TITLE:



TITLE: ISOLATION PRECAUTION GUIDELINES

PURPOSE:

To prevent the spread of communicable and other infectious diseases within the hospital. Special techniques must be followed when caring for patients with these diseases. The category of isolation that will be required will be based on Transmission-based Precautions.

To prevent contact between potentially pathogenic microorganisms and uninfected patients who have seriously impaired resistance to infection.

POLICY:

Transmission based isolation may be initiated by the physician or by the nurse, if the patient meets any of the criteria for initiation. (Refer to attachment B).

1. If initiated by the nurse, she/he will enter “Transmission based isolation precautions initiated per protocol” on the order sheet.

2. Transmission based isolation precautions may be discontinued by the physician.

The nurse is responsible for ensuring that isolation is initiated and maintained according to hospital policy. Healthcare workers (HCWs) are expected to be able to use appropriate precautions, verbalize understanding of the procedure and report concerns or problems to the Infection Control Coordinator (ICC) or designee. HCWs are also expected to report any exposures or breaks in proper precautions to the ICC or designee.

The ICC supervises and teaches isolation procedures and techniques. The ICC functions as the Infection Control Committee’s liaison, working with all departments, concerning isolation policies and Infection Control problems, updates isolation policies and reports communicable diseases to the Public Health department.

The Chairperson of the Infection Control Committee has the ultimate responsibility and authority for ensuring that isolation policies and procedures are followed.

PROCEDURE:

1. STANDARD PRECAUTIONS:

a. Standard precautions synthesizes the major features of Universal (Blood & Body Fluid) Precautions, designed to reduce the risk of transmission of bloodborne pathogens, and Body Substances Isolation protocol, designed to reduce the transmission of pathogens from moist body substances and applies them to all patients receiving care in the hospital, regardless of their diagnosis or presumed infection status. Standard precautions apply to (1) blood, (2) all body fluids, secretions, and excretions regardless of whether or not they contain visible blood, (3) non-intact skin, and (4) mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection.

b. USE STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS

i. Handwashing – Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.

ii. Use antimicrobial soap when hands are visibly contaminated. The alcohol-based hand rub (AHBR) can be used when hands are not visibly contaminated. (Exception! Exposure to Clostridium difficile requires hand washing with soap and water, decontamination with AHBR is not effective!)

iii. Gloves – Wear gloves (clean non-sterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items; put on clean gloves just before touching mucous membranes and non-intact skin. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

iv. Mask, Eye Protection, Face Shield – Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient–care activities that are likely to generate splashes or sprays or blood, body fluids, secretions, and excretions.

v. Gown – Wear a gown (a clean non-sterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients or environments.

vi. Patient-care Equipment – Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patient and environments. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed and single use items are properly discarded.

vii. Linen – Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposure, contamination or clothing, and avoids transfer of microorganisms to other patients and environments.

viii. Occupational Health and Blood-borne Pathogens – Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Never recap used needles or otherwise manipulate them using both hands, or any other technique that involves directing the point of a needle toward any part of the body, rather use either a one-handed “scoop’ technique or a mechanical devise designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand.

ix. Patient Placement – Place a patient who poses a risk to the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in a private room. If a private room is not available, consult with Infection Control Coordinator regarding patient placement or other alternatives.

2. TRANSMISSION Based Precautions

a. Transmission-based precautions are designed for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission in hospitals. There are three types of Transmission-based precautions: 1) Airborne Precautions, 2) Droplet Precautions, and 3) Contact Precautions. They may be combined together for diseases that have multiple routes of transmission. When used either singularly or in combination, they are to be used in addition to Standard Precautions.

i. Airborne Precautions - Airborne precautions are designed to reduce the risk of airborne transmission of infectious agents. Airborne transmission occurs by dissemination of either airborne droplet nuclei (small-particle residue ≤ 5 microns in size ) of evaporated droplets that may remain suspended in the air for long periods of time or dust particles containing the infectious agent. Microorganisms carried in this manner can be widely dispersed by air currents and may become inhaled by or deposited on a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors. Airborne precautions apply to patients known or suspected to be infected with epidemiologically important pathogens that can be transmitted by the airborne route.

