PROCEDURE/PROTOCOL



PURPOSE

This Procedure/Protocol provides additional precautions, beyond Standard Precautions, for patients documented or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens.

PERSONNEL

All patient care providers and support services in all departments.

COMPETENCIES

N/A

SUPPORTIVE DATA

Guidelines for Isolation Precautions in Hospitals, 1996, CDC

PROCEDURE/PROTOCOL

1. Any patient suspected of, or having an infection or condition listed in Table A of this Policy and Procedure and not covered under Standard Precautions will be placed in one of the four types of Transmission Based Precautions.

• Airborne

• Droplet

• Contact

• Special Contact

2. The types may be combined for diseases that have multiple routes of transmission and are to be used in addition to Standard Precautions.

3. Certain clinical syndromes and conditions carrying a sufficiently high risk warrant empiric use of additional precautions while a more definite diagnosis is pursued. See Table B for such conditions and the recommended precautions beyond Standard Precautions to be implemented.

4. The nurse is responsible for initiating the appropriate precautions with or without the physician order, notifying the physician and the Infection Control Coordinator. The nurse is then responsible for maintaining precautions.

INITIATION OF ISOLATION

1. Notify the physician and document this in the medical record.

2. Notify the Infection Control Coordinator or Clinical Manager.

3. Place appropriate sign on the outside of the patient’s room, found in the PPE Wall Cabinet/Cart.

• Airborne

• Contact

• Special Contact

• Droplet

4. Place Isolation Tape on the outside of the patient’s chart, write on the tape the category of precautions being initiated. (i.e., Contact, Special Contact, Airborne, Droplet).

5. Enter the Isolation Precaution category into computer under the NSR function and enter the one time charge.

6. The Infection Control Coordinator, staff RN or Unit Secretary will enter the type of Isolation Precautions the patient is on in Meditech. Upon a patient’s readmission, a clinic alert will reappear on the patient’s face sheet with the type of isolation the patient has a history of and isolation is then initiated.

7. Document the physician notified and the precautions taken in a Focus Note within the Daily Patient Care Record – Initiation of Isolation based on:

1. Admitting diagnosis

2. Positive culture reports

3. Physical assessment of patient, i.e., amount and/or color of drainage or rash noted.

4. Positive chest x-rays

5. Physician order

6. Past medical history of resistant organisms

PREPARATION OF PATIENTS/VISITORS

1. Educational Preparation

1. It is the nurse and physicians responsibility to inform the patient of the need for isolation.

2. The nurse will need to instruct the patient’s family and visitors on specific requirements of isolation to be followed. Visitors should be kept to a minimum, if possible. Instructions include proper use of gowns, gloves, masks, effective and correct hand hygiene upon entering and leaving room.

3. Diversional activities such as paperbacks, books, magazines and newspapers, if they come in contact with infective material they should be discarded. They should always be discarded or taken home if the patient is in Contact Precautions or Special Contact Precautions.

1. Airborne – TB masks, perform hand hygiene when leaving room.

2. Contact – Gloves, gowns and perform hand hygiene when leaving room.

3. Special Contact – Gloves, gowns and perform hand hygiene when leaving room.

4. Droplet – Mask, perform hand hygiene when leaving room.

Document these instructions on the Patient/Family Education Form.

4. Clothes and personal effects of the patient and any unnecessary items should be sent home. Instructions will vary according to specific disease entities. The family should be instructed as to proper laundering and/or cleaning of patient’s soiled belongings. Place in a clear plastic bag to take home.

5. The door of the patient room must be closed for patients in Airborne Precautions. This prevents the transmission of airborne pathogens into the hall.

6. Consents, Documents, Mail: Have patient perform hand hygiene before handling consents. Protect any document from becoming soiled.

7. Patient charts are not to be brought into the patient’s room.

8. All visitors should adhere to hospital policy regarding age and number of visitors and visiting hours.

9. Visitors should see the nurse before entering the isolation room for instructions concerning:

1. Proper hand hygiene, the use of gowns, masks, and gloves, and care of their personal belongings.

2. The importance of minimal direct contact with patient and strict adherence to isolation procedure.

3. Visitors should be instructed that only disposable or easily cleaned items will be allowed in the isolation room.

PREPARATION OF PERSONNEL

Anyone entering an isolation room is expected to follow isolation precautions as posted on the door.

1. Hand Hygiene:

1. Hands hygiene must be performed before and after contact with patient, after handling or touching contaminated patient articles or equipment. It is the single most important means of preventing the spread of infection.

