Inter and intra ward transfer policy for patients with infection control ...

Winchester & Eastleigh Healthcare NHS Trust 

Policy for the Inter and Intra ward Transfer of Patients with Infection Control 

Issues 

Policy for Inter and Intra ward Transfer 

of Patients with Infection Control Issues 

Authorities 

Author: 

Sponsor: 

Reviewer(s): 

Sue Dailly 

Lead Nurse Infection 

Control 

Paula Shobbrook 

Director of Infection 

Prevention and Control 

Infection Control 

Committee and 

Nurse and Midwifery 

Policy Committee 

Document Control Information 

Type: 

Scope: 

Policy 

Major 

Trust Reference CPO61 

Number: 

Issue Number: 2 

Approval body: Policy Approvals Group Status: Published 

Effective Date: June 2010 

Review Date: June 2013 

Disposal Date: June 2033 

Document Authorisation Control 

Prepared By: 

Sue Dailly 

Lead Nurse Infection Control 

Authorised Officer: 

Chris Gordon 

Acting Chief Executive 

Signature: 

Signature: 

Authorities 


Author: Sue Dailly Lead Nurse Infection Control Type: Policy 

Sponsor: Paula Shobbrook Director of infection , Scope: 

Major 

Prevention and control; Chief Nurse 

Trust Reference Number: CP061 


Date: June 2010 Status: Published 

Page 1 of 12


Policy for Inter and Intra ward Transfer of Patients with Infection Control Issues 

DOCUMENT CONTROL 

Document Amendments 

No. Details By Whom Date 

1 Up-dated to match Health Act 2006 S.Dailly, Lead 

Nurse Infection 

Control 

2 3 yearly review Up-dated to new policy format S.Dailly, Lead 

Nurse Infection 

Control 

Feb 2007 

May 2010 

Review Timetable 

Date Reason By Whom 

May 2010 3 year review Sue Dailly, 

Lead Nurse 

Infection 

Control 

May 2013 3 year review ICNs 

Date 

Completed 

May 2010 

Distribution List 

No Title 

1 Trust Intranet and Trust web site 

2 

3 

4 

5 

Authorities 




Major 


Trust Reference Number: CPO61 



Page 2 of 12



RELATED TRUST POLICIES 

CPO73 Hand Hygiene Policy 

CPO76 Standard Precautions and PPE Policy 

CPO77 Policy for Ward Closure Due to an Infection Control Issue 

CP010 Policy for management and control of diarrhoea and vomiting (Norovirus) 

Infections 

CPO28 Management of Suspected Cases of Viral Haemorrhagic Fever Policy 

CPO29 SARS/new strain influenza policy 

CPO47 Tuberculosis and multiple drug resistant tuberculosis policy 

CPO55 MRSA 

CPO64 Clostridium difficile policy 

NP06 Safe moving of patients between clinical and other areas policy 

Authorities 




Major 





Page 3 of 12



Contents 

Section Title Page No. 

1. Purpose 5 

2. Scope 5 

3. Roles and Responsibilities 6 

4 Definitions 7 

5 Intra or Interward transfer of patients for isolation 7 

6 Selection of patients to be transferred to an MRSA 7 

‘free’ ward. 

7 Guidance on MRSA screening to aid bed 8 

management 

8 Patient transfer documentation 8 

9 Cleaning of bays or side rooms after transferring 9 

patient 

10 Portering Patients between wards 9 

11 Transfer of patients out of the Trust 10 

12 Training Implications 10 

13 Monitoring Compliance and Effectiveness 10 

14 References 10 

Appendix 2 Equality Impact Assessment Tool 11 

Authorities 




Major 





Page 4 of 12



Issues 

1. PURPOSE 

1.1 Patients sometimes have to move beds or wards during their admission for 

reasons such as the need for isolation, change in clinical condition or speciality. 

Moves to assist overall bed management should be avoided. 

1.2 The movement of patients between wards must be coordinated to ensure that the 

receiving ward can accommodate the patients’ specific requirements. Site 

coordinators, Infection Control and housekeeping services must all work together 

to ensure prompt isolation of patients and safe movement of patients. 

