PDF Emergency Department Isolation Precautions

Carolinas HealthCare System Department of Infection Prevention

Emergency Department Isolation Precautions

I. SCOPE

This policy applies to all Carolinas HealthCare System Emergency Department (ED) locations (including freestanding EDs) except for Behavioral Health Emergency Departments.

II. PURPOSE

The ED, in cooperation with the Infection Prevention Committee, will implement appropriate infection prevention measures to reduce the risk for infection in patients, visitors, and healthcare workers. All teammates are expected to follow Infection Prevention policies pertinent to their job description as outlined in the Infection Prevention Manual, CHS Safety Manual and Lippincott for Nursing including, but not limited to:

? Hand Hygiene

? General Infection Prevention Practices Policy

? Standard Precautions

? TB Prevention & Control Plan

? Isolation Precautions (see Appendix A ? Isolation Precautions Quick Reference, refer to policy for additional details)

? Bloodborne Pathogens/Exposure Control Plan

III. POLICY

A. Respiratory Hygiene/Cough Etiquette a. Patients that present with upper respiratory symptoms of infection (e.g. cough, flu-like illness, increased production of respiratory secretions) should be instructed to: i. Wear a surgical mask if tolerated ii. Cover the nose and mouth when coughing/sneezing iii. Use tissues to contain respiratory secretions and dispose of them in the nearest receptacle after use iv. Perform hand hygiene after having contact with respiratory secretions or contaminated objects

B. Isolation Precautions for Specific Conditions and Organisms a. Every attempt should be made to identify patients that require isolation on arrival to the Emergency Department (at the start of the initial patient encounter). b. Isolation precautions may be initiated or discontinued (unless otherwise specified) by any physician, advanced care practitioner (ACP), Infection Preventionist, or registered nurse. c. The following table should be used to determine the type of precautions necessary for specific conditions and organisms. Contact Infection Prevention at your facility for questions.

Written: 3/2017

Emergency Department

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Condition/Organism

Isolation Type

Additional Comments

Chickenpox (acute varicella)

Airborne N95/PAPR Susceptible persons should not enter room if other immune caregivers are available.

PLUS Contact

Isolation required until all lesions are dry and crusted.

C. difficile (suspected or confirmed)

Contact Enteric

CRE - Carbapenem Resistant Enterobacteriaceae Contact

Initiate precautions: ? When C. diff testing is ordered ? If patient is already on treatment for C. diff (e.g. flagyl, PO Vancomycin, fidaxomicin) ? Based on clinical symptoms (see Appendix B - Acute Diarrhea)

Includes patients with a history at any time or those with an active infection.

Diarrhea (acute) (see Appendix B - Acute Diarrhea) Diarrhea ? defined as passage of > 3 unformed (loose/liquid/watery) stools in 24 or fewer consecutive hours Does not include infants < 1 year of age

Fifth Disease (Parvovirus B19, Erythema infectiosum)

Droplet

Avoid assignment of pregnant HCW to patient with known parvovirus or suspected parvovirus (i.e. immunosuppressed or sickle cell patient presenting with aplastic anemia).

Gastroenteritis (See C. difficile section above)

Herpes Zoster (varicella-zoster, shingles)

Susceptible persons should not enter room if other immune caregivers are available.

Localized in patient with intact immune system with lesions: - that can be covered - that cannot be covered

Standard Contact

Localized in immunocompromised patient if Contact disseminated is ruled out

Maintain precautions until all lesions are crusted. Maintain precautions until all lesions are crusted.

Disseminated* disease in any patient or Primary VZV-Chickenpox

Airborne N95/PAPR Maintain precautions until all lesions are crusted.

PLUS Contact

*Disseminated ? defined as appearance of lesions outside the primary or adjacent

dermatomes (e.g. more than 2 dermatomes or respiratory/CNS specimens)

Lice - Head (pediculosis), Body, Pubic

Contact

Isolation required for 24 hours after effective therapy started.

Written: 7/2017

Emergency Department

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Condition/Organism

Isolation Type

Additional Comments

Measles

Susceptible persons should not enter room if other immune caregivers are available.

Rubeola, all presentations

Airborne N-95/PAPR Isolation required until 4 days after onset of rash in otherwise healthy individuals. Maintain precautions for duration of illness in immunocompromised patients.

Rubella (German measles)

Droplet

Isolation required until 7 days after onset of rash.

Meningitis (suspected bacterial meningitis)

Droplet

Isolation required for 24 hours after effective therapy started.

Middle East Respiratory Syndrome (MERS)

Airborne N95/PAPR Page Infection Prevention at 704-337-0018 for details. See MERS Toolkit on PLUS Contact PLUS PeopleConnect for details. eye protection

MRSA, infection or colonization (all sites) Methicillin Resistant Staphylococcus aureus

Standard

Standard precautions included for patients physically in the ED but on inpatient hold.

