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Infection Prevention and Control
(IPC)
Standard Operating Procedure for
PROTECTIVE ISOLATION
WARNING – This document is uncontrolled when printed.
Check local intranet site for current version
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 1 of 10Document Control Sheet
Title: Standard Operating Procedure (SOP) for Protective Isolation
Document Status: Approved
Document Type: SOP
Version Number: v01.4, April 2021
Document location: Infection Prevention and Control (IPC) Athena Site
Author: Gillian Rankin, Infection Control Nurse
Owner: Infection Prevention and Control Policy Review Group
Approved By: Robert Wilson, Infection Control Manager
Date Effective April 2021
Revision History:
Version: Date: Summary of Changes: Responsible
Officer:
Issue 1 Nov 2016 Policy Review Gillian Rankin
v01.1 May 2018 Minor changes to Actichlor and Sharon Leitch
Linen
v01.2 October 2018 Reference list updated, additional Gillian Rankin
section for management of
systemic anti cancer therapy added
v01.3 July 2020 Minor changes to chlorine Lorraine Nelson
releasing agent
v01.4 April 2021 Reference list updated. Minor Gillian Rankin
update to availability of positive
pressure isolation facilities.
Approvals: this document was formally approved by:
Name & Title / Group: Date: Version:
Infection Prevention and Control Policy Review Group April 2021 v01.4
Dissemination Arrangements:
Intended audience: Method: Date: Version:
Throughout NHS Announcement on Daily Digest / April 2021 v01.4
A&A Weekly News Bulletin
Linked Documentation:
Document Title: Document File Path:
IPC mailbox InfectionControl@aapct.scot.nhs.uk
National Infection http://www.nipcm.hps.scot.nhs.uk/
Prevention and Control
Manual (NIPCM)
Laboratory Handbook http://athena/execmed/AreaLabs/Pages/LabHBkIndex.aspx
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 2 of 10Washing Clothes at http://athena/execmed/inconprev/Pages/InformationLeaflet
Home Information Leaflet s.aspx
Bloodwise.org.uk https://media.bloodcancer.org.uk/documents/Eating-well-
information leaflet with-neutropenia-Blood-Cancer-UK-info-booklet.pdf
NHS Ayrshire and Arran http://athena/adtc/DTC%20%20Code%20of%20Practice/F
Code of Practice for the orms/AllItems.aspx
Management of
Medicines – Section 12.2
Policy Statement
It is the responsibility of all staff to ensure that they consistently maintain a high
standard of infection control practice.
NB. This document is uncontrolled when printed. The contents of this
document are subject to change, any paper copy is only valid on the day of printing.
To ensure you have the most up to date version of this document, please use the
link to access the document directly from AthenA or contact the Author.
REFERENCES
1. Health Protection Scotland (2017), HPS National Infection Prevention and Control
Manual
2. Royal Devon and Exeter NHS Foundation Trust (2017), Protection Isolation Policy
3. Wigglesworth N (2003), The Use of Protective Isolation, Nursing Times Vol 99,
Issue 07
4. Centres for Disease Control and Prevention (2017), Guideline for Isolation
Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
5. Cancer.Net (2018), Neutropenia, www.cancer.net (last accessed 19/04/2021)
6. AboutKidsHealth (2010) Protective Isolation for Blood and Bone Marrow
Transplant,
https://www.aboutkidshealth.ca/Article?contentid=1537&language=English (last
accessed 19/04/2021)
7. Hall A (2017) Pancytopenia https://www.cancertherapyadvisor.com/hospital-
medicine/pancytopenia/article/601663/ (Last accessed 19/04/2021)
8. NHS Ayrshire and Arran (2012), Clean Diet Provision Across NHS Ayrshire and
Arran
9. Bloodwise (2017) Eating Well with Neutropenia – A guide for people with blood
cancer, https://media.bloodcancer.org.uk/documents/Eating-well-with-
neutropenia-Blood-Cancer-UK-info-booklet.pdf (last accessed 19/04/2021)
10. NHS Ayrshire and Arran (2019), NHS Ayrshire and Arran Code of Practice for the
Management of Medicines – Section 12.2 Systemic Anti Cancer Therapy (SACT)
for Specialist Oncology/Haematology Areas
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 3 of 101.0 GENERAL INFORMATION
Protective Protective isolation is important to provide a safe environment for
Isolation patients who have a compromised immune system and have an
increased susceptibility to infection. The evidence regarding the
use of single room isolation is conflicting; however, this does
reinforce the need for adherence to Standard Infection Control
Precautions (SICPs).
