infection control isolation

7/30/2019 Infection Control Isolation

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Infection Control and IsolationPrecautions as Part of Preparedness

Against Use of Biological Weapons: A

Module for Nursing Professionals

Felissa R. Lashley, RN, PhD, FAAN, FACMGProfessor, College of Nursing, and

Interim Director, Nursing Center forBioterrorism and Infectious DiseasePreparedness, College of Nursing

Rutgers, The State University of New Jersey



In this module, general information is given oninfection control and isolation procedures inhospitals as they pertain to nurses.

Standard and specific transmission-basedprecautions are discussed.

Following this are additional specific informationrelated to each procedure (e.g., handwashing,patient transport) or equipment (e.g., gloves,gowns).

Teaching cough etiquette to patients withrespiratory infections is covered.

Finally, some considerations for planninginfection control in an outbreak situation arementioned.

This module was supported in part by USDHHS,HRSA Grant No. T01HP01407.

Comprehensive details are found in the revised document guidelines for isolationprecautions: preventing transmission of infectious agents in healthcare settings2007. http://www.cdc.gov/ncidod/dhgp/pdf/



Objectives

At the completion of this module, participants willbe 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 anyapparent illness)

Inanimate objects such as furniture andmedical 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 includingadministration, education, other clinicalservices, and surveillance

Infection transmission in the hospitalrequires: Source or reservoir of microorganisms

Susceptible host with a portal of entry receptive to themicroorganism

Means of transmission




Hospitals-2

The term host refers to the person or animal who becomesinfected.

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 HIVinfection), medical treatments (e.g., immunosuppressive drugs orradiation), surgical procedures, and placement of invasive devices(e.g., IVs, chest tubes, and urinary catheters).

Infectious agents vary in regard to various factors such asvirulence, antigenicity, and pathogenicity

There are various outcomes that may occur after exposure to amicroorganism including colonization, symptomatic disease, andmore. The outcome depends on complex interactions amongagent, host and environment.




Hospitals-3

There are several main routes of transmission of microorganisms. Amicroorganism 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 asmedications such as contaminated IV fluids




Hospitals-4

Patient care units are usually mainlyconcerned with direct and indirectcontact, droplet and airborne

transmission. In most hospitals inthe US vector-borne transmission isnot relevant.

Environmental and engineeringaspects (including waste disposal,disposal of sharps, and laundry) arenot covered in this module




Hospitals-5

Standard precautions are used for allpatient care.

Additional isolation precautions are basedon patient’s known or suspected infection,

what is known about the microorganismcausing it, and its route of transmission.

Highly contagious or diseases with highmortality such as Ebola hemorrhagic fever

may require more stringent infectioncontrol, such as double gowning anddouble gloving.

Institutions may modify the CDC-recommended precautions to be more

stringent.




Hospitals-6

Multidrug-resistant organisms(MDRO’s)may require more stringentprotection, such as methicillin resistantStaphylococcus aureus (MRSA).

Isolation precautions may be combined fordiseases that have more than one route of transmission. For example, protectionfrom varicella requires contact andairborne precautions.

See CDC guidelines at

http://www.cdc.gov/ncidod/dhgp/pdf/ar/mdro Guideline2006 df .

http://www.cdc.gov/ncidod/dhgp/pdf/ar/mdro/Guideline2006/pdf







Hospitals-7

Standard Precautions (Basic level) Are used for care of ALL patients in a hospital all

of the time regardless of diagnosis or infectionstatus

Combine the major features of universal, andbody substance precautions, terms formerlyused

Applied to blood, body fluids, excretions andsecretions 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




Hospitals-8

Other Transmission-Based Precautions Commonly Used in HospitalsConsist 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 nolonger infectious.

If possible, dedicate same patient care staff to care of infectedpatient(s) during their stay.