1.3 The Infection Control Team is frequently asked for advice on suitable patients for 

internal transfer, particularly to wards which the Trust is committed to maintaining 

Methicillin resistant Staphylococcus aureus (MRSA) free. All patients should be 

screened for MRSA. Clinical selection of low risk cases should not be overlooked 

as a useful tool. All elective patients should be screened prior to admission; all 

emergency patients should be screened on admission. This means most hospital 

patients will have an MRSA result which can be used to assess the MRSA risk of 

a patient prior to transfer. 

1.4 Prior to the intra or inter ward transfer of any patient staff must consider whether 

that patient has any infection which must be taken into consideration prior to the 

transfer e.g. shingles, diarrhoea or MRSA. 

1.5 During outbreaks of diarrhoea and vomiting (norovirus) patients should be 

questioned on admission if they have a recent history of diarrhoea and/or 

vomiting or if anyone else in their family / home has recently been symptomatic. 

All patients admitted with diarrhoea and or vomiting should be questioned to 

ascertain if this is likely to be Norovirus and then isolated if this is a risk. Patients 

maybe admitted from outbreaks in nursing and residential homes, it is essential 

these patients are isolated because is not maybe a source of outbreak in the 

Trust. See CP010 Policy for management and control of diarrhoea and vomiting 

(Norovirus) Infections for further information. 

2.0 SCOPE 

2.1 This policy applies to all patients within the Winchester and Eastleigh Healthcare 

NHS Trust (WEHCT). 

2.2 Please refer to the NP06 Safe moving of patients between clinical and other 

areas policy for further details. 

Authorities 




Major 





Page 5 of 12



3.0 ROLES AND RESPONSIBILITIES 

3.1 Chief Executive (CEO) 

The CEO has overall responsibility for ensuring the Trust has appropriate 

strategies, policies and procedures in place to ensure the Trust continues to work 

to best practice and complies with all relevant legislation. The CEO has 

responsibility to ensure there is a safe environment for staff and patients and this 

includes the adequate provision of isolation facilities. 

3.2 Trust Board 

The Board is responsible for ensuring the strategic context of this policy is 

appropriate and meets the needs of the Trust. 

3.3 Infection Control Team (ICT) 

The Infection Control Team is responsible for updating this policy and ensuring it 

represents best practice and is based on current evidenced based information. 

They must keep the utilisation of side room spread sheet updated on a daily basis 

Monday – Friday. Changes in patient condition requiring isolation should be 

communicated to the site coordinator promptly to ensure rapid facilitation of 

isolation. Infection Control will also provide advice to trust staff on the cohorting 

and movement of patients when requested. 

3.4 Line managers 

Line mangers are responsible for ensuring adequate dissemination and 

implementation of this policy. They are responsible for identifying any training 

needs on the implementation of new or updated policies. They are responsible 

for ensuring adequate facilities and resources are utilised to assist with 

adherence to this policy. Also ensuring that any changes in practice are 

implemented. Line managers are responsible for ensuring that all Infection 

Control (IC) policies and procedures are accessible for all their staff and that they 

have read them. 

3.5 Site coordinators 

Site coordinators are responsible for ensuring that patients who require isolation 

are moved promptly to isolation facilities. When a patient has to move from one 

ward to another they must check the receiving ward has adequate facilities to 

accommodate the patient’s requirements. They must also update the utilisation of 

side room spreadsheet when movement of patients has taken place. 

3.6 All Trust employees 

All staff are responsible for ensuring their compliance to this policy to ensure the 

safety of all patients, staff, visitors and contracted staff to this Trust. Information 

regarding the failure to comply with this policy, lack of training or inadequate 

Authorities 




Major 





Page 6 of 12



equipment must be reported to the line manager and via the incident reporting 

system where appropriate. If patients or staff safety is compromised as a result of 

the revised policy, staff must inform their line manager and ensure that a risk 

assessment is completed and reported through divisional risk forums and the 

Trust incident reporting system. 

3.7 Training 

It is the responsibility of individual practitioners to ensure they receive the 

education they require to improve their knowledge, skills and competence. They 

are accountable to themselves, their line manager and the patient in 

acknowledging their limitations and to verbalize their concerns in caring for 

patients who have an infection control issue and need to move to a different ward. 

4. DEFINITIONS 

Term 

Intraward transfer 

Interward transfer 

Clinical move 

Non- clinical move 

Cohorting patients 

Definition 

Movement with in the same ward 

Movement between wards 

Patient is moved due to infectious/medical reason i.e. 