Multi-drug Resistant Organisms

Standard

Does NOT include CRE for this policy: Carbapenem-Resistant Enterobacteriaceae (see CRE)

Examples include but not limited to: ESBL: Extended-Spectrum Beta Lactamase producing organisms VISA: Vancomycin-Intermediate Staphylococcus aureus VRSA: Vancomycin-Resistant Staphylococcus aureus

Mumps

Droplet

Isolation required for 5 days after onset of swelling, consult physician.

Norovirus (suspected or confirmed)

Contact Enteric

Add droplet precautions for Norovirus when active vomiting or cleaning vomitus.

Pertussis (whooping cough, Bordetella pertussis) Droplet

Isolation required until 5 days after patient is placed on effective therapy.

Respiratory Viral Illnesses (febrile) e.g. suspected or confirmed Influenza

Droplet

If Influenza suspected, wear a fit tested N-95/respiratory or PAPR for aerosolizing procedures such as bronchoscopy or open suctioning.

SARS (Severe Acute Respiratory Syndrome)

Airborne N-95/PAPR Isolation required for duration of illness. Physician order required to discontinue

PLUS Contact

precautions.

Written: 7/2017

Emergency Department

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Condition/Organism

Scabies

Tuberculosis/TB (M. tuberculosis) suspected or confirmed

Isolation Type

Additional Comments

Contact

For typical/non-crusted scabies, isolation required for 24 hours after effective therapy started. For Norwegian/crusted scabies, keep patient on Contact Precautions until negative skin scraping or cleared by Infection Prevention/ID physician.

Airborne N-95/PAPR Patients suspected of having TB can wear a surgical mask for source containment, if tolerated, and should be placed in an exam room, preferably an AIIR, as soon as possible. If this is not possible, having the patient wear a mask and segregate him/herself from other patients in the waiting area will reduce opportunities to expose others. Since the person(s) accompanying the patient also may be infectious, application of the same precautions may need to be extended to these persons if they are symptomatic.

Refer to TB Control Plan for additional guidelines

IV. REFERENCES

Siegel JD., Rhinehart E., Jackson M., Chiarello L., and the Healthcare Infection Control Practices Advisory Committee. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. American Journal of Infection Control, 35 (10), Supplement 2, S 65 S164.

V. REVISION HISTORY Written: 7/2017

Written: 7/2017

Emergency Department

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Appendix A ? Isolation Precautions Quick Reference

(see Isolation Precautions Policy for additional details)

Room Assignment PPE for Teammates

Equipment/Room Cleaning

Patient Transport

Contact

- Private room is preferred

- Gloves & gown are required

- Routine room cleaning - Dedicate the use of non-critical patient

care equipment to a single patient whenever possible (e.g. stethoscope, blood pressure cuff) - All reusable equipment including portable vital signs machines and nondisposable thermometers MUST be disinfected after each use - Assist the patient in performing hand hygiene prior to leaving room

Droplet

- Private room is preferred (does NOT require negative pressure)

- Door may remain open - > 3 feet must be maintained between

patients if not in a private room

- Surgical masks upon entry (surgical masks for droplet precautions are one time use only)

- For aerosolizing procedures (intubation/extubation, open tracheal suctions, bronchoscopy, and sputum induction) with suspected or confirmed influenza, N95/PAPR required

- Routine equipment & room cleaning

Airborne N-95/PAPR

(see TB Prevention & Control Plan)

- Negative pressure required - Door must remain closed - At discharge: close room for 70 minutes

before next patient (time may be less for rooms with more air exchanges, consult infection prevention) - N95/PAPR required upon entry for all teammates

- Routine equipment & room cleaning - While cleaning room, teammates

(including EVS) must wear N95/PAPR even if patient is not in the room (and during the 70 minutes after discharge, cleaning of room can be performed during this time if N95/PAPR is worn)

- Patient must wear a surgical mask when - Patient must wear a surgical mask when

outside of room

outside of room

Visitors

- Instruct visitors to perform hand hygiene upon entering and before leaving room

- Encourage, offer, and educate visitors on the use of gloves and gown

*See Appendix B for Contact Enteric Precautions

- Instruct visitors to perform hand hygiene upon entering and before leaving room

- Provide and encourage use of surgical mask for visitors when entering the patient room (instruct visitors to place the mask securely over the nose and mouth)

- Instruct visitors to perform hand hygiene upon entering and before leaving room

- Visitation is discouraged but provide and encourage use of an N95 mask for visitors when entering the patient room (fit testing is not required for visitors)

Written: 7/2017

Emergency Department

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