The University of Toledo Medical Center and its Medical Staff

Transcription

1 Name of Policy: Guidelines for Isolation Precautions in Hospitals Policy Number: ISO-404 Department: Infection Control Medical Staff Hospital Administration Approving Officer: Chairman, Infection Control Committee Chief of Staff Chief Clinical and Operating Officer Responsible Agent: Infection Control Practitioner Scope: The University of Toledo Medical Center and its Medical Staff New pol cy proposal Major revision of existing policy X VV TOLEDO Effective Date: 10/13/15 Initial Effective Date: 7/1/1989 Minor/technical re vision of existing policy Reaffirmation of e xisting policy (A) Policy Statement Specific protective measures must be instituted to prevent transmission of potentially pathogenic microorganisms between infected and non-infected persons. (B) Purpose of Policy To prevent the spread of communicable and other infectious diseases within the hospital, special techniques must be followed when caring for the patient with a communicable disease or those patients whose immune systems are compromised. The procedures required are based on the following epidemiological factors: 1. The source of the infecting organisms. 2. The mode of transmission. 3. The susceptible host. (C) Procedure Types of precautions: Airborne,, -D and Droplet are to be used in addition to Standard Precautions. Standard Precautions must be followed with every patient. Proper hand-hygiene should be followed: upon entry and exiting every room/environment, and before and after every patient contact or contact with the patient environment. Hands should always be cleansed before and after glove removal. Gowns, gloves and other personal protective equipment (PPE) are not to be worn outside of the patient room except under the guidance of the Infection Control Committee. Consider all waste from an isolation room as infectious and dispose of in red bag lined waste baskets. Terminal cleaning (washing walls) is not indicated unless there is obvious contamination on the surfaces. The privacy curtains should be changed after every patient with contact precautions as part of the terminal cleaning process. Standard precautions: Standard Precautions are to be used to prevent skin and mucous-membrane exposure when contact with blood or other body fluids of any patient is anticipated. Gloves must be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids and vascular access procedures. Masks and protective eyewear or face shields must be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent

2 Policy ISO-404 Page 2 exposure of mucous membranes of the mouth, nose, and eyes. Gowns must be worn during procedures that are likely to generate splashes of blood or other body fluids. Airborne Precautions: Airborne Precautions are used to prevent the transmission of infections that are transmitted by organisms that can remain suspended in the air for considerable lengths of time and may be dispersed over long distances. Use this type of precautions for; Pulmonary tuberculosis- until 3 negative sputum smears for AFB are obtained (For additional information see TB Control Plan). Measles- for the duration of the illness. Chickenpox- until lesions are crusted (see also contact precautions). Herpes Zoster- disseminated in any patient and localized disease in immune-compromised hosts- until lesions are crusted (see also contact precautions). (Disseminated is defined as two non-continuous dermatomes or 3 continuous dermatomes). Emerging Infectious Disease per the guidance of the Infection Control Committee (e.g., SARS, MERS). Placement of Patient: Use a private room with negative pressure ventilation. The door must be kept closed at all times. If a private negative pressure room is not available, then contact Infection Prevention immediately. Notifications: Place Airborne precautions sign on the door of the room. Monitoring of Negative Pressure Room: If room has outside indicator, turn on and insure that the light is maintained in the green. Monitoring of Negative Pressure Room: Daily place a tissue at handle-level of slightly-opened door (no more than one-half inch). If the tissue is pulled in, the negative pressure is working. If the lights on the monitor are in the yellow or red, reposition the door, wait 30 seconds and the room should go back into the green. If not, keep the door closed and notify Facilities Management Department immediately by calling Document negative pressure room daily inspection using Negative Pressure Room Daily Air Exchange Monitoring Form, This form is found on the Infection Control Website ( and on the powered air purifying respirator (PAPR) cart). Respiratory Protection: All personnel entering the room must wear one of the following types of respiratory protection: N-95 respirator, or the portable PAPR hood. Order PAPR cart by calling Distribution Services Department. Anyone wearing the N-95 respirator must have a documented fit test on file within the prior 12 months. The PAPR hood should not be discarded. If hoods are used by more than one person, they are to be wiped down with the hospital disinfectant wipes and allowed to air dry. PAPRs are routinely inspected by EHRS department. When the PAPR cart is no longer needed, return to Materials Management Department... Patient Considerations: Patient should remain in the room. For testing that cannot be done in the room (e.g., MRI), schedule patient for the last test or surgery at the end of the day. All non-emergent surgeries should be delayed until the patient no longer requires airborne precautions. During transport, the patient is to wear a surgical mask. Notify receiving department of required precautions. Patients should be asked to cover their nose and mouth when coughing and sneezing with a tissue. Limit visitors and offer surgical masks to visitors. Personal Protective Equipment: Wear gowns and gloves only when indicated (e.g., contact precautions).

