Download Isolation Precautions as Part of Preparedness Against

Infection Control and Isolation
Precautions as Part of Preparedness
Against Use of Biological Weapons: A
Module for Nursing Professionals
Felissa R. Lashley, RN, PhD, FAAN, FACMG
Professor, College of Nursing, and
Interim Director, Nursing Center for
Bioterrorism and Infectious Disease
Preparedness, College of Nursing
Rutgers, The State University of New Jersey
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In this module, general information is given on
infection control and isolation procedures in
hospitals as they pertain to nurses.
Standard and specific transmission-based
precautions are discussed.
Following this are additional specific information
related to each procedure (e.g., handwashing,
patient transport) or equipment (e.g., gloves,
gowns).
Teaching cough etiquette to patients with
respiratory infections is covered.
Finally, some considerations for planning
infection control in an outbreak situation are
mentioned.
This module was supported in part by USDHHS,
HRSA Grant No. T01HP01407.
Comprehensive details are found in the revised document guidelines for isolation
precautions: preventing transmission of infectious agents in healthcare settings
2007. http://www.cdc.gov/ncidod/dhgp/pdf/
Objectives
At the completion of this module, participants will
be able to:
1. Describe the types of isolation precautions.
2. Describe the three elements for infection
transmission.
3. Identify components of effective handwashing.
4. Describe conditions under which to use standard
precautions.
5. Describe conditions under which to use contact
precautions.
6. Describe conditions under which to use droplet
precautions.
7. Describe conditions under which to use airborne
precautions.
Infection Control
Infection Control-2
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Sources of microorganisms can include:
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These sources can include:
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Patients
Health care workers
Visitors
Persons with acute illness or infection
Those who are carriers, and
Those who are colonized with microorganisms
(harbor the organism without showing any
apparent illness)
Inanimate objects such as furniture and
medical equipment can also be sources of
microorganisms.
Patient Isolation Precautions for
Hospitals
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Are designed to prevent transmission of
infections in the hospital setting
Require cooperation and responsibility
from various units including
administration, education, other clinical
services, and surveillance
Infection transmission in the hospital
requires:
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Source or reservoir of microorganisms
Susceptible host with a portal of entry receptive to the
microorganism
Means of transmission
Patient Isolation Precautions for
Hospitals-2
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The term host refers to the person or animal who becomes
infected.
Hosts differ in susceptibility due to characteristics, some innate,
such as:
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Age (the elderly and infants are more susceptible to infection),
Immune status,
Genetic susceptibility factors,
Malnutrition, and
Factors, such as underlying illness (e.g., diabetes mellitus and HIV
infection), medical treatments (e.g., immunosuppressive drugs or
radiation), surgical procedures, and placement of invasive devices
(e.g., IVs, chest tubes, and urinary catheters).
Infectious agents vary in regard to various factors such as
virulence, antigenicity, and pathogenicity
There are various outcomes that may occur after exposure to a
microorganism including colonization, symptomatic disease, and
more. The outcome depends on complex interactions among
agent, host and environment.
Patient Isolation Precautions for
Hospitals-3
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There are several main routes of
transmission of microorganisms. A
microorganism may be spread by a single
or multiple routes. These are:
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Contact, direct or indirect
Droplet
Airborne
Vectorborne (usually arthropod) and
Common environmental sources or vehicles includes foodborne and waterborne as well as
medications such as contaminated IV fluids
Patient Isolation Precautions for
Hospitals-4
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Patient care units are usually mainly
concerned with direct and indirect
contact, droplet and airborne
transmission. In most hospitals in
the US vector-borne transmission is
not relevant.
Environmental and engineering
aspects (including waste disposal,
disposal of sharps, and laundry) are
not covered in this module
Patient Isolation Precautions for
Hospitals-5
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Standard precautions are used for all
patient care.
Additional isolation precautions are based
on patient’s known or suspected infection,
what is known about the microorganism
causing it, and its route of transmission.
Highly contagious or diseases with high
mortality such as Ebola hemorrhagic fever
may require more stringent infection
control, such as double gowning and
double gloving.
Institutions may modify the CDCrecommended precautions to be more
stringent.
Patient Isolation Precautions for
Hospitals-6
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Multidrug-resistant organisms
(MDRO’s)may require more stringent
protection, such as methicillin resistant
Staphylococcus aureus (MRSA).
