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, 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 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 microorganisms. Patient Isolation Precautions for Hospitals 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: 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 The term host refers to the person or animal who becomes infected. 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 Hospitals-3 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 Hospitals-4 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 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 stringent. Patient Isolation Precautions for Hospitals-6 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 Standard Precautions (Basic level) 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 non- intact 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 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 Nursing 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- versa 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 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 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 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 contact 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 necessary. Note: some authorities recommend use of shoe coverings. During transport, be sure clean PPE is used Contact Precautions-4 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 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 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 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 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 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 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 hands. 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 Hygiene-3 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 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) 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 (PPE)-2 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 Long sleeves Need to be large enough to completely cover clothing Undisrupted front Impermeable (water repellent) Gowns-2 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 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 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 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 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 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 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 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 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 environment To leave room, gloves 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 Institution 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 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 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 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 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 precautions. 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 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 There will need to be a plan for rapid receiving and triage as well as for allocation and reallocation of sparse resources. 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 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 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.