2. Wash hands for 10 to 15 seconds using friction. The principle of good hand washing technique is primarily that of a mechanical removal of dirt and microorganism by combining sudsing, using friction and rinsing with running water.

3. Wash hands and forearms using friction and rotating motion, giving special attention to spaces between the fingers and under the fingernails.

4. Rinse and allow warm water to run from fingertips to forearms, keeping hands elevated above the elbows.

5. Dry hands with paper towel starting at fingertips working down to forearms.

6. The same paper towel should be used to turn off faucets. Consider all faucets contaminated.

7. Alcohol base hand sanitizers can be used when hands are not visibly soiled to reduce bacteria on the skin. Procedure for use of hand sanitizer:

1.7.1 Pump a thumbnail size amount on to the hands.

1.7.2 Rub briskly all surfaces of the hands and fingers.

1.7.3 Do not rinse or remove with a towel.

2. Gowning:

1. Remove coats and jackets.

2. Wash hands.

3. Put on gown to cover clothes.

4. Remove gown so the inside is out, roll gown and place in clear bag waste container. Discard in red bag only if contaminated with free-flowing blood or body fluids.

5. Never hang gown up and reuse.

6. Never leave room with gown on.

3. Masking:

1. Before entering isolation room obtain clean mask.

2. Apply mask over mouth and nose. Never touch mask after it is applied. For extended use they may be changed every twenty to thirty minutes. Moisture from breathing renders the mask ineffective after this time period.

3. Perform hand hygiene prior to removing mask. Handle only the bands of the mask. Discard mask in trash receptacle provided in patient care area.

4. When entering an Airborne Precaution room with a rule out TB patient, healthcare workers must wear a (N95) approved mask. Respiratory protection must be worn before entering the room only by those trained (see TB Exposure Control Plan). Remove mask after leaving the room and handle only bands on the mask and discard in a clear plastic bag –perform hand hygiene.

5. Healthcare workers entering the room of a patient with measles (Rubeola) or chickenpox (Varicella) must wear a regular high efficiency mask.

6. Healthcare workers who are non-immune to chickenpox (Varicella) can not take care of a patient with chickenpox.

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4. Gloving

1. Put on gloves, making sure that cuffs of gown are secured under glove, if gown is worn.

2. Change gloves as often as necessary.

3. Change gloves between patients.

4. Perform hand hygiene after glove removal.

PREPARATION OF EQUIPMENT

1. Place appropriate isolation sign on the door of room.

2. Line the trash receptacle with clear plastic bag, placing close to door.

3. Use single use patient digital thermometer for all patients in Isolation Precautions. Rinse with water and wipe clean with an alcohol sponge after use and store in plastic sleeve to protect between uses.

4. Bedpan and urinal may be placed in the bathroom.

5. Disposable equipment should be discarded in the clear plastic garbage bag provided in the patient room. It is preferred that disposable equipment is used whenever possible.

6. Disposable stethoscope shall be placed in Contact Precautions and Special Contact Precautions rooms and discarded upon patient discharge.

7. Reusable:

1. Equipment (i.e., inhalation therapy) should be left in patient’s room for the duration of isolation whenever possible.

2. All reusable articles should be cleaned of all gross contamination before being removed from the room using the hospital approved disinfectant. Reusable equipment such as IVAC’s, feeding pumps and commodes (empty first rinse and clean with hospital approved disinfectant) will be wiped down before being placed in the utility room.

3. Perform hand hygiene after removing gloves and handling any disposable or reusable contaminated equipment.

4. Blood Glucose monitoring devices used for patients in Contact Precautions or Special Contact Precautions must be covered by the plastic bag provided for these machines. Remove bag before leaving room and perform hand hygiene.

8. Portable Equipment for all of the following caregivers shall follow the instructions on the door and wear proper PPE:

1. ECG and EEG Equipment

1. Place electrodes on patient in the usual manner and perform hand hygiene before touching machine.

2. Perform the procedure in the regular manner.

3. After completing procedure, EEG electrodes are to be washed with soap and water in the patient’s room. Wipe EEG and ECG cable leads with hospital approved disinfectant. Place all clean equipment in cart drawer before leaving the room. Never leave patient room with gown on. Patients in Contact Precautions or Special Contact Precautions, unplug the machine, clean surface with hospital approved disinfectant at doorway before leaving.

2. X-ray Equipment

1. Before entering room, place x-ray cassette in clean pillowcase or plastic bag.

2. Enter room and take x-ray in usual manner. Do not remove pillowcase or bag until x-ray is taken.

3. After taking the x-ray, remove the pillowcase and place in a laundry bag or if a plastic bag was used discard in the garbage receptacle provided in the room

4. Perform hand hygiene before leaving room.

5. Never leave patient room with gown on. Patients in Contact Precautions or Special Contact Precautions, unplug machine, clean surface with hospital approved disinfectant at doorway before leaving room.