Isolation precautions may be combined for
diseases that have more than one route of
transmission. For example, protection
from varicella requires contact and
airborne precautions.
See CDC guidelines at
http://www.cdc.gov/ncidod/dhgp/pdf/ar/
mdro/Guideline2006/pdf.
Patient Isolation Precautions for
Hospitals-7
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Standard Precautions (Basic level)
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Are used for care of ALL patients in a hospital all
of the time regardless of diagnosis or infection
status
Combine the major features of universal, and
body substance precautions, terms formerly
used
Applied to blood, body fluids, excretions and
secretions regardless of whether they contain
visible blood, mucous membranes and nonintact skin
All other transmission-based precautions include
(are in addition to) Standard Precautions
Level of use depends on anticipated contact with
patient
Patient Isolation Precautions for
Hospitals-8
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Other Transmission-Based Precautions Commonly Used in Hospitals
Consist of:
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Direct and Indirect Contact Precautions
Airborne Precautions
Droplet Precautions
These may be used in combinations depending on whether the
microorganisms and infection in question have multiple routes of
transmission with barrier nursing.
Special adaptations may be needed for multidrug resistant organisms
and Category A agents of bioterrorism.
For all, appropriate signage meeting unit criteria should be at
entrance to patient room.
Unit staff should be educated and updated frequently as to
appropriate infection control for patients on their unit.
Unit staff with certain transmissible diseases, such as infective
conjunctivitis, should be relieved from direct patient contact until no
longer infectious.
If possible, dedicate same patient care staff to care of infected
patient(s) during their stay.
Infection Control and Barrier
Nursing
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Barrier nursing is a term sometimes used
to describe the use of barriers to carry out
the appropriate infection control protocol
for the particular infection
Nurses and other health care professionals
use appropriate infection control
precautions to prevent transmission of a
microorganism from:
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Infected patient to other patients and viceversa
Infected patient to visitors and vice-versa
Infected patient to general hospital
environment and vice-versa
Infected patient to health care worker and
vice-vesa
Infection Control and Barrier
Nursing-2
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The general hospital
environment and
"permanent"
equipment need to be
protected
Appropriate
sharp/needle
precautions should be
followed as should
proper disposal of
clinical waste and
laundry
Patient Isolation Precautions
Standard Precautions
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Hand hygiene after patient contact
Wear clean, non-sterile protective gloves
when touching blood, body fluids,
secretions, excretions and contaminated
items
Wear mask, eye protection or facial shield
and gown during procedures likely to
generate splashes or spray of blood, body
fluids, secretions or excretions. Use
depends on anticipated exposure and safe
injection practices as well
Patient Isolation Precautions
Standard Precautions-2
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Handle contaminated patient-care equipment and linen in a
manner that prevents the transfer of microorganisms to
people or equipment
Use care when handling sharps and follow proper disposal
of needles and other sharp instruments
Use a mouthpiece or other ventilation device as an
alternative to mouth-to-mouth resuscitation when practical
Place the patient in a private room when feasible if they
may contaminate the environment
Three new elements have been added to standard
precautions. These are:
Respiratory hygiene/cough etiquette
 Safe injection practices
 Use of masks for insertion of catheters or injection into spinal
or epidural areas
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Contact Precautions
Consists of standard precautions (see previous
frames) plus precautions for direct and indirect
contact
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Intended to prevent spread of microorganisms
from an infected patient through direct means
(touching the patient) and indirect means
(touching surfaces or objects that have been in
contact with the patient). These objects include
chairs, bedrails, telephones, IV pumps, light
switches and so on. Used in such illnesses as
impetigo, herpes simplex, and hepatitis A.
Placing the patient in a private room is preferred
or when not available, it is recommended that a
set of principles be followed such as cohorting
with someone with the same infection.
Contact Precautions-2
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Use gloves when entering the room. Change gloves after
contact with infective material. Remove gloves before
leaving the room. Wash hands or use appropriate gel after
glove removal. Do not touch infective material or surfaces
with hands. Clean, non-sterile gloves are usually adequate.
Use protective gown when entering the room if direct
contact with patient or potentially contaminated surfaces or
equipment near patient is anticipated or if the patient has
diarrhea or colostomy or wound drainage that is not
covered by a dressing. Remove gown and observe hand
hygiene prior to leaving room, and do not come in contact
with potentially contaminated environmental surfaces
Contact Precautions-3
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Limit the movement or transport of the patient
from the room. Be sure any infected or colonized
areas are contained or covered and PPE is
discarded. Perform hand hygiene.
