Infection Control and Isolation Precautions

1
Infection Control and Isolation Precautions
2
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.

3
Infection Control
4
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.

5
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

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Patient Isolation Precautions for Hospitals

• 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.

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Patient Isolation Precautions for Hospitals

• 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

8
Patient Isolation Precautions for Hospitals

• 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

9
Patient Isolation Precautions for Hospitals

• Standard precautions are used for all patient
  care.
• Additional isolation precautions are based on
  patients 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.

10
Patient Isolation Precautions for Hospitals

• Multidrug-resistant organisms (MDROs)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/dh
  gp/pdf/ar/mdro/Guideline2006/pdf.

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Patient Isolation Precautions for Hospitals

• 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

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Patient Isolation Precautions for Hospitals-

• 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.

13
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

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Infection Control and Barrier Nursing

• 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

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Patient Isolation PrecautionsStandard 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

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Patient Isolation PrecautionsStandard
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

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Contact PrecautionsConsists 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.

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Contact Precautions

• 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

19
Contact Precautions

• 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

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Contact Precautions

• 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 patients
  environment.

21
Airborne PrecautionsConsists 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.

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Airborne Precautions

• 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.

23
Airborne Precautions

• 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

24
Droplet PrecautionsConsists 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.

25
Droplet Precautions

• 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.

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Droplet Precautions

• 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

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Handwashing and Hand Hygiene

• One of the most important ways to protect against
  transmission of microbes and disease is hand
  hygiene

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Handwashing and Hand Hygiene

• 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

29
Handwashing and Hand Hygiene

• 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

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Handwashing and Hand Hygiene

• 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

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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

32
Personal Protective Equipment (PPE)

• 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

33
Gowns

• Long sleeves
• Need to be large enough to completely cover
  clothing
• Undisrupted front
• Impermeable (water repellent)

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Gowns

• 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

35
Gloves

• Wear gloves when anticipated contact with
  patients 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

36
Gloves

• 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

37
Gloves

• 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

38
Eye/Facial Protective Devices

• Usually goggles or face shields should be used to
  protects eyes and face from microorganism
  contamination, splattering or spraying of
  patients 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

39
Eye Protective Devices

• 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
40
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

41
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

42
Masks

• 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.

43
Work "Clean" to "Dirty"

• Disinfect gloves if any possible contact with
  secretion/excretion of patient to reduce
  transmission into environment
• To leave room,
• Disinfect gloves
• Remove gloves with right glove hand
• Take off right glove turning it inside out with
  left glove

44
Work "Clean" to "Dirty"

• 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

45
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

46
Infected Patient Transport Within Institution

• 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

47
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.

48
Respiratory Hygiene/Cough Etiquette/Patient
Teaching

• 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.

49
Patient Teaching/Cough Etiquette

• 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.

50
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents

• Special situations require the activation of each
  institutions 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

51
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents

• 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.

52
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents

• 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.

53
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents

• 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.

54
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents

• 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.

55
Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents

• 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.

56
Further Reading OSHA. OSHA Best Practices for
Hospital- based First Receivers of victims,
2005http//www.osha.gov/dts/osta/bestpractices/fi
rstreceivers_hospital.pdf
Center for Health Policy, Columbia University
School of Nursing Adapting Standards of Care
Under Extreme Conditions. American Nurses
Association, March, 2008.