation unit is arranged.

Standard Isolation(Source Isolation) - For most communicable diseases, single room with hand wash sink & ideally en-suite facilities

Respiratory Isolation - For diseases where the main route of transmission is airborne, including pulmonary tuberculosis

Protective Isolation - For individuals suffering from a weakened immune system and susceptible to microorganism invasion are isolated to
avoid exposure

High Priority for Isolation – patients with the following conditions MUST be prioritised
for single room accommodation (ideally with en-suite facilities):

Diarrhoea and vomiting

Clostridium difficile

Chickenpox

Tuberculosis

Meningitis (confirmed or suspected)

Multi-drug resistant organisms (including MRSA)

Influenza/influenza like symptoms

Pyrexia of unknown origin with recent history of foreign travel

Patients requiring source isolation should be cared for in a single bedroom (ideally en-

suite) and with a hand wash sink. Where several patients have the same infection they

may be nursed together in one bay, this is called co-horting.

The Infection Control Nurse will advise accordingly.

Transfer of Patients with a Known/Suspected Infection to other Departments and

Organisations

If the patient requires transfer to another ward/department or other healthcare care facility, suitable and sufficient information on the
patient’s status must be given to the receiving department.

The Nurse-in-charge is responsible for advising the receiving department e.g. ECT, A&E, X-ray, Ambulance, other ward/care home etc. of any
necessary precautions to be taken.

Only in exceptional circumstances would the patient’s infectious status prevent infections or procedures being undertaken in other
departments.

Any staff transporting patients must be advised of any precautions to be taken e.g. correct use of PPE, hand hygiene etc.

Porters are not required to wear gloves or aprons unless they are physically moving the patient and contact with blood or bodily fluids is likely.
Hands however must be decontaminated with soap/water before & after contact with the patient, their environment or personal belongings.

Following transport of an isolated patient the trolley/wheelchair should be wiped down with detergent wipes, paying particular attention to
contact points e.g. armrests.

Training

Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their
role and responsibilities.Please refer to the Trust’s Mandatory & Risk Management Training Needs Analysis for further details on training
requirements, target audiences and update frequencies.

Monitoring / Review of this Procedure

In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the
review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness.
Appendix 1
SOURCE ISOLATION – for Patients with a Known or Suspected Infection
The decision to isolate a patient or clinical area should be based on the infection risk posed and decided after discussion with the Infection
Control Team.
Preparing the
Source Isolation Room
Ideally the patient must be
cared for in a single room with a
hand wash basin and preferable
en-suite toilet.
The patient should be informed
of the reason & need to comply
with isolation requirements.
The care plan must reflect
individual specific requirements
to prevent transmission.
Ensure that all unnecessary
equipment is removed from the
room prior to patient placement.
Ensure that all the equipment in
the room is designated to the
isolated patient if possible and
safe to do so (i.e. commode, BP
machine).
All personal belongings and
equipment should be washable or
disposable if possible.
Care in Isolation
Standard infection control
precautions must be adhered to
at all times by all staff.
Hand hygiene must be
performed before entering and
prior to leaving the room.
Wear all appropriate personal
protective equipment (PPE) as
directed - disposable gloves and
apron to be donned before
entering the room and removed
before leaving the room followed
by hand washing.
All bodily fluid spillage, waste &
soiled linen to be dealt with
immediately and removed from
the room.
Place all used sharps into an
approved sharps bin immediately
after use and store safely
between uses.
Visitors
Explain in appropriate language
the reasons for isolation.
Advise on the importance of
hand hygiene prior to entering
and before leaving the room.
Advise on correct use of PPE as
appropriate.
Discourage visitors from visiting
or having contact with any other
patients.
Visitors and staff from other
departments must report to the
Nurse-in-Charge before entering
the room or co-hort area.
If unsure discuss requirements
with the Infection Control Nurse.
Discontinuation of Isolation
Isolation may be discontinued
when the patient is no longer a
risk for spreading infection to
others and following discussion
with and approval by the infection
control team
The room must be cleaned
thoroughly (even if the patient is
staying in the room). It should be
cleaned again thoroughly when it
is vacated and curtains laundered
(disposable curtains must be
discarded & replaced before the
room can be re-occupied).
The care plan must be reviewed
and updated each shift and the
patient notes must record when
the isolation was discontinued.
 Keep charts and care plans
outside the room.
Ensure all clinical waste bags,
paper towels, alcohol hand gels
etc. are to hand and if necessary
locked in a cupboard.
Place a source isolation sign on
the door.
If en-suite bath/shower not
available the patient in source
isolation should bath/ shower last
and the bath/shower must be
cleaned/ disinfected before &
after their use.
Visits to other departments
should be avoided, however if
unavoidable, this must be made
by prior arrangements with the
receiving department who must
be informed
of the patients status & any
precautions.
As far as possible keep the door
closed at all times, ensuring the
situation is regularly assessed
and re-evaluated.
Ensure PPE is always available
for use.
Bed linen should be changed
daily as a minimum.
* Remember alcohol gel can only
be used on visibly clean hands
and not at all if Clostridium
difficile or Norovirus is diagnosed
or suspected –use soap & water
Appendix 2
PROTECTIVE ISOLATION – for Patients vulnerable to Infection e.g. Immunocompromised/ Neutropenic
*The decision to isolate a patient or clinical area should be based on the infection risk posed and decided after discussion with the Infection
Control Team.
Preparing the Protective
Isolation Room
Ideally the patient must be
cared for in a single room with a
hand wash basin and preferably
an en-suite toilet.
The patient should be informed
of the reason & need to comply
with isolation requirements.
The care plan must reflect
individual specific requirements
to prevent transmission.
Ensure that all unnecessary
equipment is removed from the
room prior to patient placement.
Ensure that all the equipment in
the room is cleaned thoroughly &
designated to the isolated patient
if possible and safe to do so (i.e.
commode, BP machine).
All personal belongings and
equipment should be washable or
disposable if possible.
Keep charts and care plans
Care in isolation room
Standard infection control
precautions must be adhered to
at all times.
Protective isolation rooms
should be cleaned FIRST using
disposable equipment.
Hand hygiene must be
performed before entering and
prior to leaving the room.
Wear all appropriate personal
protective equipment (PPE) as
directed - disposable gloves and
apron to be donned before
entering the room and removed
before leaving the room followed
by hand washing.
All bodily fluid spillage, waste &
soiled linen to be dealt with
immediately and removed from
the room.
Place all used sharps into an
approved sharps bin immediately
Vistors
Explain in appropriate language
the reasons for isolation.
Advise on the importance of
hand hygiene prior to entering
and before leaving the room.
Advise on correct use of PPE as
appropriate.
Discourage visitors from visiting
if they have any signs of illness
e.g. cold, sore throat, D/V etc.
Visitors and staff from other
departments must report to the
Nurse-in-Charge before entering
the room.
If unsure discuss requirements
with the Infection Control Nurse.
Discontinuation of Isolation
Isolation may be discontinued
when the patient is no longer a
risk for
acquiring an infection and
following approval by the medical
team.
The room must be cleaned
thoroughly (even if the patient is
staying in the room). It should be
cleaned again thoroughly when it
is vacated and
curtains laundered (disposable
curtains must be discarded &
replaced before the room can be
re-occupied).
The care plan must be reviewed
and updated and the patient
notes record when the isolation
was discontinued.
outside the room.
Ensure all clinical waste bags,
paper towels, alcohol hand gels
etc. are to hand and if necessary
locked in a cupboard.
Place a protective isolation sign
on the door.
after use and store safely
between uses.
If en-suite bath/shower not
available the patient in protective
isolation should bath/ shower
first and the bath/shower must
be cleaned/ disinfected before &
after use.
Visits to other departments
should be avoided, however if
unavoidable, this must be made
by prior arrangements with the
receiving department who must
be informed of the patients risk
status.
As far as possible keep the door
closed at all times, ensuring the
situation is regularly assessed
and re-evaluated.
Ensure PPE is always available
for use.
Bed linen should be changed
daily as a minimum
* Remember alcohol gel should
be used to clean hands between
tasks with the same patient
Appendix 3