3. HEPA Portable Filtration Machines:

1. Call Maintenance to bring machine to the room for a patient airborne isolation, only if a negative pressure room is unavailable. The negative pressure rooms are LDRP#2, ICU# 3, OPD# 5, Medical Imaging room #4,#5, ER #11and Dcontam. Room.

2. Follow the policy/protocol for HEPA portable machine located in the Red Infection Control Manual.

4. Other portable equipment (Hemodialysis, GI Procedure, Bronchs, Crash Carts, Telemetry Transmitters)

1. The caregiver is to follow instructions on the door, as well as standard precautions concerning hand hygiene and attire.

2. Limit equipment and supplies being brought into isolation rooms.

3. Patients in Contact Precautions or Special Contact Precautions, unplug machine. Clean surface with hospital approved disinfectant spray or wipes at the doorway before leaving patient room.

4. Dedicate the use of non-critical patient care equipment to the single patient in Contact Precautions or Special Contact Isolation.

• BP Cuffs

• Stethoscopes

• Thermometers

5. If sharing equipment or items is unavoidable, then clean and disinfect with hospital approved disinfectant spray or wipes before use on another patient.

TRANSMISSION BASED PRECAUTIONS

1. Airborne Precautions (in addition to Standard Precautions)

To reduce the risk of airborne transmissions of infectious agents transmitted by droplet nuclei (small particle residue that remain suspended in the air) such as Tuberculosis, Varicella (Chicken Pox).

1. Patient Placement

• A private room.

• Monitored negative air pressure in relation to the surrounding areas.

• 6 to12 air change per hour.

• Appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital.

• When a private room is not available:

• Cohorting of patients with the same type of infectious process may occur. Contact the Infection Control Coordinator for approval.

2. Respiratory Protection

• Wear TB Mask (N95 Respirator) when entering the room of a patient with known or suspected Infectious Pulmonary Tuberculosis. Only healthcare workers who have been properly FIT Tested for the TB Mask may enter. Exit room and remove mask.

• Non-immune healthcare workers should not enter the room of patients known or suspected to have measles (Rubeola) or chickenpox (Varicella).

3. Patient Transportation

• Limit the transport and movement of the patient from the room for essential purposes only.

• When transport is necessary, minimize patient dispersal of droplet nuclei by placing a mask on the patient.

4. Perform hand hygiene before leaving patient’s room.

2. Droplet Precautions (In addition to Standard Precautions)

To reduce the risk of microorganisms transmitted by droplets (large particle > 5 um in size) generated by the patient during coughing, sneezing, talking or the performance of procedures such as suctioning and sputum induction.

1. Patient Placement

• A Private Room

• When a private room is not available:

• Cohorting of patient’s with the same infectious process may occur. Contact the Infection Control Coordinator for approval.

• When a private room is not available and cohorting is not achievable, maintain partial separation of at least 3 feet between the infected patient and other patients and visitors. Special air handling and ventilation are not necessary and the door may remain open.

2. Mask

• Wear a mask upon entering this room.

3. Patient Transport

• Limit the transport and movement of the patient from the room for essential purposes only.

• When transport is necessary, minimize patient dispersal of droplets by masking the patient.

4. Perform hand hygiene before leaving the patient’s room.

3. Contact Precautions (In addition to Standard Precautions)

To reduce the risk of transmission by direct contact with the patient, or by indirect contact with environmental colonized with epidemiological important microorganisms such as resistant organisms (MRSA, ESBL or VRE).

1. Patient Placement

• A Private Room

• B. When a private room is unavailable:

• Cohorting of patients with the same microorganism may occur. Contact the Infection Control Coordinator for approval.

2. Gloves and Hand Hygiene

• Wear gloves upon entering the room.

• Remove and discard gloves in waste container before leaving the patient’s room.

• Hand hygiene must be performed after removing gloves and before leaving the patient’s room.

3. Gown

• Wear a gown if when having direct patient contact or contact with patient’s environment and equipment.

• Remove soiled gown before leaving patient’s room and perform hand hygiene

4. Patient Transportation

• Allowing the patient with MRSA, VRE or other resistant organisms in a wound which is covered and drainage contained to leave the room (i.e., go to therapy).

• Allowing the patient with MRSA, VRE or other resistant organisms in the urine, who has a foley to go to therapy. In the event the foley needs to be emptied, the patient must be returned to their room.

