The potential for transmission of infection must be assessed on the patient's arrival to the care area (or before arrival if possible), before transferring a patient to another care area and should be continuously reviewed throughout their stay. The assessment should support placement decisions in accordance with clinical or care need(s).

Patients who may present a transmission risk in any setting may include  those:

• with symptoms such as loose stools or diarrhoea, vomiting, fever or respiratory symptoms. 
• with a suspected or laboratory confirmed infectious agent for which appropriate duration of precautions as outlined in the A-Z of pathogens are not yet complete
• who are suspected or confirmed to have been previously positive with a Multi-drug Resistant Organism (MDRO), for example MRSA, CPE
• who have been hospitalised (inpatient) outside Scotland in the last 12 months (including those who received dialysis)

This is not an exhaustive list, and risks need to be assessed for each patient.

Further information regarding general respiratory screening questions can be found within the resources section of the NIPCM.

Within healthcare settings, different types of specialised ventilation isolation facilities are used to prevent transmission of infection.  Those most commonly found in NHS Scotland are;

• Negative pressure isolation room (NPIR)
• Positive pressure isolation room (PPIR)
• Positive Pressure Ventilated Lobby (PPVL) room

A description of these rooms and their intended use can be found in the glossary.

Isolation facilities should be prioritised depending on the suspected or confirmed infectious agent (refer to Appendix 11).  All patient placement decisions and assessment of infection risk (including isolation requirements) must be clearly documented in the patient notes.

• Patient placement should be reviewed daily, taking account of the clinical judgement and expertise of the staff involved in a patient's management. Where required, the advice of the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought, for example, for isolation prioritisation when single rooms are in short supply.
• When specialised ventilated isolation is indicated but unavailable, the next best option should be considered with an appropriate risk assessment. Options are provided in Appendix 11.
• Those who are at increased risk of acquisition and adverse outcomes resulting from HAI should also be prioritised for placement in a single room.

Hospital settings

Patients who present transmission risk should be risk assessed and placed in appropriate isolation as follows:

• Patients with a suspected or confirmed R2 or R3 respiratory infectious agent, should be placed in a specialised negative pressure isolation room where available.

• • If this is not available, the patient should be placed in a single room when it is appropriate and following risk assessment.

• Patients with suspected or confirmed infection spread by the contact route, should be placed in a single room.
• Signage should be used on doors or areas to communicate isolation and TBP requirements.
• Doors to isolation rooms should be kept closed, where it is safe to do so.
• Infectious patients should only be transferred to other departments if medically necessary.  If the patient has an infectious agent transmitted by the air route, then, if possible or tolerated, the patient should wear a surgical face mask during transfer.
• Receiving department or hospital and transporting staff must be aware of the necessary precautions.

Cohorting in hospital settings

Cohorting of patients

Cohorting of patients should only be considered when single rooms are in short supply and should be undertaken in conjunction with the local IPCT.

Patients who should not be placed in multi bed cohorts:

• patients with different infectious agents or strains and patients with unknown infectious agents (laboratory confirmation still awaited)
• patients considered more vulnerable to infection
• patients who are unlikely to comply with TBPs

Patients with suspected infection should not be cohorted alongside  those with confirmed infection even if the same infectious agent is suspected.

• In such circumstances, suspected patients should be prioritised for single-room isolation.

Staff cohorting

Where possible, consider assigning a dedicated team of care staff to patients in isolation or cohort rooms as an additional infection control measure during outbreaks/incidents.

Primary care or out-patient settings

• Where possible, virtual assessments (by telephone, email or other appropriate media) of infection risk should be conducted for patients who are due to attend these settings.
• Patients attending these settings with suspected or confirmed infection or colonisation should be prioritised for assessment or treatment, for example scheduled appointments at the start or end of the clinic session. Infectious patients should be separated from other patients whilst awaiting assessment and during care management wherever possible.
• Patients should be asked to wear a surgical face mask if attending with a suspected or confirmed respiratory infection
• If transfer from a primary care facility to hospital is required, the ambulance service should be informed of the infectious status of the patient.

Additional considerations

Before discontinuing isolation in hospital settings

Individual patient risk factors should be considered, for example there may be prolonged shedding of certain infectious agents in immunocompromised patients. Clinical and, where appropriate, molecular tests to show the absence of microorganisms may be considered in the decision to discontinue isolation and can reduce isolation times. The clinical judgement and expertise of the staff involved in a patient’s management and the Infection Prevention and Control Team (IPCT) or Health Protection Team (HPT) should be sought on decisions regarding isolation discontinuation.

Residual respiratory exposure risk

If a patient vacating a room has a suspected or confirmed respiratory infection, the room may need to be left vacant for a period of time to ensure that any remaining potentially infectious particles are adequately cleared from the air to minimise the exposure risk to the next occupant. The clinical team should assess:

• the stage of infection, and whether the vacating patient continues to pose a transmission risk.
• the R category of the infectious agent (R1, R2, or R3), and the vulnerability of the incoming patient

If a vacancy period is required, and should a healthcare worker need to enter the room during the vacancy period, healthcare workers should wear appropriate PPE: a surgical mask or respiratory protective equipment (RPE) should be used in line with the respiratory category associated with the vacating patient. Refer to Appendix 15. This would include when undertaking cleaning post discharge.

See Hierarchy of Controls (engineering controls) for information on the impact of ventilation on clearance times.

Ensure a minimum of 10 minutes has passed to allow the largest particles to settle on surfaces before terminal decontamination – see terminal decontamination for additional information.

Resources

Further information can be found in the patient placement literature review.