3 Policy ISO404 Page 3 Patient Care Equipment: If possible, keep dedicated equipment in the patient room and use disposable equipment when indicated. Cleaning: Routine cleaning should be done with staff wearing the proper respiratory protection. At discharge, the door is to remain closed for a minimum of 1 hour before personnel may enter without proper respiratory protection. Cleaning may be completed within this hour window, providing staff wears appropriate respiratory protection. Precautions: precautions are used to prevent the spread of infectious pathogens that are transmitted by direct contact with the patient's skin or other mucous membranes, or by indirect contact with the patient's environment. Use this type of precautions for: Antibiotic resistant organisms- such as multi-drug resistant organism (MDRO) Acinetobacter, carbapenemresistant enterobacteriaceae (CRE), extended spectrum beta-lactamase-positive (ESBL) pathogens, or other organisms that are only susceptible to one antibiotic or no antibiotics. History of MDROs can be found on the isolation area on the patient's face sheet. Chickenpox - (Also see Airborne Precautions) - until lesions are crusted over. Clostridium difficile (see -D precautions). Conjunctivitis- acute viral- for the duration of the illness. Group A streptococcal necrotizing fasciitis- until culture negative (see also droplet precautions). Lice/Scabies- for 24 hours after therapy is initiated. See the appendix for a complete list. Note: Methicillin-resistant SI aureus (MRSA) and vancomycin-resistant enterococcus (VRE) are not isolated, unless there is a physician order or drainage that cannot be contained. In the event that patient-to-patient transmission would be discovered, such as vancomycin-resistant S. aureus (VRSA) or other totally resistant organisms are identified, the Infection Control Committee would convene to determine if a change in isolation practice would be necessary. Specific Procedures for precautions: Placement of Patient: Use a private room or in high census times, may cohort with other patient with same organism. Notifications: Place precautions sign on the door of the room immediately. The door may remain open. Personal Protective Equipment (PPE): Gown and gloves must be worn by all personnel when entering the room. Gowns are not to be re-used, and are to be placed in the blue linen hamper in the room after use. Patient Considerations: Patient should remain in the room. For tests that cannot be completed in the room, schedule patient for the last test or surgery of the day. All non-emergent surgeries should be delayed until the patient no longer requires precautions, if possible. Limit visitors; instruct them how to protect themselves by wearing gloves and washing hands. If participating in care of patient, instruct visitors to wear gown and gloves. Patient Care Equipment: If possible, keep dedicated equipment in the patient room and use disposable equipment (e.g., stethoscope, blood pressure cuff, thermometers).

