COVID-19 guidance for Adult Social Care providers

This local guidance has been devised in order to help support community settings gain a greater understanding of what CPEs are and how residents who are identified as having these bacteria can be safely managed in these settings.

The information within this document aims to provide assurance to care settings that combined with the correct environments and adherence to IPC standards, residents within the facility can be safely managed. This guidance will allow settings to assess if their facility can accommodate residents safely.

What are CPE?

CPE are a group of bacteria that live harmlessly in the gut of humans and animals. They include bacteria such as E.coli, Klebsiella and Enterobacter. However, these organisms are also, some of the most common causes of infections, including urinary tract infections, intra-abdominal and bloodstream infections.

Carbapenems are a valuable group of antibiotics that are normally reserved to treat serious life-threatening infection including some multidrug-resistant bacterial infections in hospitals. They include meropenem, ertapenem and imipenem. Resistance to some or all carbapenems is a natural characteristic of some bacteria. Others can produce enzymes (carbapenemases) that can destroy carbapenem antibiotics, making them resistant.

In summary, CPEs are strains of bacteria that are producing an enzyme (carbapenemase) which makes them resistant to the carbapenem group of antibiotics.

The identification of a CPE is also important because the resistant gene contained within these bacteria can move from one group of bacteria e.g., E. coli to another e.g., Klebsiella.

Controlling CPE

Uncontrolled spread of CPE will lead to an increasing risk to public health. Screening regimes are now in operation in hospitals to detect its presence in some high-risk groups of patients. Community screening is currently not recommended.

Screening often identifies those patients that are colonised (living with it in their guts). Screening is carried out by hospitals to identify vulnerable patients who may go on to get severe infections leading to an increased length of stay, increased risk of morbidity, and mortality, compared to bacteria that are not resistant.

Screening regimes will depend on local epidemiology, type of patients and location. Hospitals will be following national guidance. It should be noted that not every patient is screened for CPE carriage. Community screening is currently not recommended.

Who will be screened and why?

Please refer to page 12 in the national Actions to contain carbapenemase-producing Enterobacterales - GOV.UK document.

Routine screening for primary care settings or on admission to a care or residential home is not recommended.

A positive CPE status/result should be recorded on the discharge summary and or patient transfer documents if the patient has been screened during their admission. This information should continue to be communicated for any future transfers to other healthcare & social care facilities or admission to hospital, including out-patient appointments.

How CPE is identified

The hospital staff will take the following samples as part of a CPE screen:

• a rectal swab, making sure faecal material and/or discolouration is visible on the swab (a stool specimen if a rectal swab is not feasible or acceptable)
• and a wound swab (if present) or a urine sample (if catheterised)

NB: Staff screening is not recommended.

Outbreaks of CPE

Occasionally outbreaks caused by CPE have been identified in hospitals. When this is identified, close contacts (patients meeting these criteria will be identified by the IPCT) will also be screened for a number of weeks whilst they are in hospital. There is no need to continue this screening once the patient is discharged.

Information regarding patient’s potential exposure to CPE may be included on inter hospital or intra hospital transfer documents and or discharge summary to alert relevant healthcare providers (including GPs). If this information is documented, please contact the C&W ICB IPCT via the email address below.

Potential outbreaks in care settings will be managed in accordance with outbreak policies and in conjunction with UKHSA and public health local authorities. Inform C&W ICB IPCT team via outbreak email address warnoicb.covwarksc19outbreaks@nhs.net

Minimising transmission

• Ensure strict adherence to Infection Prevention and Control measures especially hand hygiene
• Transmission to other residents is reduced with the continued use of standard infection, prevention & control practices and use of transmission-based precautions – please refer to local policy and also the National IPC Manual NHS England » National infection prevention and control
• Residents identified with having CPE must have a single room with a private en-suite (including a toilet, handwash basin with liquid soap and paper hand towels and shower/bath). ‘Jack and Jill’ bathrooms would not be sufficient
• The risk of transmission is increased by uncontrolled faecal and urinary incontinence which potentially can contaminate the environment

Key recommendations:

• There is no effective method of decolonisation for these residents, and it is suggested that such individuals may always be colonised with CPE, or they may clear it and then re-colonise when they have repeated courses of antibiotics.
• They must have a single room with full en-suite facility (hand washbasin with liquid soap and paper hand towels, toilet and shower/bath)
• All staff must be aware of the residents who have CPE to ensure they follow IPC strict practices
• Avoid having excess amounts of equipment in the individual’s room
• The resident’s room, communal areas (including common touch points) and equipment must be cleaned daily with a recognised detergent and followed by disinfection, paying particular attention to bathrooms, commodes, raised toilet seat, hoist etc
• Residents must have their own equipment e.g., cushion, hoist slings, slide sheets, wheelchair, Zimmer frame, pressure relieving cushion etc
• Disposable cloths and mops should be used for cleaning, and discarded immediately after use
• Wastewater should be ideally emptied in the janitorial sluice or if not available the slop hopper within the dirty utility
• Residents should have a clinical waste bin in their bedroom
• Disposal of blood and body fluids should be discarded in the clinical sluice in the dedicated washer disinfector (ensure the washer disinfector is on a maintenance plan) and ensure that items are clean at the end of a cycle
• All basins, sinks and showers should be maintained so they drain efficiently, any issues should be reported immediately to the home manager
• Residents’ linen, towels and clothing should be managed as per protocol for fouled/infected linen e.g., red alginate bag with a secondary outer bag
• Cutlery and cups, plates etc should be re-processed through the central dishwasher in the main kitchen
• Personal Protective Equipment (PPE) for all staff contact:
  • Gloves
  • Aprons
  • Long sleeved gowns can be worn where any part of the uniform (work wear) is not adequately protected by an apron for example turning the resident, or where there is a risk of extensive splashing of blood and or other body fluids for example excessive wound exudate, diarrhoea, faecal incontinence
• PPE for visitors:
  • Visitors who are not providing direct care, do not need to wear aprons or gloves etc. However, they must wash their hands thoroughly when leaving the room. Visitors who are carrying out direct care should adhere to the above guidance, on PPE use

Admission of CPE residents to the care setting

Non-acute settings should not refuse admission or readmission of service users on the grounds that they are colonised or infected with CPE.

A risk assessment should be undertaken to identify the risks with each resident. Please refer to the Risk assessment tool.

Sinks, basins, showers and drains

Do not store items under u-bends of sinks.

Nutrients such as food waste may both increase bacterial numbers and affect drainage and should not be disposed of via the resident's sinks. Hand wash basins should only be used for hand hygiene and not for:

• disposal of body fluids
• disposal of tea, coffee or other nutrient containing beverages
• washing any resident equipment
• storage of used equipment awaiting decontamination

For personal washes use a dedicated bowl for the resident. The wastewater (and water used for cleaning the room) must be discarded in a slop hopper in the dirty utility. Ensure the dirty utility room is cleaned on a daily basis which should be included on the cleaning schedule. Immediately after use the resident's wash bowl must be cleaned with detergent followed by disinfection using a chlorine releasing agent or a disinfectant that meets the approved EN14476 or EN1276 standard.

Hand wash basins, baths, and showers in bathrooms and W/Cs:

• Use the appropriate colour coded gloves (PPE) and disposable cloths in line with national cleaning standards
• Use one cloth per Handwash Basin/Shower/Bath
• Using the cloth wipe clean the tap starting from the waterspout to the base of the tap
• Clean the remainder of the tap and handles
• Do not touch the spout again once cleaned
• Clean the external surfaces of the handwash basin/bath/shower
• At any point if the cloth becomes dirty, dispose, and use a new cloth for the remaining area
• Next wipe clean the internal surfaces of the hand wash basin/bath/shower and then discard the cloth
• Do Not Use the same cloth to clean the next handwash Basin/Shower/bath

NB: General Care of cleaning equipment:

• Empty, clean & dry all reusable equipment
• Never soak cloths or mop heads e.g., mop heads left to soak in bleach in a bucket overnight
• For rooms where residents have an identified infection disposable mop heads and cloths should always be used
• All equipment should be correctly stored in a dedicated cleaner’s cupboard
• After tasks are completed remove gloves & decontaminate hands with soap and water. Dry thoroughly using disposable paper hand towels

Decontamination following resident discharge/death

• Mattress and pressure relieving cushion integrity must be physically checked to ensure there has been no strike through. They must be cleaned thoroughly with detergent followed by a disinfectant or sent off to an approved company for decontamination
• The chair within the resident’s room should also be thoroughly checked for strike through and discarded if any seepage/damage has occurred
• If the mattress/cushion cover is damaged, the mattress/cushion should be condemned
• Pillows should be disposed of
• Pressure relieving mattresses (dynamic mattresses) should be disassembled, cleaned and disinfected, usually by specialist external contractor
• Shower curtains, privacy curtains should be removed and laundered or be single patient use only and discarded after use
• All used or unused single-use items or consumables in the resident’s immediate vicinity (that may have become contaminated by hand contact) should be discarded, keeping limited stocks near the residents reduces the need for this
• Avoid having excess amounts of equipment in the individual’s room
• Tubes of ointment and lubricant should be discarded
• Lavatory brushes and their holder should be disposed of as part of the discharge or terminal clean
• Curtains and carpets should be steam cleaned

Future Antibiotic prescribing

Controlling the use of antibiotics is essential to prevent bacteria becoming resistant to antibiotics.

Treatment options for this group of residents must involve infection specialists including medical, nursing and pharmacy.

Communication

The National CPE Framework states that the patient's screening results should be included on the discharge summary. Failure to provide this information by the discharging ward to the community provider contravenes the above and would be classed as a reportable clinical incident.

If the resident needs to go into either hospital or another care facility (either emergency or planned), or out-patient appointment ensure that the organisation is informed that they have CPE, including the ambulance service.