Infection Control and Barrier

Nursing Barrier nursing is a term sometimes used

to describe the use of barriers to carry outthe appropriate infection control protocolfor the particular infection

Nurses and other health care professionalsuse appropriate infection controlprecautions to prevent transmission of amicroorganism 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 andvice-vesa



Infection Control and Barrier

Nursing-2

The general hospitalenvironment and"permanent"equipment need to be

protected Appropriate

sharp/needleprecautions should befollowed as should

proper disposal of clinical waste andlaundry



Patient Isolation Precautions

Standard Precautions

Hand hygiene after patient contact

Wear clean, non-sterile protective gloveswhen touching blood, body fluids,

secretions, excretions and contaminateditems

Wear mask, eye protection or facial shieldand gown during procedures likely togenerate splashes or spray of blood, bodyfluids, secretions or excretions. Usedepends on anticipated exposure and safe

injection practices as well



Patient Isolation Precautions

Standard Precautions -2

Handle contaminated patient-care equipment and linen in amanner that prevents the transfer of microorganisms topeople or equipment

Use care when handling sharps and follow proper disposalof needles and other sharp instruments

Use a mouthpiece or other ventilation device as analternative to mouth-to-mouth resuscitation when practical

Place the patient in a private room when feasible if theymay 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 spinalor epidural areas

C t t P ti



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 includechairs, bedrails, telephones, IV pumps, lightswitches and so on. Used in such illnesses asimpetigo, herpes simplex, and hepatitis A.

Placing the patient in a private room is preferredor when not available, it is recommended that aset of principles be followed such as cohortingwith someone with the same infection.



Contact Precautions -2

Use gloves when entering the room. Change gloves aftercontact with infective material. Remove gloves beforeleaving the room. Wash hands or use appropriate gel afterglove removal. Do not touch infective material or surfaceswith hands. Clean, non-sterile gloves are usually adequate.

Use protective gown when entering the room if directcontact with patient or potentially contaminated surfaces orequipment near patient is anticipated or if the patient hasdiarrhea or colostomy or wound drainage that is notcovered by a dressing. Remove gown and observe handhygiene 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 patientfrom the room. Be sure any infected or colonizedareas are contained or covered and PPE isdiscarded. Perform hand hygiene.

Ensure that patient care items, bedsideequipment, and frequently touched surfacesreceive daily cleaning.

Dedicate use of non-critical patient careequipment to a single patient, or cohort of patients with the same pathogen. If not feasible,

adequate disinfection between patients isnecessary.

Note: some authorities recommend use of shoecoverings.

During transport, be sure clean PPE is used



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 dropletnucleii (5 m or smaller in size) or dust particlescontaining the infectious agent.

These can remain suspended in the air or bedispersed widely by air currents even throughventilation 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 withanteroom if possible, that has negative airpressure, 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 visibleindicator

Use of respiratory protection (e.g., fit tested N95respirator) 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.



Droplet Precautions Consists of standard precautions plus specifics for

droplet precautions

Used to reduce the risk of transmission of microorganisms transmitted by large particledroplets (larger than 5 m in size).

This type of transmission usually requiresclose contact between the source personand the recipient because droplets do notremain suspended in the air. They usually

travel 3 feet or less within the air and thusspecial air handling is not required, howevernewer recommendations suggest a distanceof 6 feet be used for safety.



Droplet Precautions -2

Droplet transmission involves contact of the conjunctiva of the eyes or the mucousmembranes of the nose or mouth of a

person with the microorganism generatedfrom the infected source person duringcoughing, sneezing or talking, or duringthe 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 maskon the patient if they need to be moved and followrepiratory hygiene/cough etiquette

Keep patient at least 3 feet apart between infected patientand 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

http://www.cdc.gov/ncidod/sars/







Handwashing and Hand

Hygiene

One of the mostimportant ways to

protect againsttransmission of microbes anddisease is hand

hygiene




Hygiene-3

Wash with soap and water at least 15seconds when hands are visibly soiled andfollow institutional procedures

Use friction Can use alcohol-based rubs to

decontaminate hand, if soiled

Fingernails should be short, clean and freefrom polish

Artificial nails should be avoided




Hygiene-4

Rings should not be worn

Watches and bracelets should be removed

For alcohol-based rubs, apply to palm of one hand and rubhand together covering all surfaces of hand and fingersuntil hands are dry

Paper towels should be used to dry hands. Do not touchfaucet handles with hands after washing

Wash hands with soap and water before eating and afterusing the restroom and if exposure to B. anthracis issuspected 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 healthcaresettings. 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 combinationdepends on the nature of themicroorganism, certain

characteristics of the host (i.e. abilityto cooperate), and microbial route of transmission

Only work if used appropriately andcorrectly



Gowns

Long sleeves

Need to be largeenough to

completely coverclothing

Undisrupted front

Impermeable(water repellent)