The biggest risks for patients are their own resident flora and cross
transmission from staff, visitors, other patients and the
environment.
The decision to implement Protective Isolation is made by the
patient’s consultant/clinician or Senior Charge Nurse (where
appropriate).
Definitions Immunocompromised: Having an impaired or compromised
immune response
Pancytopenia is a deficiency of all types of blood cells including
white blood cells, red blood cells and platelets. Occurs in 2 forms:
Idiopathic: cause unknown but often autoimmune, meaning the
body attacks its own tissues as foreign substances
Secondary: caused by environmental factors
Common causes of Pancytopenia are viral infection, chemotherapy
or radiation treatments, drug reactions and exposure to toxins.
Neutropenia is a low level of neutrophils, a type of white blood cell
(infection fighting cell). Often induced by cancers affecting the
bone marrow e.g. leukaemia, lymphoma, chemotherapy and
radiotherapy.
Protective isolation is usually indicated when the neutrophil count
falls, or is expected to fall, below 0.5 x 109/l.
Common Neutropenia – neutrophil count below 0.5 x 109/l
causes of Pancytopenia
Immuno- Organ Transplant
suppression Bone Marrow / Stem Cell Transplant
Chemotherapy (IV, Subcutaneous, Intramuscular and Oral)
Immuno-suppressant Drugs (Corticosteroids, Cyclosporin,
Azathioprine, Monoclonal Antibodies)
Haematological malignancy
Extensive burns
HIV
Underlying immune disorders
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 4 of 10Haematology / Protective isolation is needed for on treatment acute
Oncology leukaemias and for any other treatment related neutropenia
Patients Neutropenia due to haematological conditions e.g.
Myelodysplastic Syndrome (MDS) does not always require
Protective Isolation, but might be sought if the patient is being
treated for sepsis
Informing the The IPCT do not require notification of patients in Protective
IPCT Isolation, however, if you have any questions or concerns contact
the Infection Prevention and Control Team (IPCT) by phoning
(01563) 825765 or by emailing the IPCT mailbox
InfectionControl@aapct.scot.nhs.uk
2.0 INFECTION CONTROL PRECAUTIONS FOR PROTECTIVE ISOLATION
2.1 Standard Infection Control Precautions (SICPs)
Standard Infection Control Precautions (SICPs), Section 1 of the Health Protection
Scotland (HPS) National Infection Prevention and Control Manual, must be used by
all staff, in all care settings, at all times, for all patients whether infection is known to
be present or not to ensure the safety of those being cared for, as well as staff and
visitors in the care environment.
SICPs are the fundamental IPC measures necessary to reduce the risk of transmission
of infectious agents from both recognised and unrecognised sources of infection.
Potential sources of infection include blood and other body fluids secretions or
excretions (excluding sweat), non-intact skin or mucous membranes and any
equipment or items in the care environment that could have become contaminated.
2.2 Transmission Based Precautions (TBPs)
TBPs are categorised by the route of transmission of an infectious agent. These are
not required for patients in Protective Isolation without clinical signs of infection.
When a patient is known or suspected to have infection then the appropriate TBPs
should be implemented as indicated by the organism identified. Refer to organism
specific Standard Operating Procedures as required.
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 5 of 10Patient The decision to implement Protective Isolation is made by
Placement the patient’s consultant/clinician or Senior Charge Nurse
(where appropriate)
Patients should be isolated in a single room with ensuite facilities
and:
- The door should remain closed. If this is not possible, a risk
assessment must be included in the nursing notes e.g.
patient at risk of falls
- A protective isolation notice must be placed on the outside of
the door ( or be clearly visible)
Continue isolation until advised by the patient consultant that
precautions are no longer required
Consider regular assessment of immune status e.g. daily bloods
In some instances the level of immuno-suppression may indicate
isolation in specialist rooms with positive pressure ventilation.
