Addendum to the Isolation Policy
DRAFT Version7, updated 7/11/04

INTRODUCTION

Purpose: To control transmission of multidrug-resistant Acinetobacter (MDR-AB) among patients of the Johns Hopkins Hospital and to prevent the organism from becoming endemic in the environment at our institution.

Case Definition:For outbreak investigation/ isolation purposes: Any patient with a clinical culture, or surveillance culture, growing MDR Acinetobacter. MDR Acinetobacter is any isolate that is sensitive (S) to no more than one class of antibiotics (excluding colistin).

ISOLATION

IC09 flagging: Patients with known MDR-AB will be flagged with an IC09 code in the SMS system. This code will appear on the patient’s hospital card. The Department of Hospital Epidemiology and Infection Control (HEIC) will provide the names of patients with MDR-AB for coding. The admissions facilitator who processes the admission of an IC09 coded patient will notify HEIC of the patient's identification and location. The facilitator will also notify the respective Shift Coordinator, the Attending/Resident and Charge Nurse in the Emergency Department, and the Charge Nurse of the admitting floor when posting a MDR-AB patient for admission to a hospital unit.

Newly identified patients with MDR-AB: Patients whose cultures grow MDR-AB after admission to the hospital will be identified for isolation. The microbiology laboratory will notify HEIC of any culture found to meet the MDR-AB criteria. HEIC also conducts ongoing surveillance to identify patients with MDR-AB.

Isolation: Patients should be placed in a Private Room, unless cohorted with another MDR-AB patient. Patients will be placed on Maximum Precautions (gowns and gloves on entering the room plus the added precautions outlined below). Masks will be worn whenever contact with respiratory fluids or secretions can be reasonably anticipated, such as disconnecting ventilator, suctioning or if possibility of splashing or exposure to secretions, i.e., productive cough, emptying ventilator tubing condensation (as per Standard Precautions). Masks will be used at all times if the patient has had a sputum culture positive for MDR-AB. Masks will also be used for all wound dressing changes on these patients. Sign-in sheets on patients’ doors will not be routinely required, but may be requested at any time by HEIC. Surveillance cultures of other patients on the unit will not be routinely required, but may be requested at any time by HEIC.

Surveillance for MDR-AB: There has been a recent increase in the number of patients admitted in transfer from other healthcare institutions, nursing homes, or rehabilitation facilities who have clinical cultures positive for MDR-AB on admission. Therefore, surveillance cultures shall be performed upon admission for all of these patients. Surveillance cultures should include sputum (if available), wound (if present), and swab of the antecubital fossa. Mark Microbiology slips “Surveillance Culture r/o Acinetobacter” in the comment section. Any patient admitted from another institution, a nursing home or a rehabilitation facility with pneumonia or with open wounds should be placed on Contact Isolation until these surveillance cultures are finalized and negative for MDR-AB.

Removal from isolation: At this time, there are no criteria for removing patients from isolation for MDR-AB. Negative cultures do not indicate that the patient is free from colonization with the organism. This will be reconsidered as we acquire more data and experience controlling MDR-AB.

STAFFING

Nursing care: Patients with MDR-AB must have one to one nursing unless patients with MDR-AB are cohorted in one location and the nurse is assigned to care for two or more patients with MDR-AB. Nurses caring for patients with MDR-AB should not care for non-MDR-AB patients. If the nurse absolutely must enter the room of a non-MDR-AB patient, the nurse should practice “reverse isolation” with the other patient. The nurse should wear a clean gown and gloves into the other patient’s room. Nurses caring for patients with MDR-AB should not enter the room of a non-MDR-AB patient who is immunocompromised or who has a tracheostomy or wounds.

Physician care: Every attempt will be made to assure that as few different groups of physicians and limited numbers of individuals care for patients with MDR-AB. This means that teams of physicians should limit the number of physicians and medical students entering the room to the essential caregivers whenever possible. When physician teams must care for both MDR-AB and Non-MDR-AB patients, patients with MDR-AB should be seen last during rounds whenever possible. Physicians must abide by the required gowns, gloves, and masks for patient care and should perform careful hand hygiene after leaving the patient’s room. Additionally, when a physician performs a line placement, wound debridement or other invasive procedure for an MDR-AB patient, that physician should

1. wear scrubs (or clothes), gown, gloves, and mask during the procedure and then remove the gown, gloves, and mask and change into fresh scrubs or clean clothes after the procedure, prior to seeing non-MDR-AB patients.
OR
2. practice “reverse isolation” with all subsequent patients for the rest of the day by wearing a clean gown and gloves into all other patient rooms.

