Source Isolation in Radiology - Management of Patients Who Require

Publication: 18/08/2014  --
Last review: 22/09/2021  
Next review: 22/09/2024  
Standard Operating Procedure
CURRENT 
ID: 3928 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of Patients Who Require Source Isolation in Radiology

This SOP describes the actions required to ensure safe management and placement of patients who are being nursed in source isolation for a known or suspected infection when undergoing a radiological investigation.

Aims

  • To standardise and optimise the management of patients who are being nursed in source isolation who require a radiological investigation.
  • To minimise the potential for cross infection.

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Background and indications for standard operating procedure

  • This SOP describes the measures to be taken by radiology teams when a patient with a known or suspected infection requires source isolation and needs to be applied in conjunction with the LTHT IPC Isolation guidelines.
  • The principles described within the SOP need to apply to all patients who attend radiology for any investigation.
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Procedure method (step by step)

Ensuring Safe Transfer From Ward/ Clinical Area

Any patient with a known or suspected infection should be placed at the end of the clinical session.

The transferring ward will need to ensure the patient’s infection status is documented on the referral (electronic or paper) and identified on the CARPs system, before the patient is transferred by the portering team.

Before The Procedure

  • The patient will need to be placed at the end of the clinical session.
    • If this is not feasible, then the patient will need to be brought to the department when the procedure room is vacant.
  • Ensure that all equipment and frequent contact points are clean; and that any unnecessary equipment is removed or placed away from the near patient environment to prevent contamination.
  • After a visual inspection, any equipment/ frequent contact points found to be visibly dirty should be cleaned using a chlorine releasing agent or an approved cleaning product (following decontamination advice from IPC Team of the manufacturer’s recommendations).

During The Procedure

  • The patient will need to be transferred from source isolation on the ward directly into the procedure room and the door closed behind them.
    • Staff will need to ensure that traffic in and out of the room is kept to a minimum.
  • If waiting is unavoidable, the patient should not wait in public areas. They will need to wait in another area or room by themselves.
  • Before entering the procedure room, or having any interaction with the patient, staff will need to clean their hands with alcohol hand rub or soap and water using the correct technique. See LTHT IPC Hand Hygiene policy.
  • Personal protective equipment (PPE) must also be worn. If there is a high risk of splashing, then ensure that other PPE (visors, gown and FFP3 masks) is available. Please see LTHT Standard Infection Prevention and Control Precautions policy and the current LTHT COVID-19 PPE guidance (https://www.leedsth.nhs.uk/covid19/clinical-guidelines/).
  • If a member of staff moves away from the patient (e.g. from the trolley or procedure table), apron and gloves will need to be removed and hands washed with soap and water ensuring the correct technique is used.
  • All waste arising out of the procedure room must be treated as clinical infectious waste and disposed of in the correct waste stream (Please see LTHT Waste policy).

After The Procedure

  • Once the radiological procedure has been completed, apron and gloves will need to be removed and hands washed with soap and water ensuring the correct technique is used.
  • The patient will need to wait in the procedure room, with the door shut until the portering team arrive to transfer the patient back to the ward
    • If waiting is unavoidable, the patient should not wait in public areas. They will need to wait in another area or room by themselves.
  • Once the patient leaves the procedure room, put on a new apron and gloves to clean the equipment and environmental surface/s.
  • Equipment and environmental surfaces will need to be cleaned using a chlorine releasing agent or an approved product following IPC decontamination risk assessment. Please ensure that staff working in the department are informed of what cleaning products can be used on the radiological equipment.
  • Once the equipment and surfaces have been cleaned, apron and gloves will need to be removed and hands washed with soap and water ensuring the correct technique is used.

Provenance

Record: 3928
Objective:

Aims

  • To standardise and optimise the management of patients who are being nursed in source isolation who require a radiological investigation.
  • To minimise the potential for cross infection.

Background and indications for standard operating procedure/protocol

  • This SOP describes the measures to be taken by radiology teams when a patient with a known or suspected infection requires source isolation and needs to be applied in conjunction with the LTHT IPC Isolation guidelines.
  • The principles described within the SOP need to apply to all patients who attend radiology for any investigation.

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Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

LTHT IPC Isolation policy,
detail.aspx?ID=678

Ayliffe GAJ, Lowbury EJL, Geddes AM and Williams JD. Control of Hospital Infection – a Practical Handbook, 3rd Edition. London: Blackwell Scientific Publications, 1988: 70.

CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee

DH (2011) Isolating patients with healthcare associated infection: A summary of best practice. . [online]. [Accessed 03/10/11]. Available from World Wide Web http://hcai.dh.gov.uk/files/2011/03/Document_Isolation_Best_Practice_FINAL_100917.pdf

DH (1995) Hospital Infection Control; Guidance on the control of infection in hospitals. Prepared by the hospital infection working group of the Department of Health and Public Health Laboratory Services London: HMSO

PHE (2021) COVID-19: Guidance for maintaining services within health and care settings: Infection prevention and control recommendations
Version 1.2 [online]. [Accessed 20/09/21]. Available from World Wide Web
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/
attachment_data/file/990923/20210602_Infection_Prevention_and_
Control_Guidance_for_maintaining_services_with_H_and_C_settings__1_.pdf

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

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