4 Policy ISO404 Page 4 Transport of patient: Place clean sheet over patient during transport. Use clean gurney or wheel chair before and after each transport. Wash hands after removing gloves and other personal protective equipment. Notify receiving department of required precautions. Cleaning: Re-useable instruments should be thoroughly cleaned with PDI Sani-wipes before using on another patient and when removed from room. Routine cleaning should be completed wearing gown and gloves. At discharge, leave the sign until the room is cleaned. -D Precautions: -D precautions are used to prevent the spread of pathogens that are transmitted by contact with stool, such as C. difficile or Norovirus. These organisms can be transmitted by direct contact with the patient or indirect contact with the patient environment. Use this type of precautions for: C. difficile. Norovirus. Diarrhea in incontinent patients or patients using adult briefs. Discontinue -D precautions: After completion of treatment and no diarrhea for 48 hours. Note: a negative C. difficile test does not warrant discontinuing isolation. If uncertain, discuss with Infection Prevention or Infectious Disease Physician. Placement of Patient: Use a private room or in high census times, may cohort with other patient with same organism. Notifications: Place -D precautions sign on the door of the room immediately. Theodor may remain open. Personal Protective Equipment (PPE): All personnel entering the room must wear gloves and gown. Clean gowns are found in the yellow hamper outside the door. Gowns are not to re-used, and are to be placed in the blue linen hamper in the room after use. All linen is handled the same, no special procedures are needed for linen. Patient Considerations: Patient should remain in the room. For tests that cannot be completed in the room, schedule patient for the last test or surgery of the day. All non-emergent surgeries should be delayed until the patient no longer requires precautions, if possible. Limit visitors; instruct them how to protect themselves by wearing gloves and washing hands. If participating in care of patient, instruct them to wear the gown. Equipment: If possible, dedicate equipment to the room Stethoscope and blood pressure monitor- use disposable equipment or cleanse after each use. Thermometers- use disposable equipment or cleanse after each use. Linen and dishes- no special handling. Sputa and other specimens: standard handling. Transport of patient: Place clean sheet over patient during transport. Clean gurney or wheel chair before and after each transport with bleach wipes. Hands must be washed with soap and water when exiting room and after removing gloves and other personal protective equipment (PPE). Notify receiving department of required precautions.

5 Policy ISO-404 Page 5 When to discontinue isolation: Continue -D precautions unless discontinued by a physician or upon consultation/approval by Infection Preventionist. Cleaning: Use disposable equipment if possible. Re-usable equipment is to be cleaned with bleach wipes (exception: glucometer). Routine cleaning should be done with bleach with staff wearing proper personal protective equipment. For C. difficile, staff should use approved bleach products for cleaning and use soap and water to wash hands when exiting room. At discharge, leave the sign until the room is cleaned. The room will be cleaned with bleach. Environmental Services will continue to clean the room with bleach for 3 days after the patient is discharged. Droplet Precautions: Droplet Precautions are used to prevent the transmission of microorganisms spread by close respiratory or mucous membrane contact with large droplet particles through talking, coughing, and sneezing. Use this type of precautions for: Meningitis, meningococcemia and meningococcal pneumonia for 24 hours after the initiation of appropriate therapy. Influenza- for duration of illness. Mumps- for 9 days after the onset of swelling. Parvovirus- for duration of illness. Rubella- for 7 days after onset of rash. Pertussis - after 5 days of treatment. H. influenza pneumonia- for duration of illness. Group A streptococcal pneumonia - after 24 hours of appropriate treatment. Placement of Patient: Use a private room or in high census times, may cohort with other patient with same organism. Notifications: Place Droplet precautions sign on the door of the room immediately. The door may remain open. Personal Protective Equipment (PPE): Surgical masks should be worn when within three feet of the patient. Gowns and gloves must be worn when indicated by Precautions. Patient Considerations: Patient should remain in the room. For tests that cannot be done in the room, schedule patient for the last test or surgery of the day. All non-emergent surgeries should be delayed until the patient no longer requires precautions, if possible. Limit visitors and instruct them how to protect themselves by wearing surgical mask when within three feet of the patient. Patient Care Equipment: If possible, keep dedicated equipment in the patient room and use disposable equipment when indicated. Transport of patient: Treatment must wear a surgical mask during transport. Clean cart or wheelchair before and after each transport with PDI Sani-wipes. Wash hands after removing gloves and other personal protective equipment. Notify receiving department of required precautions.