Physical therapy/ Occupational therapy/ Speech therapy: In each of these disciplines, one therapist per day will be assigned to see the patients with MDR-AB. The designated therapist will not see other patients. However, it is acceptable for the designated therapist to see non-MDR-AB patients first and then see the patients with MDR-AB at the end of the day. Similarly, patients with MDR-AB who travel to the wound care room will receive their wound care at the end of the day after all non-MDR-AB patients have been seen.

Respiratory Therapy: One therapist per day will be assigned to see the patients with MDR-AB. The designated therapist will not see other patients. The nature of RT makes it impossible for the designated therapist to see non-MDR-AB patients first and patients with MDR-AB at the end of the day. Ventilators used by patients with MDR-AB will be reprocessed according to manufacturer recommendations. A list of patients with MDR-AB will be provided to RT by HEIC for the purposes of ventilator reprocessing.

Support Associates and Environmental Services: One (or more) staff member(s) will be designated to clean the room(s) of patients with MDR-AB. Cleaning guidelines are outlined below. Support associates and environmental services personnel who care for patients with MDR-AB should not care for or clean the rooms of non-MDR-AB patients.

Radiology: When x-ray technologists perform sequential studies on multiple patients in one unit (i.e. in intensive care units), patients with MDR-AB should have their x-rays performed last, after x-rays of all non-MDR-AB patients have been taken. The technologist should pay strict attention to standard precautions, isolation procedures, and hand hygiene and should carefully clean and disinfect any equipment taken into the isolation room.

Other staff entering isolation rooms: Any other staff entering MDR-AB patient rooms should see only patients with MDR-AB or see patients with MDR-AB last whenever possible. When such staff are only briefly in the patient room and must see other patients, they should pay strict attention to standard precautions, isolation procedures, and hand hygiene. In order to limit the number of healthcare workers entering the room, procedures such as phlebotomy should be performed by the nurse caring for a patient with MDR-AB whenever possible.

Completing a Shift: If a healthcare worker has shift time remaining after they finish caring for a patient with MDR-AB (i.e. the patient with MDR-AB is discharged from the care area), the HCW may care for other patients after changing into fresh clothes or scrubs and performing thorough hand hygiene.

PATIENT PLACEMENT

Non-critical care patients: Every attempt will be made to cohort all non-critical care patients with MDR-AB in one location. We propose to use the 4 currently closed beds on Jefferson 2 for this purpose. Physician coverage for the medicine patients will be provided by the Department of Medicine hospitalist service or the patient’s primary service may continue to care for the patient. Surgical patients will be boarders and will be cared for by a surgical team. For surgical patients, and other patients requiring specialty and subspecialty physician care, the number of physicians entering the room should be kept to a minimum. In addition, physicians should see patients with MDR-AB last on rounds if their clinical status allows. As above, after a physician has performed a line placement, or other invasive procedure on a patient with MDR-AB, that physician should change into clean clothes or scrubs or practice “reverse isolation” with all subsequent patients for the rest of the day. The nursing coverage for these rooms will be determined by nursing administrators. All services will need to cooperate to share beds with the Department of Medicine if their patients with MDR-AB occupy beds on Jefferson 2.

Critical care patients: Ideally, all critical care patients with MDR-AB would be located in one area. This is not possible, however, due to the highly specialized nursing care that many of these patients require. Therefore, we propose to place all surgical critical care patients with MDR-AB in the SICU and all medical critical care patients with MDR-AB in the MICU whenever possible. When deemed necessary for their medical care, patients with MDR-AB will stay in the CCU or CSICU but should be transferred to MICU or SICU when this becomes feasible.

CLEANING AND SUPPLIES

Personnel: As above, support associates and environmental services personnel who are designated to patients with MDR-AB should not care for or clean the rooms of non-MDR-AB patients.

Cleaning: Rooms should be cleaned everyday by the designated personnel with disposable or dedicated MDR-AB equipment. Mop water should be changed after each patient room is completed. Mop handles will be wiped down with disinfectant and the mop head will be bagged and sent to the laundry. All equipment must be cleaned with hospital approved disinfectant after each use.