MRSA; observable bed 

Patient is moved to make i.e. same sex bed 

Placing patients with the same infectious issue in the 

same bay. 

5. 0 Intra or Interward transfer of patients for isolation 

If ICNs, ward staff or other clinical staff identify a patient who requires barrier 

nursing in a single room they should initially try to isolate the patient on their 

present ward. If a side room is not available then they must contact the site 

coordinator to arrange for the patient to move wards. The transferring ward must 

inform the receiving ward of the patient’s clinical needs, infection issue and inform 

the patient and their family of the move. See NP06 Safe moving of patients 

between clinical and other areas policy for further details. 

5.1 Patients who are moved out of ICU will have a written ICU discharge plan with 

Multi-disciplinary input. 

6. Selection of patients to be transferred to an Methicillin Resistant 

Staphylococcus Aureus (MRSA) ‘free’ ward. 

The following points should be considered: 

6.1 Any patient who is transferred must be clinically fit for the transfer and suitable for 

clinical management in the new environment. Staff must check the National Care 

Records System (NCRS) patient page and medical records for details of any 

infection the patient may have prior to consideration for transfer. 

Authorities 




Major 





Page 7 of 12



6.2 The more hands on care a patient receives the more likely he/she is to acquire 

MRSA or another healthcare associated infection e.g. Clostridium difficile. 

6.3 The following criteria are useful in selecting patients least likely to have MRSA: 

MRSA negative on admission screen or pre-admission screen 

No history of MRSA acquisition 

Admitted from own home not a residential or nursing home or another 

institution 

Not an inpatient in hospital or a client of a residential / nursing home within 

the last year 

Not a diabetic 

Not recently admitted 

Does not have chronic skin breaks e.g. leg ulcer or eczema 

Does not have an indwelling urinary catheter 

An MRSA screen may have been taken prior to admission if elective or on 

admission if an emergency patient. Results should be available within 24 – 48 

hours. 

7. Guidance on MRSA screening to aid bed management 

7.1 The principle of aiming to keep certain surgical wards MRSA free is to be 

maintained 

7.2 Patients who are MRSA positive or have a history of MRSA should not be 

transferred to the elective orthopaedic ward, vascular, gynae wards, or where 

breast implant patients care is accommodated or the treatment centre. 

7.3 Transfers to elective orthopaedic ward, vascular and breast surgery ward must 

have a negative MRSA screen taken within the last 7 days or be assessed as low 

risk according to point 6.1. 

8 Patient transfer documentation 

8.1 The combined electronic handover record is to be used to record patient 

information and infection control issues. 

8.2 If the patient is transferred to another ward the patient transfer letter must contain 

explicit details of the patients individual needs and any infection the patient has or 

has recently had. Transfer letter available on Trust internet, documents. This 

includes problems like MRSA, Clostridium difficile, pneumonia, Extended 

Spectrum Beta lactamase producer (ESBL), shingles or diarrhoea. It is the 

responsibility of the transferring ward to ensure the receiving ward is aware of the 

patient’s infection status. It is the responsibility of the receiving ward to check the 

Authorities 




Major 





Page 8 of 12



patients transfer documentation and clinical records to ensure they are aware of 

any infection control issue, and review the placement of the patient if necessary. 

Transfer letter can be found at http://trustnet/Docs/OnlineForms Print Only Forms 

section. 

8.2 If a transfer letter is not sent with the patient the sending ward must record on the 

NCRS or EMAU documentation a summary of the patient’s individual needs 

including any infection the patient has or has recently had. 

8.3 When NCRS is upgraded the Patient Transfer document will be electronic. 

Training of ward based staff will take place during the upgrade. 

8.4 The nurse or site coordinator arranging the transfer must ensure the receiving 

ward can accommodate the patients’ specific needs e.g. a single room with toilet 

and has the appropriate equipment e.g. FFP3 masks. Equipment such as masks 

may need to be supplied by the sending ward until supplies can be arranged. 

8.5 Cohort bays are usually set up by the Infection Control Team and the site 

coordinators and ward staff. Patients with similar infections / colonisations can be 

cohort nursed. The housekeeping supervisor and ward housekeeper will be 

informed when a cohort bay is planned to be opened or closed. 