These are currently available within the Oncology Inpatient Ward
UHC. Positive pressure rooms must never be used for isolation
of patients with infection transmitted by droplet or airborne routes
Personal Before undertaking any procedure staff should assess any likely
Protective exposure and ensure PPE is worn that provides adequate protection
Equipment against the risks associated with the procedure or task being
undertaken.
Hand Hygiene Hands must be decontaminated as per your 5 moments for Hand
Hygiene:
1. Before touching a patient
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings
Patient Care Where available, use single use/single patient use equipment.
Equipment Equipment should be kept to a minimum
All shared or reusable equipment must be decontaminated
between patients using general purpose detergent
Items contaminated with blood or body fluids must be
decontaminated using a chlorine releasing agent at a dilution of
1,000 parts per million available chlorine (ppm available chlorine
(av.cl.)). Please refer to manufacturers’ instructions for
compatibility of product
Communal facilities such as baths, bidets and showers should
be cleaned and/or decontaminated between all patients
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 6 of 10Environmental Enhanced routine cleaning of the patient’s accommodation with
cleaning by a chlorine releasing agent at a dilution of 1,000 parts per million
Hotel Services available chlorine (ppm available chlorine (av.cl.)), should be
undertaken by hotel services staff until instructed otherwise. It is
the responsibility of nursing staff to ensure that domestic
assistants are aware of this requirement
Following the removal of the patient, the room should have a
routine clean carried out prior to the next patient being admitted
Clinical Waste Waste to be segregated into the following categories:
Domestic
Clinical
Sharps
Linen Used linen should be placed into a white laundry bag
All infected linen should be placed in a water soluble bag then
into a clear plastic bag and lastly into a red laundry bag
Labels should be attached to each linen bag on sealing, clearly
stating:
- Hospital of origin
- Ward or Department
- Date
Safe Spillages must be decontaminated immediately with a chlorine
management releasing agent using the following dilutions:
of blood and Blood spillages (or bodily fluid with associated blood): a dilution
body fluids of 10,000 parts per million available chlorine (ppm available
chlorine (av.cl.))
Body fluid spillages (with no associated blood): a dilution of 1,000
parts per million available chlorine (ppm available chlorine
(av.cl.)). Remove spillage with disposable paper roll prior to
applying a chlorine releasing agent to reduce the risk of
chemical reaction
Occupational Contact the Occupational Health Department if you have any
exposure occupational exposure to blood and/or body fluids
Staff with upper respiratory tract infections, oral-facial herpes
simplex or any other signs / symptoms of infection should be
excluded from direct contact with these patients
Safe Refer to the Code of Practice Section 12.2 Systemic Anti Cancer
management Therapy for Specialist Oncology / Haematology Areas
of systemic - Safe handling of contaminated linen (Section 14)
anti cancer - Safe handling of body fluids (Section 14)
therapy - Occupational exposure (Section 15)
(SACT) - Management of spillages (Sections 16)
Respiratory No additional actions are required
Hygiene and
Cough
Etiquette
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 7 of 103.0 OTHER RELEVANT INFORMATION
Transferring Minimise patient transfers until Protective Isolation is no longer
Patients required
Prior to transfer, staff must inform any receiving ward/department
that the patient is immunocompromised,
Prior to transfer, you must ensure the ward receiving the patient
has suitable accommodation
If a patient is transferred to another ward/ care facility you must
ensure that immunocompromised status is included in any
transfer documentation.
Specimens Send specimens as clinically indicated (also refer to the Laboratory
Handbook)
Care After
Death A body bag is not required.
Patient Laundry going home, must be placed into a clear bag and then into
Clothing a patient clothing bag. The Washing Clothes at Home Information
Leaflet must be issued.
Visitors Those who are immunocompromised and small children should
be advised not to visit
Those who have signs or symptoms of infection should be
advised not to visit
Keep number of visitors at any given time to a minimum (usually
2 at a time) particularly in positive pressure ventilation rooms
Documentation Ensure that the patient is fully aware of their immunocompromised
status and that the provision of this information has been
documented in the nursing and medical notes.
Action to be Patient confidentiality must be maintained at all times. Information
taken concerning any infection risks must only be given to others on a
need to know basis.