1. In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small particle residue ≤ 5 microns ) of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance.

a. Patient Placement – Place the patient in room 101 or 102 that has:

i. Monitored negative air pressure in relation to the surrounding areas,

ii. A minimum of six air changes per hour, and

iii. Appropriate discharge of air outdoors.

b. Keep the room door closed and the patient in the room.

c. Enter room through anteroom only.

d. Notify Engineering of patient placement in Airborne Precaution isolation (negative pressure isolation).

e. Adequacy of negative pressure status of room to be checked daily by Engineering while patient remains in Airborne precaution isolation (See Attachment A).

2. Respiratory Protection – Wear N95 Respirator when entering the room of a patient with known or suspected infectious tuberculosis. Do not enter the room of patients known or suspected to have measles (rubeola) or varicella (chickenpox) if susceptible to these infections. (Masks are not required to be worn by HCWs entering the room of patients known or suspected to have measles or chicken pox if the HCW is not susceptible to these infections.)

3. Patient Transport – Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a surgical mask on the patient.

4. In addition to Standard Precautions, use Airborne Precautions for patient known or suspected to have serious illnesses transmitted by airborne droplet nuclei include:

a. Aerosolizable spore-containing powder or other substance that is capable of causing serious human disease, e.g. Anthrax/Bacillus anthracis

b. Avian influenza/Avian influenza A viruses (strains capable of causing serious disease in humans)

c. Varicella disease (chickenpox, shingles)/Varicella zoster and Herpes zoster viruses, disseminated disease in any patient. Localized disease in immunocompromised patient until disseminated infection ruled out

d. Measles (rubeola)/Measles virus

e. Monkeypox/Monkeypox virus

f. Novel or unknown pathogens

g. Severe acute respiratory syndrome (SARS)/SARS-associated coronavirus (SARS-CoV)

h. Smallpox (variola)/ Varioloa virus

i. Tuberculosis

j. Any other disease for which the CDC or CDPH recommends airborne infection isolation

ii. Droplet Precautions – Droplet precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of the conjunctivae, or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (> 5 microns on size) containing microorganisms generated from a person who has a clinical disease or is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking, and during the performance of certain procedures such as suctioning and bronchoscopy. Transmission via large-particle droplets requires close contact between source and recipient persons since droplets do not remain suspended in the air and generally travel only short distances, usually 3 feet or less, through the air. Droplet Precautions apply to any patient known or suspected to be infected with epidemiologically important pathogens that can be transmitted by infectious droplets.

1. In addition to Standard Precautions, use Droplet Precautions for a patient known or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets> 5 microns) that can be generated by the patient during coughing, sneezing, talking or the performance of procedures.

2. Patient Placement – Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism, but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, maintain spatial separation of at least 3 feet between the infected patient and other patients and visitors.

3. Mask – In addition to standard precautions, wear a standard surgical mask when working within 3 feet of the patient.

4. Patient Transport – Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimized patient dispersal of droplets by masking the patient.

5. In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets include:

a. Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglotitis, and sepsis

b. Invasive Neiserria meningiditis disease including meningitis, pneumonia, and sepsis

c. Invasive multidrug resistant Streptococcus pneumonia disease, including meningitis, pneumonia, sinusitis and otitis media

d. Other serious bacterial respiratory infections spread by droplet including:

i. Diphtheria (pharyngeal)

ii. Mycoplasma pneumonia

iii. Pertussis

iv. Pneumonic Plague

v. Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children

vi. Serious viral infections spread by droplet transmission, including:

1. Adenovirus

2. Influenza

3. Mumps

4. Parvovirus B19

5. Rubella

iii. Contact Precautions

a. Contact Precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn a patient, give a patient a bath or perform other patient-care activities that require physical contact. Direct-contact transmission can also occur between two patients (e.g., by hand contact), with one serving as the source of infectious microorganisms and the other as a susceptible host. Indirect-contact transmission involves contact of a susceptible host with contaminated intermediate object, usually inanimate, in the patient’s environment. Contact Precautions apply to specified patients known or suspected to be infected or colonized (presence of microorganism in or on patient but without clinical signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct-or indirect-contact.

b. In addition to Standard Precautions, use Contact Precautions, or the equivalent, for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient care activities that require touching the patient’s dry skin) or indirect contact (touching) with environmental surfaces or patient-care items in the patient’s environment.