8.6 Please see CP055 MRSA Policy regarding managing an MRSA cohort bay. 

Please see CP101 Policy for the management and control of diarrhoea and 

vomiting (Norovirus) infections re cohort nursing patients with diarrhoea and/or 

vomiting during an outbreak. 

9. Cleaning of bays or side rooms after transferring patient 

9.1 The transferring ward must inform the ward housekeeper that a bed space or a 

side room requires cleaning after the patient has been isolated or moved to side 

room. Ideally bed moves should take place in the morning when there are more 

housekeeping staff on duty to facilitate the prompt cleaning. The ward staff must 

inform the housekeeping staff what precautions are required whilst cleaning the 

room e.g. masks required for swine flu. 

9.2 Infection control and the site coordinators will also liaise with housekeeping staff 

on the movement and cohorting of patients with infection control issues. 

10 Portering Patients between wards 

Use alcohol gel when entering the ward, if hand visibly clean. 

If the patient is being barrier nursed wear a yellow apron and gloves if the 

patient requires hands on assistance to move onto the trolley or wheelchair. 

Authorities 




Major 





Page 9 of 12



Discard the yellow apron in the room after assisting the patient 

Leave the gloves on whilst transporting the patient 

Put on another yellow apron on the receiving ward to assist the patient 

Remove apron and gloves and wash hands before leaving the room 

Use the alcohol gel outside the room 

10.1 After any trolley or wheelchair has been used for any patient transfer it must be 

cleaned. Use disinfectant wipes like Clinell® or use detergent and water to wash 

the surfaces, dry thoroughly. 

10.2 Please refer to the Safe moving of patients between clinical and other areas 

policy NP06 

11. Transfer of patients out of the Trust 

Staff must inform any healthcare institute, hospital or nursing or residential home 

if the patient has or has recently had an infection or infection control issue, i.e. 

colonised with MRSA or had a wound infection post surgery, prior to the transfer. 

12. Training Implications 

12.1 Specific training for staff on the transfer of patients with infection control issues is 

not provided but is mentioned in updates and through the sharing of the audit 

results with staff. 

12.2 NCRS upgrade training will include the use of the electronic transfer letter 

12.3 If there is an increase in complaints or clinical incidents associated with the 

movement of patients more specific training will be provided via the Infection 

Control Link Practitioners. 

12.4 Housekeeping staff receive specific training on the cleaning of bed spaces and 

side rooms of patients with infections during their stay and after discharge. 

13. Monitoring Compliance and Effectiveness 

13.1 The ICNs will facilitate an audit of compliance with this policy on an annual basis. 

13.2 The use of side rooms will also be audited to review the proportion of side rooms 

used by patients with MRSA and other infections to aid future planning of ward 

layouts and refurbishments. 

13.3 Results will be reported to and subsequent action plans will be monitored by the 

Infection Control Committee. 

Authorities 




Major 





Page 10 of 12



14. REFERENCES 

See Trust Policies 

Authorities 




Major 





Page 11 of 12



Issues 

Appendix 1 - Equality Impact Assessment Form 

To be completed and attached to any controlled document when submitted to the appropriate 

committee for consideration and approval. 

Yes/No 

Comments 

1. Does the policy/guidance affect one group less or 

more favourably than another on the basis of: 

Race 

Ethnic origins (including gypsies and travellers) 

Nationality 

Gender 

Culture 

Religion or belief 

Sexual orientation including lesbian, gay and 

bisexual people 

Age 

no 

no 

no 

no 

no 

no 

no 

no 

no 

Disability - learning disabilities, physical disability, 

sensory impairment and mental health problems 

2. Is there any evidence that some groups are 

affected differently? 

3. If you have identified potential discrimination, are 

any exceptions valid, legal and/or justifiable? 

4. Is the impact of the policy/guidance likely to be 

negative? 

5. If so can the impact be avoided? no 

6. What alternatives are there to achieving the 

policy/guidance without the impact? 

7. Can we reduce the impact by taking different 

action? 

no 

no 

no 

no 

no 

no 

If you have identified a potential discriminatory impact of this procedural document, please refer 

it to the Board Secretary, together with any suggestions as to the action required to avoid/reduce 

this impact. For advice in respect of answering the above questions, please contact the Board 

Secretary (Tel No: 01962 825903). 

Authorities 




Major 





Page 12 of 12

Inter and intra ward transfer policy for patients with infection control ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?