6 Policy ISO-404 Page 6 Cleaning: Re-useable instruments should be thoroughly cleaned before using on another patient with PDI Sani-wipes. Routine cleaning should be done with staff wearing the proper personal protective equipment. At discharge, leave the sign until the room is cleaned. The room may be cleaned as usual. Ebola Hemorrhagic Fever Precautions: See Infectious Disease Agent and Max Surge Plan EP on Environmental Health and Radiation Safety Website, ( References: Recommendations for Isolation Precautions in Hospitals: Hospital Infection Control Practices Advisory Committee, MMWR 2004,, 2007; UTMC Tuberculosis Exposure Control Plan and Bloodborne Pathogens Plans Isolation Precautions; APIC Text of Infection Control and Epidemiology, Volume I, Essential Elements, 2014, Approved by: \ I?*^ \-X C -^^~~~ *C* Michael Ellis, MD Chairman, Infection Control Committee O. Thomas Schvv^iin; MD C%f of Staff / l'jv-v Carl Sirio Chief Clinical and Operating Officer Review/Revision Completed By: Infection Control Committee Policies Superseded by This Policy: 31:ISO O f-jtt ( ^ Date 2^ V2- \~ Date ±\<r Date Review/Revision Date: 5/18/81 7/28/2008 8/16/82 11/14/ /21/83 5/23/2011 5/21/84 07/16/2014 7/15/85 10/13/18 6/30/86 6/16/87 8/88 10/4/88 8/7/89 8/10/90 11/4/91 9/14/94 6/2/97 5/1/99 4/15/02 4/21/05 Next Review Date 08/1 7/20 1 8

7 Policy ISO-404 Page? Synopsis of Types of Precautions and Patients Requiring the Precautions Standard Precautions - Use Standard Precautions for the care of all patients Airborne Precautions - In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include: Measles Varicella (including disseminated zoster)t Tuberculosis:): SARS and MERS; Use both contact and airborne Droplet Precautions - In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by droplets. Examples of such illnesses include: Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis Other serious bacterial respiratory infections spread by droplet transmission, including: Diphtheria (pharyngeal) Mycoplasma pneumonia Pertussis Pneumonic plague Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children Serious viral infections spread by droplet transmission, including: Adenovirusf Influenza Mumps Parvovirus B19 Rubella Precautions - In addition to Standard Precautions, use Precautions for patients known or suspected to have diseases easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include: Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance Enteric infections with a low infectious dose or prolonged environmental survival, including: For diapered or incontinent patients: enterohemorrhagic Escherichia coll O157:H7, Shigella, hepatitis A, or rotavirus Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children Skin infections that are highly contagious or that may occur on dry skin, including: Diphtheria (cutaneous) Herpes simplex virus (neonatal or mucocutaneous) Impetigo Major (noncontained) abscesses, cellulitis, or decubiti Pediculosis SARS Use both contact and airborne precautions Scabies Staphylococcal furunculosis in infants and young children Zoster (disseminated in any patient or localized in the immunocompromised host)t Viral/hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, or Marburg)

8 Policy ISO-404 PageS D Precautions Clostridium difficile Norovirus Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent Transmission of Epidemiologically Important Pathogens Pending Confirmation of Diagnosis* Clinical Syndrome or Conditionf Diarrhea Acute diarrhea with a likely infectious cause in an incontinent or diapered patient Diarrhea in an adult with a history of recent antibiotic use Meningitis Rash or exanthems, generalized, etiology unknown Petechial/ecchymotic with fever Vesicular Maculopapular with coryza and fever Respiratory infections Cough/fever/upper lobe pulmonary infiltrate in an HIV-negative patient or a patient at low risk for HIV infection Cough/fever/pulmonary infiltrate in any lung location in a HIV-infected patient or a patient at high risk for HIV infection (23) Paroxysmal or severe persistent cough during periods of pertussis activity Respiratory infections, particularly bronchiolitis and croup, in infants and young children Risk of multidrug-resistant microorganisms History of infection or colonization with multidrug-resistant organisms Skin, wound, or urinary tract infection in a patient with a recent hospital or nursing home stay in a facility where multidrug-resistant organisms are prevalent Skin or Wound Infection Abscess or draining wound that cannot be covered Potential Pathogens! Empiric Precautions Enteric pathogens Clostridium difficile Neisseria meningitidis D Droplet Neisseria meningitidis Varicella Droplet Airborne and Airborne Rubeola (measles) Mycobacterium tuberculosis Airborne Mycobacterium tuberculosis Airborne Bordetella pertussis Respiratory syncytial or parainfluenza virus Droplet Resistant bacterial Resistant bacterial Staphylococcus aureus, group A streptococcus f Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (eg, pertussis in neonates and adults may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgment. { The organisms listed under the column "Potential Pathogens" are not intended to represent the complete, or even most likely, diagnoses, but rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out. These pathogens include enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, and rotavirus. Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical or epidemiological significance.