1. Patient Placement

Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism, but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, consider the epidemiology of the microorganism and the patient population when determining patient placement; consultation with infection control professionals is advised before patient placement.

2. Gloves and Handwashing

In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean nonsterile gloves are adequate) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). Remove gloves before leaving the patient’s room and discard in the regular trash and wash hands immediately with an antimicrobial agent. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room to avoid transfer of microorganisms to other patients or environments.

3. Gown

In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean nonsterile gown is adequate when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient’s room, or if the patient is incontinent, or has diarrhea, an ileostomy, a colostomy, or wound drainage not contaminated by a dressing. Remove the gown before leaving the patient’s environment. After gown removal, ensure that clothing does not contact potentially contaminated environment. The gown, if properly hung just inside the patient’s room, may be reused by the same personnel until obviously soiled or contaminated. It should be disposed of in the regular trash or linen. Non disposable gowns are always disposed of in regular linen hampers, even if contaminated with blood or body fluids. Disposable gowns should be placed in regular trash unless saturated with blood or body fluids. If disposable gowns are saturated with blood or body fluids, they should be disposed of in biohazardous waste.

4. Patient Transport

Limit the movement and transport of the patient from the room to essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.

5. Environmental Control

Ensure that patient-care items, bedside equipment, and frequently touched surfaces receive daily cleaning. Linens and garbage does not need special isolation precautions, other than what is used for all patients to ensure no cross contamination and proper disposal and biohazardous waste occurs.

6. Patient-Care Equipment

When possible, dedicate the use of non-critical patient-care equipment and items such as a stethoscope, sphygmomanometer, bedside commode, or electronic rectal thermometer to a single (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient.

c. In addition to Standard Precautions, use Contact Precautions for patients know or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment including:

• Gastronintestinal, respiratory, skin or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance. (MRSA) (VRE)

• Enteric infections with a low infectious dose or prolonged environmental survival including:

➢ Clostridium difficile

➢ For diapered or incontinent patients:

▪ Enterohemorrhagic Escherichia coli 0157:H7

▪ Shigella

▪ Hepatitis A

▪ Rotavirus

• Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children.

• Skin infections that are highly contagious or that may occur on dry skin, including:

➢ Diphtheria (cutaneous)

➢ Herpes simplex virus (neonatal or mucocutaneous)

➢ Impetigo

➢ Major (non-contained) absceses, cellulitis, or decubiti

➢ Pediculosis

➢ Scabies

➢ Staphylococcal furunculosis in infants and young children

➢ Staphylococcal scalded skin syndrome

➢ Zoster (disseminated or in the immunocompromised host)

• Viral/hemorrhagic conjunctivitis

• Viral hemorrhagic fevers (Lassa fever or Marberg virus)

References: Federal Register Mon. Nov 7, 1994, Part V Department of Health and Human Services. CDC Draft Guidelines Isolation Precautions in Hospitals

Attachments:

• Negative Pressure Isolation Logsheet,

• Synopsis of Precautions and Patients Requiring the Precautions,

• Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent Transmission of Epidemiologically Important Pathogens Pending Confirmation of Diagnosis

• Type and Duration of Precautions Needed for Selected Infections and Conditions.

• Communicable and Infectious Disease Precautions in the Home Health Setting.

New: 11/87 Revised: 03/96, 09/08

Approval Signatures:

________________________________ ______________________

Infection Control Coordinator Date

_______________________________________ ___________

Chairperson, Infection Control Advisory Committee Date

_____________________________________________ ___________

Chairperson, Integrated Quality Management Committee Date

________________________________ ______________________

Medical Chief of Staff Date

________________________________ ______________________

Chief Executive Officer Date

________________________________ ______________________

President, Board of Directors Date

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