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 8 of 10Additional Flowers and plants could potentially be a reservoir for gram
information negative bacteria and fungal spores and, therefore, should be
avoided within rooms used for protective isolation
Immunocompromised patients are at increased risk of food-
borne illness, therefore, they are advised to avoid some high risk
foods e.g. soft cheeses, food made with raw eggs, bottled water
and take away food. Further advice can be obtained from the
Dietetic Service. See Bloodwise.org.uk information leaflet –
Dietary Advice for Haematology Patients with Neutropenia
Water can potentially be colonised by organisms, particularly
gram negative bacteria found in the plughole and overflow outlet
of sinks. Water flushing regimes and water safety practices
should be implemented as per Pseudomonas Guidelines within
high risk areas
Patients are at risk of infection from their own endogenous
organisms, as a result they should be encouraged to maintain
good personal hygiene practices and given support where
required
Built Any activity involving refurbishment or repair within a
Environment ward/department must be risk assessed as per Healthcare
Associated Infection – Systems for Controlling Risk in the Built
Environment (HAI SCRIBE)
All projects will have a multi-disciplinary risk assessment to
agree the control measures required to minimise the risk of
infection from dust, water, soil etc.
External works may pose a risk of infection from particles
released into the environment from dust, water, soil etc. When
this work is adjacent to a department caring for
immunocompromised patients then window closures may be
advised:
- Where possible transfer the patient to a positive pressure
isolation room with sealed windows
- If patient isolated ensure that the windows within the room
are kept closed at all times
- If patient cannot be isolated then the windows throughout the
ward/department must be kept closed at all times
- Full advice and support will be provided by the project group
as part of the HAI SCRIBE assessment
Prior to any work commencing, no matter how minor, it is
essential to highlight immunocompromised patients to ensure all
appropriate precautions are implemented. See Appendix 1
Please contact the IPCT ext 25765 or an Estates Officer if you
have any concerns
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
Page 9 of 10Aspergillus and at Risk Patients during Construction Activity During Construction/Renovation
Activities. NDS 2002
(Extracted from National Guidelines for the Prevention of Nosocomial Invasive Aspergillosis
(http://www.hpsc.ie/a-z/respiratory/aspergillosis/guidance/)
Risk Patient groups Physical Measures
Group
Group 1 1. Staff members, Service Providers and Nil
No Contractors
evidence 2. All patients not listed in Groups 2 – 4
of Risk below
Group 2 1. Patients on prolonged courses of high Patients are usually dispersed
Increased dose steroids particularly those throughout the hospital and
Risk hospitalised for prolonged periods therefore physical protection
2. Severely immunosuppressed AIDS may be impractical.
patients Consideration should be given
3. Patients undergoing mechanical to moving patients away from
ventilation the construction area.
4. Patients having chemotherapy who are
not neutropenic**
5. Dialysis patients
Group 3 1. Neutropenia for less than 14 days Patients should receive
High Risk following chemotherapy protection if the area of
2. Adult acute lymphoblastic leukaemia treatment is juxtaposed
(ALL) on high dose steroid therapy or near the hospital
3. Solid organ transplantation construction area or if it is
4. Chronic Granulomatous Disease of otherwise likely that
Childhood (CGDC) Aspergillus-contaminated air
5. Neonates in intensive care units (ICU) may enter the area. High-risk
patients should be nursed in a
ward with sealed windows and
suitable air quality
Group 4 1. Allogeneic bone marrow Patients should receive
Very High transplantation maximum protection
Risk a. during the neutropenic period irrespective of the type/size of
b. with graft versus host disease the building programme. All
2. Autologous bone marrow very high-risk patients should
transplantation, i.e. during the be nursed in HEPA filtered
neutropenic period positive pressure rooms during
3. Peripheral stem cell transplantation, the neutropenic period. If they
i.e. during the neutropenic period are subsequently
4. Non-myeloablative transplantation transferred to a ward the
5. Children with severe combined windows should be sealed and
immuno-deficiency syndrome (SCIDS) suitable air quality provided
6. Prolonged neutropenia for greater than
14 days following chemotherapy or
immunosuppressive therapy
7. Aplastic anaemia patients
Standard Operating Procedure for Protective Isolation in a Healthcare Setting
v01.4, April 2021
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