• Prohibiting the incontinent patient with MRSA, VRE or other resistant organisms in the urine or stool from going to the therapy departments (PT, OT, Speech).

• Permitting the patient with MRSA, VRE or other resistant organisms in the urine who is continent to go to therapy, but must be returned to their room for toileting.

• Prohibiting the patient with MRSA, VRE or other resistant organisms whose wound cannot be contained under a dressing from going to therapy.

3.5 Behavioral Health Unit – Due to the nature of the patient population, a modified Contact Precautions will be instituted.

♦ A patient that is identified with any multi-drug resistant organism (MDRO) will have the Contact Precaution sign placed on the patient’s room door and an isolation label will be placed on the front of the chart.

♦ The staff will wear gloves when having patient contact and perform hand hygiene per

policy.

♦The patient must be instructed by staff on the importance of hand hygiene.

♦The patient must put on clean clothing daily.

♦If a patient has as draining wound/lesion and cultured with a MDRO from this site, the patient must be transferred off the unit.

♦Call/page the Infection Control Coordinator or Infection Control Chairman with questions.

4. Special Contact Precautions (In addition to Standard Precautions)

To reduce the risk of transmission by direct contact with patient or by indirect contact with environmental colonized with Clostridium difficile.

Follow #3 Contact Precautions policy and procedure as stated except for when performing hand hygiene and cleaning common use items.

4.1 Hand Hygiene - When hand hygiene is performed, only antimicrobial soap and water can be use. Alcohol rinse/foam can not be used.

4.2 Use bleach wipes on all common use equipment.

3. Behavioral Health Unit- Follow #3.5 specific for the Behavioral Health Unit.

4. If a patient is incontinent or unable to perform good hygiene, the patient must be transferred off the unit.

5. Call/page the Infection Control Coordinator or Infection Control Chairman with questions.

5. General Patient Transportation Guidelines

1. The area to which the patient is to be taken should be notified that the patient is in isolation and the type of precautions being used in addition to standard precautions.

1. Verbal communication,

2. Marking the requisition with the type of isolation on the line provided.

3. All equipment used for patients in isolation are to be cleaned with hospital approved disinfectant spray or wipes after use.

2. Limit the transport and movement of the patient from the room for essential purposes only.

3. When transportation is necessary, minimize patient dispersal of microorganisms by:

• All carts/wheelchairs must be cleaned prior to patient use. Utilizing the hospital approved disinfectant spray or wipes after use.

• Instructing the patient to wash their hands before leaving the room. Assist patient in this task if necessary.

• A clean gown for the patient and clean cover sheet on the cart or wheelchair shall be provided.

• Making sure the drainage of any wound is contained with an adequate dressing.

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ADMINISTRATION OF MEDICATIONS

1. Perform hand hygiene.

2. Wear proper attire as stated on isolation signs

3. Give medication in usual manner. Leave medication cart and medication book outside patient’s room.

4. Dispose of medicine cups in trash receptacle in patient’s room.

5. Dispose of syringes and needles in syringe and needle box provided in patient’s room.

6. Perform hand hygiene.

DIETARY

1. In adherence with Standard Precautions all patients will receive meals on standard nutritional service dishware.

1. Perform hand hygiene.

2. Wear proper attire as indicated on door sign.

3. Serve patient their tray.

4. When patient is done, remove tray in usual manner.

5. Wear gloves when removing patients tray in Contact Precautions and Special Contact Precautions. Remove gloves and perform hand hygiene before leaving patient’s room

DISPOSE OF SECRETIONS, EXCRETIONS AND DRESSINGS

1. The diseases and the mode of transmission of the organism in question will determine the preventive measures to be taken when disposing of secretions, excretions and soiled dressings:

Airborne: Droplet Nuclei

Droplet: Droplet

Contact: Secretions, excretions, respiratory secretions containing blood and body fluids

Special Contact : Stool

Standard: Blood, all body secretions and excretions, except sweat, regardless of whether or not they contain visible blood.

Wear gloves and perform hand hygiene when coming in contact with any secretions, excretions, or contaminated dressings or trash. Teach patient to perform hand hygiene also.

2. Secretions – Oral and Respiratory

1. Instruct patient to cough into tissue; discard in trash receptacle provided. Make sure this trash receptacle, which is convenient to the patient, is lined with a clear plastic bag.

2. When suctioning a patient, use gloves, and disposable suction set. Use mask with eye protection or goggles with a mask and a gown if splattering is likely to occur. Add isolizer to suction canister in the patient’s room, secure the cap and then place the container in a clear plastic bag or in a red bag and place in the utility room in the specially marked receptacle “PIMW” (Potentially Infectious Medical Waste).