Ensure that patient care items, bedside
equipment, and frequently touched surfaces
receive daily cleaning.
Dedicate use of non-critical patient care
equipment to a single patient, or cohort of
patients with the same pathogen. If not feasible,
adequate disinfection between patients is
necessary.
Note: some authorities recommend use of shoe
coverings.
During transport, be sure clean PPE is used
Contact Precautions-4
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Leak resistant bag for linens should be at
bedside.
Dedicated thermometer, B/P apparatus and
stethoscopes are preferred unless
unavoidable and then must be cleaned and
completely disinfected before using with
other patient.
Indirect contact transmission can occur
when a susceptible patient is in contact
with an intermediate inanimate object in
the patient’s environment.
Airborne Precautions
Consists of standard precautions plus specifics for
airborne precautions
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Used to prevent or reduce the transmission of
microorganisms that are airborne in small droplet
nucleii (5 m or smaller in size) or dust particles
containing the infectious agent.
These can remain suspended in the air or be
dispersed widely by air currents even through
ventilation systems.
They can be inhaled by or deposited on a host in
the same room or further away.
Includes such diseases as pulmonary
tuberculosis, rubeola (measles), and varicella.
Airborne Precautions-2
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Place the patient in an AIIR private room with
anteroom if possible, that has negative air
pressure, with 6-12 air changes/per hour.
Appropriate monitored, high-efficacy filtration of
air before it is discharged from the room.
Pressure should be monitored with visible
indicator
Use of respiratory protection (e.g., fit tested N95
respirator) or powered air-purifying respirator
(PAPR) when entering the room
Limit movement and transport of the patient. Use
a mask on the patient if they need to be moved
Keep patient room door closed.
Airborne Precautions-3
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If private room absolutely not available, consult
infectious disease consultants before cohorting
patient
Limit patient movement or transport only if
necessary
Use surgical or N95 mask on patient if transport
is needed (see frame on patient transport for
details)
Known susceptible health care workers should
not enter room of patients with varicella or
rubeola if other workers are available
If AIIR not available, transfer to a facility that has
one
Droplet Precautions
Consists of standard precautions plus specifics for
droplet precautions
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Used to reduce the risk of transmission of
microorganisms transmitted by large particle
droplets (larger than 5 m in size).
This type of transmission usually requires
close contact between the source person
and the recipient because droplets do not
remain suspended in the air. They usually
travel 3 feet or less within the air and thus
special air handling is not required, however
newer recommendations suggest a distance
of 6 feet be used for safety.
Droplet Precautions-2
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Droplet transmission involves contact of
the conjunctiva of the eyes or the mucous
membranes of the nose or mouth of a
person with the microorganism generated
from the infected source person during
coughing, sneezing or talking, or during
the performance of procedures such as
suctioning and bronchoscopy.
Includes such diseases as influenza,
rubella, parvovirus B19, and mumps.
Droplet Precautions-3
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Place the patient in a private room
If not available, cohort with patient with active infection
with same microorganism
Use of respiratory protection such as a mask when entering
the room recommended and definitely if within 3 feet of
patient
Limit movement and transport of the patient. Use a mask
on the patient if they need to be moved and follow
repiratory hygiene/cough etiquette
Keep patient at least 3 feet apart between infected patient
and visitors
Room door may remain open
Specific regulations are available for SARS and influenza,
http://www.cdc.gov/ncidod/sars/, and
http://www.cdc.gov/flu/aivian
Handwashing and Hand
Hygiene
One of the most
important ways to
protect against
transmission of
microbes and
disease is hand
hygiene
Handwashing and Hand
Hygiene-2
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Should be done:
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Before gloving,
After removing gloves
After touching blood, body fluids, tissues,
secretions, excretions or any contaminated
items. If not visibly soiled can use alcoholbased but if visibly soiled or contaminated with
proteinacious material use soap and wash
hands.