Following discharge of an MDR-AB patient, aggressive cleaning must occur before another patient occupies the room. The room MUST be terminally cleaned. This includes changing the curtains and wet disinfectant/mopping of floors, walls, bed, bedside table, telephone, IV poles, etc. Curtains, sheets, and other durable items will be bagged and sent to the laundry.

Equipment Cleaning: Single-use or disposable equipment should be used for the care of patients with MDR-AB whenever possible. When durable equipment is used, including but not limited to portable x-ray machines, IMEDS, EKG machines, dialysis machines, etc., the equipment should be thoroughly cleaned with hospital approved disinfectant and/or according to manufacturer’s recommendations before the equipment is used to care for another patient.

Supply cabinets/Scan Modules: If the patient’s MDR-AB diagnosis is known prior to admission to a room, the scan module or any supply cabinets should be relocated outside of the room. The minimum amount of supplies that are needed should be taken into the room at any one time. Any supplies or equipment that enters the room must stay in the room and must be discarded with terminal cleaning after the patient is discharged. If the patient is determined to have MDR-AB after admission, the supply cabinet or scan module stays in the room, but all supplies in scan module and in wire baskets must remain in the room and must be discarded after patient discharge. The support associate or environmental services personnel will wipe out the cabinet after everything is thrown out as part of terminal cleaning.

PATIENT MOVEMENT IN THE HOSPITAL

Patient Transport: Procedures and tests should be performed at bedside when possible and patient transport should be kept to a minimum. When transport to tests and procedures is necessary, transport personnel who need to touch the patient (i.e. bagging a ventilated patient, suctioning a patient with a tracheostomy, etc.) should wear a gown and gloves to perform patient care en route. The gowned and gloved transport staff should not touch anything in the environment, and they should be accompanied by a staff member not in isolation garb who will open doors and push elevator buttons. A designated stretcher should be used for the transport. If the patient’s bed and/or other equipment such as an IV pole accompany the patient on the transport, then bedrails and equipment should be wiped down with hospital approved disinfectant prior to transport. If no patient contact is anticipated en route, then a designated stretcher or wheelchair should be used and transport personnel should not wear a gown or gloves. The testing or procedure area receiving the patient should be notified of the patient’s isolation status before transport. The testing or procedure area should be thoroughly cleaned with hospital approved disinfectant after the MDR-AB patient leaves the area.

Communication: It is essential that prompt and proper communication occurs whenever a patient on MDR-AB isolation leaves their room to travel to another area of the hospital to receive care. This means that all receiving areas, including but not limited to CVDL, radiology, PT/OT, operating rooms, etc., should be notified of the patient’s isolation status before the patient is transported.

Ambulation: Patients with MDR-AB should remain in their rooms whenever possible. However, when it is essential to their recovery, PT or the patient’s RN may ambulate the patient with a physician order. Ambulation should occur with a minimum of contact with other patients and the hospital environment. Patients should not ambulate unless accompanied by staff. All wounds should have drainage contained by clean dressings. The patient should wear a clean gown and a mask if the organism has been found in the sputum. The assisting staff will wear gown and gloves to assist the patient (and a mask if risk of splash). The patient should use dedicated equipment (i.e. wheelchair, cane, walker, etc…) and this equipment should be stored in patient’s room. The patient must return to the room immediately after ambulating.

VISITORS

Visitors of patients who are on Maximum Isolation for MDR-AB should abide by the isolation requirements. This means that visitors should wear a gown and gloves when in the patient’s room. A mask should also be worn if the organism is in the patient’s sputum. When the visitor exits, the gown, gloves and mask should be removed inside the room and hand hygiene with soap and water or alcohol-based hand cleanser should be performed. If visitors follow these requirements, there is no restriction on their movement in the hospital.

In the case of visitors who sleep in the patient’s room (i.e. parents staying with a child on isolation for MDR-AB) isolation requirements should be followed whenever possible. However, if gowns and gloves are not worn (i.e. when sleeping or during prolonged hospitalizations) then prior to exiting the patient’s room the visitor should put on a clean change of clothes and perform thorough hand hygiene. Disposable scrubs may be available for use if no clean change of clothes is available. If these isolation requirements cannot be met for any reason, then when leaving the patient’s room the visitor should proceed directly out of the hospital without visiting other patients or any common-use areas.