Nursing Review

Guidelines for Isolation Precautions
The Hospital Infection Control Advisory Committee and the Centers for Disease Control and Prevention (1996) have concluded that some fluids, secretions, and excretions not covered under Universal Precautions (UP) represent a potential source of nosocomial and community-acquired infections. The term Universal Precautions has been replaced in the hospital setting by a two-tiered system of isolation: Standard Precautions for control of nosocomial infections; and Transmission-based Precautions for patients known or suspected to be infected with highly transmissible pathogens. Standard Precautions incorporate the major components of blood and body fluid precautions from Universal Precautions. Transmission-based Precautions may be combined for diseases that have multiple routes of transmission and are used in addition to Standard Precautions. Standard Precautions Use Standard Precautions, or the equivalent, for the care of all patients. Hand washing. 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. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. Use a plain (non-antimicrobial) soap for routine hand washing. Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (control of outbreaks or hyperendemic infections), as defined by the infection control program. Gloves. Wear gloves (clean, nonsterile gloves are adequate) when touching: blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient; wash hands immediately to avoid transfer of microorganisms to other patients or environments. 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 of blood, body fluids, secretions, and excretions. Gown. Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to 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. 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. 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 patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that singleuse items are discarded properly. Environmental control. Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being followed. Linen. Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and that avoids transfer of microorganisms to other patients and environments. 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 use 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 device designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers that are located as close as practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable. Patient placement. Place a patient who contaminates 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 professionals regarding patient placement or other alternatives. Transmission-Based Precautions Airborne Precautions In addition to Standard Precautions, use Airborne Precautions, or the equivalent, for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue \|5 microns or smaller in size] of evaporated droplets containing microorganisms that remain suspended in the air and that can be dispersed widely by air currents within a room or over a long distance). Patient placement. Place the patient in a private room that has (1) monitored negative air pressure in relation to the surrounding area, (2) 6 to 12 air changes per hour, and (3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital. Keep the room door closed and the patient in the room. When a private room is not available, place the patient in a room with a patient who has active infection with the same microorganism, unless otherwise recommended, but with no other infection. When a private room is not available and cohorting is not desirable, consultation with infection control professionals is advised before patient placement. Respiratory protection. Wear respiratory protection when entering the room of a patient with known or suspected infectious pulmonary tuberculosis. Susceptible persons should not enter the room of patients known or suspected to have measles or varicella if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have measles (rubeola) or varicella, they should wear respiratory protection. Persons immune to measles (rubeola) or varicella need not wear respiratory protection. 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, if possible. Additional precautions for preventing transmission of tuberculosis. Consult CDC “Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities” Droplet Precautions In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for a patient known or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures). 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 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 ft between the infected patient and other patients and visitors. Special air handling and ventilation are not necessary, and the door may remain open. Mask. In addition to standard precautions, wear a mask when working within 3 ft of the patient. (Logistically, some hospitals may want to implement the wearing of a mask to enter the room.) 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 droplets by masking the patient, if possible. Contact Precautions 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. 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 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 Gloves and hand washing. 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 environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and hand washing, 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. 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 contained by a dressing. Remove the gown before leaving the patient’s environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments. Patient transport. Limit the movement and transport of the patient from the room to essential purposes only. If 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. Patient care equipment. When possible, dedicate the use of noncritical patient care equipment to a single patient (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, adequately clean and disinfect them before use for another patient.

Guidelines for Isolation Precautions

The Hospital Infection Control Advisory Committee and the Centers for Disease Control and Prevention (1996) have concluded that some fluids, secretions, and excretions not covered under Universal Precautions (UP) represent a potential source of nosocomial and community-acquired infections. The term Universal Precautions has been replaced in the hospital setting by a two-tiered system of isolation: Standard Precautions for control of nosocomial infections; and Transmission-based Precautions for patients known or suspected to be infected with highly transmissible pathogens. Standard Precautions incorporate the major components of blood and body fluid precautions from Universal Precautions. Transmission-based Precautions may be combined for diseases that have multiple routes of transmission and are used in addition to Standard Precautions.

Standard Precautions

Use Standard Precautions, or the equivalent, for the care of all patients.

Hand washing.

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. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites.
Use a plain (non-antimicrobial) soap for routine hand washing.
Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (control of outbreaks or hyperendemic infections), as defined by the infection control program.

Gloves. Wear gloves (clean, nonsterile gloves are adequate) when touching: blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient; wash hands immediately to avoid transfer of microorganisms to other patients or environments.
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 of blood, body fluids, secretions, and excretions.
Gown. Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to 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. 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.
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 patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that singleuse items are discarded properly.
Environmental control. Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being followed.
Linen. Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and that avoids transfer of microorganisms to other patients and environments.
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 use 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 device designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers that are located as close as practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area.
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.

Patient placement. Place a patient who contaminates 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 professionals regarding patient placement or other alternatives.

Transmission-Based Precautions

Airborne Precautions

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

Patient placement. Place the patient in a private room that has (1) monitored negative air pressure in relation to the surrounding area, (2) 6 to 12 air changes per hour, and (3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital. Keep the room door closed and the patient in the room. When a private room is not available, place the patient in a room with a patient who has active infection with the same microorganism, unless otherwise recommended, but with no other infection. When a private room is not available and cohorting is not desirable, consultation with infection control professionals is advised before patient placement.
Respiratory protection. Wear respiratory protection when entering the room of a patient with known or suspected infectious pulmonary tuberculosis. Susceptible persons should not enter the room of patients known or suspected to have measles or varicella if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have measles (rubeola) or varicella, they should wear respiratory protection. Persons immune to measles (rubeola) or varicella need not wear respiratory protection.
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, if possible.
Additional precautions for preventing transmission of tuberculosis. Consult CDC “Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities”

Droplet Precautions

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

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 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 ft between the infected patient and other patients and visitors. Special air handling and ventilation are not necessary, and the door may remain open.
Mask. In addition to standard precautions, wear a mask when working within 3 ft of the patient. (Logistically, some hospitals may want to implement the wearing of a mask to enter the room.)
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 droplets by masking the patient, if possible.

Contact Precautions

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.

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 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
Gloves and hand washing. 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 environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and hand washing, 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.
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 contained by a dressing. Remove the gown before leaving the patient’s environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments.
Patient transport. Limit the movement and transport of the patient from the room to essential purposes only. If 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.
Patient care equipment. When possible, dedicate the use of noncritical patient care equipment to a single patient (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, adequately clean and disinfect them before use for another patient.