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					   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
   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,
   Teaching cough etiquette to patients with
    respiratory infections is covered.
   Finally, some considerations for planning
    infection control in an outbreak situation are
   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
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
3. Identify components of effective handwashing.
4. Describe conditions under which to use standard
5. Describe conditions under which to use contact
6. Describe conditions under which to use droplet
7. Describe conditions under which to use airborne
Infection Control
              Infection Control-2
   Sources of microorganisms can include:
       Patients
       Health care workers
       Visitors
   These sources can include:
       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
    Patient Isolation Precautions for
   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
       Source or reservoir of microorganisms
       Susceptible host with a portal of entry receptive to the
       Means of transmission
    Patient Isolation Precautions for
   The term host refers to the person or animal who becomes
   Hosts differ in susceptibility due to characteristics, some innate,
    such as:
        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
   There are several main routes of
    transmission of microorganisms. A
    microorganism may be spread by a single
    or multiple routes. These are:
       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
   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
   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 CDC-
    recommended precautions to be more
    Patient Isolation Precautions for
   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
        Patient Isolation Precautions for
   Standard Precautions (Basic level)
       Are used for care of ALL patients in a hospital all
        of the time regardless of diagnosis or infection
       Combine the major features of universal, and
        body substance precautions, terms formerly
       Applied to blood, body fluids, excretions and
        secretions regardless of whether they contain
        visible blood, mucous membranes and non-
        intact skin
       All other transmission-based precautions include
        (are in addition to) Standard Precautions
       Level of use depends on anticipated contact with
         Patient Isolation Precautions for
   Other Transmission-Based Precautions Commonly Used in Hospitals
    Consist of:
        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
   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:
       Infected patient to other patients and vice-
       Infected patient to visitors and vice-versa
       Infected patient to general hospital
        environment and vice-versa
       Infected patient to health care worker and
       Infection Control and Barrier
   The general hospital
    environment and
    equipment need to be
   Appropriate
    precautions should be
    followed as should
    proper disposal of
    clinical waste and
      Patient Isolation Precautions
         Standard Precautions
   Hand hygiene after patient contact
   Wear clean, non-sterile protective gloves
    when touching blood, body fluids,
    secretions, excretions and contaminated
   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
   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
             Contact Precautions
    Consists of standard precautions (see previous
    frames) plus precautions for direct and indirect
   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
   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
   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
   Note: some authorities recommend use of shoe
   During transport, be sure clean PPE is used
          Contact Precautions-4
   Leak resistant bag for linens should be at
   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
   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
   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
   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
   If private room absolutely not available, consult
    infectious disease consultants before cohorting
   Limit patient movement or transport only if
   Use surgical or N95 mask on patient if transport
    is needed (see frame on patient transport for
   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
               Droplet Precautions
    Consists of standard precautions plus specifics for
                    droplet precautions
   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
   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
   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
   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,, and
     Handwashing and Hand

One of the most
 important ways to
 protect against
 transmission of
 microbes and
 disease is hand
               Handwashing and Hand
   Should be done:
       Before gloving,
       After removing gloves
       After touching blood, body fluids, tissues,
        secretions, excretions or any contaminated
        items. If not visibly soiled can use alcohol-
        based but if visibly soiled or contaminated with
        proteinacious material use soap and wash
            Between patients
            After procedures on some patients to prevent cross-
             contamination of different body sites
            After contact with patients intact skin or inanimate
             objects near the patient
       Handwashing and Hand
   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
   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
   May consist of:
       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
   The appropriate combination
    depends on the nature of the
    microorganism, certain
    characteristics of the host (i.e. ability
    to cooperate), and microbial route of
   Only work if used appropriately and
   Long sleeves
   Need to be large
    enough to
    completely cover
   Undisrupted front
   Impermeable
    (water repellent)
   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
   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
   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
   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
   Single use gloves should not be washed or
   Glove selection is task-appropriate
    Eye/Facial Protective Devices
   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
   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
   To remove handle by
    "clean" ear or head
   Also piece to protect
    against large droplets such
    as in RSV infection is
   Eyeglasses such as
    prescription eye glasses
    are not a substitute for
    proper shield
   For further details see
    CDC. Eye protection for
    infection control. May
    Boots/Overshoes/Foot Coverings
   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
   Should be
    appropriately fitted
   A N-95 mask such
    as the 3M is
    preferred to filter
    out small airborne
   Discard after use
    or change if
    becomes moist
   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"
   Disinfect gloves if any possible
    contact with secretion/excretion of
    patient to reduce transmission into
   To leave room,
     Disinfect
     Remove gloves with right glove hand
   Take off right glove turning it inside
    out with left glove
        Work "Clean" to "Dirty"-2
   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
   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
   Disinfect all transport equipment and
   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
       Respiratory Hygiene/Cough
       Etiquette/Patient Teaching
   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
   Elements and Instruction should include:
        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
        Using surgical masks on coughing person when
        Providing alcohol-based hand-rubbing dispensers
         and supplies for handhygiene, and educating
         patients and staff in their use,
        Encouraging handhygiene after coughing or
Patient Teaching/Cough Etiquette-3
   Instruction should include cont.:
       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
   Health care workers should use standard
    precautions with all patients.
    Special Situations Relating to Bioterrorism
     Linked Outbreaks of Biological Agents
   Special situations require the activation of each
    institution’s preparedness plan which should include:
       Processes for triage and care for large numbers of affected
       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
       Procedure for distribution of chemoprophylaxis or
        medications, and
       Others
    Special Situations Relating to Bioterrorism
     Linked Outbreaks of Biological Agents-2
   There will need to be a plan for rapid
    receiving and triage as well as for
    allocation and reallocation of sparse
        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
    Special Situations Relating to Bioterrorism
     Linked Outbreaks of Biological Agents-3
   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.
    Special Situations Relating to Bioterrorism
     Linked Outbreaks of Biological Agents-4
   This plan will usually clear all non-
    emergency 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
   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
   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

Center for Health Policy, Columbia University School of Nursing
Adapting Standards of Care Under Extreme Conditions. American
Nurses Association, March, 2008.