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Between patients
After procedures on some patients to prevent crosscontamination of different body sites
After contact with patients intact skin or inanimate
objects near the patient
Handwashing and Hand
Hygiene-3
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Wash with soap and water at least 15
seconds when hands are visibly soiled and
follow institutional procedures
Use friction
Can use alcohol-based rubs to
decontaminate hand, if soiled
Fingernails should be short, clean and free
from polish
Artificial nails should be avoided
Handwashing and Hand
Hygiene-4
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Rings should not be worn
Watches and bracelets should be removed
For alcohol-based rubs, apply to palm of one hand and rub
hand together covering all surfaces of hand and fingers
until hands are dry
Paper towels should be used to dry hands. Do not touch
faucet handles with hands after washing
Wash hands with soap and water before eating and after
using the restroom and if exposure to B. anthracis is
suspected since some antiseptic agents have poor activity
against spores.
Detailed information on hand washing may be found at:
CDC. (2002). Guidelines for hand hygiene in healthcare
settings. MMWR, 51 (RR-16), 1-44
Personal Protective Equipment
(PPE)
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May consist of:
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Gloves
Gowns, usually impermeable
Aprons, usually impermeable
Face shields
Eye wear, such as goggles to protect eyes
Masks, such as N-95, which should be
appropriately fitted
Boots or shoe coverings
Leggings
Head covering
Personal Protective Equipment
(PPE)-2
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The appropriate combination
depends on the nature of the
microorganism, certain
characteristics of the host (i.e. ability
to cooperate), and microbial route of
transmission
Only work if used appropriately and
correctly
Gowns
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Long sleeves
Need to be large
enough to
completely cover
clothing
Undisrupted front
Impermeable
(water repellent)
Gowns-2
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Back closure
Add apron if extensive contact with fluid or
splashing is anticipated
Inner layer of clothes under gown should be
scrub suit or clothes can be disposed of, if
contaminated in certain situations
When re-gowning avoid touching outside,
unfasten neck ties, loosen gown by grasping edge
near neck tie, grasp inside sleeve cuff and
remove sleeve over hand, grasp opposite cuff
and pull off, roll inside out in bundle and drop in
appropriate container
Gloves
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Wear gloves when anticipated contact with
patient’s blood, body fluids and tissue
Are not substitute for appropriate hygiene
Do not need to be sterile unless procedure
requires it
Be appropriate for hand size
Materials may be latex, vinyl or surgical
but thin
Must be long enough to reach above the
wrist (4-6 inches from wrist along arm)
and overlap cuff of gown
Gloves-2
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Change gloves
between procedures,
same patient after
contact with material,
or tissue that may
contain a high number
of microbes
Remove gloves
immediately after use
and before caring for
another patient
Gloves-3
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Decontaminate hands before and after
gloves are removed
In highly infectious situations, such as
care of patients with viral hemorrhagic
fever, may double glove
Use care in removing gloves if soiled, so
as not to contaminate hands or
environment
Single use gloves should not be washed or
reused
Glove selection is task-appropriate
Eye/Facial Protective Devices
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Usually goggles or face shields should be
used to protects eyes and face from
microorganism contamination, splattering
or spraying of patient’s body fluid, saliva,
or blood secretions
May have side panels or be complete face
shield
Should not impair vision
Eyewear that forms a seal around eyes
gives highest degrees of protection
Fit over mask or respirator
Eye Protective Devices-2
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To remove handle by
"clean" ear or head
Also piece to protect
against large droplets such
as in RSV infection is
needed
Eyeglasses such as
prescription eye glasses
are not a substitute for
proper shield
For further details see
CDC. Eye protection for
infection control. May
13,2008
http://www.cdc.gov/niosh/topics/eye/eye-infectious.html
Boots/Overshoes/Foot Coverings
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Used if floor is only
contaminated or wet
Protects wearer from
the microorganisms
Prevents transport of
microbes from health
care worker's shoes in
infectious patient's
rooms of non-infected
patients
Masks
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Should be
appropriately fitted
A N-95 mask such
as the 3M is
preferred to filter
out small airborne
particles
Discard after use
or change if
becomes moist
Masks-2
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Worn by healthcare providers and visitors
to protect against microbes transmitted by
airborne or droplet means
May also be worn by patient with airborne
or droplet transmissible diseases,
especially under certain circumstances
such as during direct care or transport
The appropriate mask and circumstance
depends on microorganism and setting.