Gowns-2

Back closure

Add apron if extensive contact with fluid orsplashing 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 edgenear neck tie, grasp inside sleeve cuff andremove sleeve over hand, grasp opposite cuff and pull off, roll inside out in bundle and drop inappropriate container



Gloves

Wear gloves when anticipated contact withpatient’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 glovesbetween procedures,same patient aftercontact with material,

or tissue that maycontain a high numberof microbes

Remove gloves

immediately after useand before caring foranother patient



Gloves-3

Decontaminate hands before and aftergloves are removed

In highly infectious situations, such ascare of patients with viral hemorrhagic

fever, may double glove Use care in removing gloves if soiled, so

as not to contaminate hands orenvironment

Single use gloves should not be washed orreused Glove selection is task-appropriate



Eye/Facial Protective Devices

Usually goggles or face shields should beused to protects eyes and face frommicroorganism contamination, splatteringor 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 eyesgives highest degrees of protection Fit over mask or respirator



Eye Protective Devices-2

To remove handle by"clean" ear or head

Also piece to protectagainst large droplets suchas in RSV infection isneeded

Eyeglasses such asprescription eye glassesare not a substitute forproper shield

For further details seeCDC. Eye protection forinfection control. May13,2008

http://www.cdc.gov/niosh/topics/eye/eye-infectious.html







Boots/Overshoes/Foot Coverings

Used if floor is onlycontaminated or wet

Protects wearer fromthe microorganisms

Prevents transport of microbes from healthcare worker's shoes ininfectious patient's

rooms of non-infectedpatients



Masks

Should beappropriately fitted

A N-95 mask suchas the 3M ispreferred to filterout small airborneparticles

Discard after useor change if becomes moist



Masks-2

Worn by healthcare providers and visitorsto protect against microbes transmitted byairborne or droplet means

May also be worn by patient with airborneor droplet transmissible diseases,especially under certain circumstancessuch as during direct care or transport

The appropriate mask and circumstancedepends on microorganism and setting.



Work "Clean" to "Dirty"

Disinfect gloves if any possiblecontact 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 insideout with left glove



Work "Clean" to "Dirty"-2

Dispose of gloves

Disinfect hands

Go into anteroom

Remove goggles avoiding contact withfront and your eyes

Disinfect goggles

Disinfect hands

Take off mask, avoiding touching front

Discard mask

I f d P i T Wi hi



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 andwhen patient is coming

Protect stretchers or wheelchairs appropriately

Appropriate hand hygiene should be used



R i t H i /C h



Respiratory Hygiene/Cough

Etiquette/Patient Teaching

Initiate at first point of contact witheven a potentially infected personwith respiratory infection.

Includes education which may bevisual and/or verbal at anappropriate educational level withcultural considerations of patientsand the people who accompanythemas well as health care staff.

These are now incorporated into

standard precautions.



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 haveseparate locality.

Instructing patients and providers not to toucheyes, nose, or mouth.

Having health care personnel observedroplet precautions in addition to standardprecautions.

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 eachinstitution’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




Linked Outbreaks of Biological Agents-2

There will need to be a plan for rapidreceiving and triage as well as forallocation and reallocation of sparse

resources. For example, it must be considered how

limited numbers of ventilators would bedistributed and used in the case of an outbreakof botulism which respiratory failure would besudden and ongoing.

Further discussion is beyond the scope of thismodule.





Usually each health care institution willdesignate a specific area or area that will:

Receive and identify patients,

Triage them, Treat immediately or admit, or

Transport or house patients with the specificinfection, in a designated wing or building, or

in some cases, a site separated from thehospital, such as a nearby school or outsidetented area.





Health care workers may receivechemoprophylaxis or immunizationdepending on the organism involved.

Patients may need to removecontaminated clothing and store them inlabelled plastic bags for chain of evidence.

Patients may need to shower with soap

and water and shampoo hair depending onthe available facilities and need to do so.

S S





Medical equipment may need to be sharedamong patients with the same infection.

In the event of a large-scale outbreak orepidemic, optimal infection control, such

as private rooms for infected patientsprobably will not be possible. Each nurse should be familiar with the

preparedness plan at their own institutionsand in their community.

Planning must include how infectioncontrol principles can be applied underpotential emergency conditions withsparse supplies and lack of running water.

Further Reading:



Further Reading:

OSHA. OSHA Best Practices for Hospital- based First

Receivers of victims, 2005http://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. AmericanNurses Association March 2008

http://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf

http://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf

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