3. Secretions from draining wounds, lesion, or orifices.

1. Place soiled dressings in a clear plastic bag, and discard in the trash receptacle in the soiled utility room. If it is considered PIMW dispose of in the trash receptacle in the soiled utility room marked PIMW (See – Waste Management Policy and Procedure).

2. Limit the number of dressings you bring into the patients room.

4. Excretions – Urine and Feces

1. Use only a disposable bedpan and urinal. (Label with patient name when sharing a bathroom.)

2. All excreta should be flushed down the toilet in the patient’s room.

3. Pediatric patients should use only disposable diapers. Discard in the trash receptacle, lined with a plastic bag, located in the patient’s room. When leaving the patients room, tie the plastic bag securely and discard in the appropriate receptacle located in the soiled utility room.

LINEN

Isolation linen will be handled the same as regular linen. Use the plastic linen bags provided for all patients. Single bagging is adequate unless strike through of moist, wet linen is anticipated. Then double bagging is required. All linen should be placed in the soiled linen receptacle or down the linen chute after securely tying the bag. Do not throw loose soiled linen down the linen chute or on the floor, chairs or windowsills.

WASTE MANAGEMENT

The removal of and disposable of waste from the inside of an isolation room is handled the same as any other hospital waste, unless it is considered PIMW. (See Waste Management Policy and Procedure.)

CULTURING & COLLECTING LABORATORY SPECIMENS FROM PATIENTS IN ISOLATION

1. Special transport media may be necessary for obtaining anaerobic cultures. Anaerobic specimen collector may be obtained from microbiology laboratory.

2. Bring only necessary equipment for collecting specimens into patient’s room, two culturettes. Laboratory technician’s tray should not be brought into the room.

3. All specimens are presumed infectious.

4. Labeling specimen as infectious is not required, as all specimens are handled the same. Following Standard/Universal Precautions.

5. All specimens are to be taken to the laboratory immediately after collection. Stool specimens for ova and parasites should never be refrigerated.

6. Plastic transport bags with the Biohazard symbol shall be utilized in the patient’s room and the requisitions shall be placed on the outside of the bag.

CARE OF PATIENT AFTER DEATH

1. Put on gown, mask and gloves. As indicated according to the category of isolation and following Standard/Universal Precautions.

2. Drape stretcher with sheet.

3. Prepare body.

4. Confine any draining areas with dressings.

5. Mark the I.D. cards with the appropriate isolation precautions.

6. Place body in zipped body bag.

7. Place patient on stretcher and cover with another sheet.

8. Remove gloves and perform hand hygiene.

9. Remove isolation attire and change into clean isolation attire.

10. Transport patient to the morgue. Place body in the morgue.

11. Remove personal protective equipment and discard in waste receptacle in the morgue.

12. Perform hand hygiene.

CLEANING THE ISOLATION ROOM

1. Daily Cleaning – Isolation rooms should be cleaned last.

1. Cleaning is to be done by the designated department/personnel (further and more specific instructions are detailed in the Environmental Services manual).

2. Personnel are to wear attire indicated on the door sign.

3. The nurse should assist in instructing personnel with any questions concerning attire, hand hygiene, etc.

2. Cleaning at the time of discharge or transfer.

1. The personnel responsible for cleaning of the isolation room at time of discharge or transfer shall follow the specific instructions detailed in the Environmental Services Manual.

2. Nursing is responsible for carrying out the following procedures before final cleaning of the isolation room:

1. Leave isolation sign on the door of patient room until cleaning is completed.

2. Empty secretions in all receptacles (commode and suction canisters).

3. Personnel cleaning the room will remove any gross contamination from reusable equipment and wipe down with hospital-grade disinfectant spray or wipes before removal from the patient’s room to the soiled utility room where it will be picked up by CPD.

4. Discard all disposable patient care equipment in the room and tie the garbage bag securely and dispose of in the appropriate containers located in the soiled utility room.

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PERSONAL PROTECTION CABINETS/CARTS

Are located throughout all patient care areas and the equipment is to be used by any employee who may:

• Come in contact with any patient’s blood/body fluids.

• Come in contact with patients in one of the four categories of Isolation, Airborne, Droplet, Contact or Special Contact.

PPE CABINET/CART CONTENTS

|Gloves, Exam (medium) |Masks with face shields |

| | |

|Isolation Gowns |Goggles |

| | |

|Masks (yellow ) |Bleach Wipes |

| | |

|Four Color Coded Isolation Cards |TB Masks N95 (5W, ICU, ER, MI, OB, OPD) |

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|Red Bags | |

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