Work "Clean" to "Dirty"
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Disinfect gloves if any possible
contact with secretion/excretion of
patient to reduce transmission into
environment
To leave room,
 Disinfect
gloves
 Remove gloves with right glove hand
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Take off right glove turning it inside
out with left glove
Work "Clean" to "Dirty"-2
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Dispose of gloves
Disinfect hands
Go into anteroom
Remove goggles avoiding contact with
front and your eyes
Disinfect goggles
Disinfect hands
Take off mask, avoiding touching front
Discard mask
Infected Patient Transport Within
Institution
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If patient has airborne or droplet transmitted
infection should only leave room, if essential
Patient should wear mask during transport
Transport personnel should wear appropriate PPE
Transport route should avoid populated areas
Receiving personnel should be aware of what PPE
and infection control procedures are needed and
when patient is coming
Protect stretchers or wheelchairs appropriately
Appropriate hand hygiene should be used
Infected Patient Transport Within
Institution-2
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Disinfect all transport equipment and
linens
Patient should be in clean gown
Patient should wear or use
appropriate barriers such as
impermeable dressings for wounds
Let patients know how they can
assist
Respiratory Hygiene/Cough
Etiquette/Patient Teaching
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Initiate at first point of contact with
even a potentially infected person
with respiratory infection.
Includes education which may be
visual and/or verbal at an
appropriate educational level with
cultural considerations of patients
and the people who accompany
themas well as health care staff.
These are now incorporated into
standard precautions.
Respiratory Hygiene/Cough
Etiquette/Patient Teaching-2
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Elements and Instruction should include:
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Informing personnel if they have any symptoms
of respiratory infection,
Having tissues provided to patients and visitors,
Covering mouth/nose with tissue
Throwing tissues away properly when coughing or
sneezing,
Using surgical masks on coughing person when
appropriate
Providing alcohol-based hand-rubbing dispensers
and supplies for handhygiene, and educating
patients and staff in their use,
Encouraging handhygiene after coughing or
sneezing.
Patient Teaching/Cough Etiquette-3
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Instruction should include cont.:
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Offering masks to persons who are coughing,
Separating coughing persons at least 3 feet
away from others in a waiting room or have
separate locality.
Instructing patients and providers not to touch
eyes, nose, or mouth.
Having health care personnel observe
droplet precautions in addition to standard
precautions.
Health care workers should use standard
precautions with all patients.
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents
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Special situations require the activation of each
institution’s preparedness plan which should include:
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Processes for triage and care for large numbers of affected
individuals,
Chain of command information
Personnel policies for staff,
Obtaining necessary and sufficient equipment and supplies,
including pharmaceuticals,
Handling of those with anxiety and panic,
Plan to control traffic,
Communication plan,
Plan to provide care without running water or usual power
sources,
Procedure for distribution of chemoprophylaxis or
medications, and
Others
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-2
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There will need to be a plan for rapid
receiving and triage as well as for
allocation and reallocation of sparse
resources.
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For example, it must be considered how
limited numbers of ventilators would be
distributed and used in the case of an outbreak
of botulism which respiratory failure would be
sudden and ongoing.
Further discussion is beyond the scope of this
module.
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-3
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Usually each health care institution will
designate a specific area or area that will:
Receive and identify patients,
 Triage them,
 Treat immediately or admit, or
 Transport or house patients with the specific
infection, in a designated wing or building, or
in some cases, a site separated from the
hospital, such as a nearby school or outside
tented area.
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Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-4
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This plan will usually clear all nonemergency patients and visitors who are
not exposed to the agent in question.
The infected patients should be
segregated from others.
Parts of the plan depend on what agent
was used and whether it is transmissible
naturally, or has been altered to be
transmissible, from person to person.
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-5
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Health care workers may receive
chemoprophylaxis or immunization
depending on the organism involved.
Patients may need to remove
contaminated clothing and store them in
labelled plastic bags for chain of evidence.
Patients may need to shower with soap
and water and shampoo hair depending on
the available facilities and need to do so.
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-6
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Medical equipment may need to be shared
among patients with the same infection.
In the event of a large-scale outbreak or
epidemic, optimal infection control, such
as private rooms for infected patients
probably will not be possible.
Each nurse should be familiar with the
preparedness plan at their own institutions
and in their community.
Planning must include how infection
control principles can be applied under
potential emergency conditions with
sparse supplies and lack of running water.
Further Reading:
OSHA. OSHA Best Practices for Hospital- based First
Receivers of victims, 2005
http://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf
Center for Health Policy, Columbia University School of Nursing
Adapting Standards of Care Under Extreme Conditions. American
Nurses Association, March, 2008.