GENERAL ISOLATION PRECAUTIONS – suitable in all cases

Hands Hand washing before and after contact with the patient and their immediate environment is the single most important
measure in preventing the spread of infection
‘Bare below the elbows’ & the Hand Hygiene Policy guidelines must be adhered to at all times by all parties.
Alcohol gel must NOT be relied upon as an alternative to hand washing particularly where Clostridium difficile infection
or Norovirus exist in the affected area.
PPE Gloves & aprons must be donned prior to direct patient contact.
Gloves & apron must be discarded as clinical waste prior to leaving the room & hands washed.
Face/eye protection to be worn as/when required (dependant on route of transmission & risk).
Room Door Provided the patient’s safety is not compromised, the isolation room door should remain closed at all times.
A sign indicating type of isolation precautions required should be placed on the door.
Activities/Therapies All group/communal activities must be suspended for duration of isolation – specific advice can be sought from the
Infection Control Nurse
Visitors Everyone entering the isolation room must comply with the Infection Control Teams recommended procedures.
The ultimate responsibility for deciding who may visit a patient rests with the patients Consultant & Ward Manager, but
specific advice can be obtained from the Infection Control Team.
Equipment Limit the number of items taken into or stored in the isolation room to essential equipment only.
All equipment must be cleaned after use & when removed from the room prior to re-use. Single use items must be
discarded
Crockery & Cutlery No special precautions, cleaning crockery (including medicine tots if not disposable) should be carried out in a
dishwasher (avoid quick cycle).
Linen Soiled linen should be placed immediately into a linen bag, secured & removed from the room immediately and placed
ready for collection.
Infected/heavily soiled linen must be placed into an water soluble bag & secured then into a RED linen bag. Bags must
be secured & removed immediately and placed ready for collection.
Waste All waste classed is as clinical waste. Bins to be emptied at least daily. Further information available in the Waste
Management policy & procedures.
Decontamination Any spillage of blood or body fluid should be made safe prior to cleaning using a chlorine releasing agent [see Infection
Blood/Body Fluid Prevention and Control Assurance
Cleaning of Rooms Separate cleaning equipment must be reserved for EACH isolation room.
Rooms must be cleaned daily as a minimum.
Nursing staff are responsible for the standard of hygiene in isolation rooms and for decontaminating spillages of blood
& body fluids.
Nursing staff must identify hazards and undertake a risk assessment before allowing domestic staff to clean the room.
Domestic staff should be advised on specific precautions by the Nurse-in-charge/Infection Control prior to
entering/cleaning the room