9 UNIVERSITY MEDICAL CENTER Isolation Guide for Inpatients MRSA & VRE patients are isolated if there is drainage that cannot be contained or with a physician order Blue Plastic Bag. Use gloves when handling linen. Blue Plastic Bag. Use gloves when handling linen. Droplet Neisseria meningitis Seasonal Influenza Mumps Rubella Pneumonia (Group A Strep, Mycoplasma, H. inflnemae, Adenovirus) Pertussis Blue Plastic Bag. Use gloves when handling linen. Waste Handling All waste from room goes into red bags. All waste from room goes into red bags. All waste from room goes into red bags. All waste from room goes into red bags. Instrument Handling Gloves. Send for processing as usual Gloves. Send for processing as usual Gloves. Send for processing as usual. Gloves. Send for processing as usual. PPE Gown and gloves always required upon entry to room. Gown and gloves always required upon entry to room. Standard mask within three feet of patient. PAPR or N-95 Respiratory mask if fit tested within the last year Mask used if there is a risk of fluid splash or spray. Easily transmitted on the hands. Standard precautions, gloves, and other barriers are used when needed Type of precautions Disease Examples (not all inclusive) Linen Scabies, Lice, Shingles, RSV, MDR Acinetobacter,, ESBL- positive isolates, CRE organisms Codtact D C. difficile Norovirus Diarrhea and pt. is incontinent or using adult briefs Airborne TB Measles Chickenpox Ebola (see Infectious Disease Agent and Max Surge Plan EP ) Blue Plastic Bag. Use gloves when handling linen. Must be fit tested by Employee Health ex.t 5555 Easily transmitted on the hands. H Clothing Change If clothing has been unprotected by PPE or grossly soiled. If clothing has been unprotected by PPE or grossly soiled. If clothing has been unprotected by PPE or grossly soiled. If clothing has been unprotected by PPE or grossly soiled. Standard Precautions are to be used to prevent skin and mucous-membrane exposure when contact with blood or other body fluids of any patient is anticipated. Gloves must be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids and vascular access procedures. Masks and protective eyewear or face shields must be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes. Gowns must be worn during procedures that are likely to generate splashes of blood or other body fluids. If patient requires more than one type of isolation, follow measures for all types of isolation required. Revised: Oct., 2015

10 UNIVERSITY MEDICAL CENTER Type of precautions Isolation Guide for Inpatients Droplet D Airborne Staffing Recommendations Normal Normal Normal Normal Equipment Disposable or clean well between patients with Sani-wipes or hospital disinfectant. Disposable or clean well between patients with bleach wipes. Disposable or clean well between patients with Sani-wipes or hospital disinfectant. Disposable or clean well between patients with Sani-wipes or hospital disinfectant. Transport Gloves, gown to assist patient on and off bed and stretcher. Wipe down pushing surface of bed/stretcher with Sani wipes. Cover patient with clean sheet. Remove gown, gloves prior to transport, wash hands. Carry clean PPE to destination, don when assisting patient. Clean stretcher thoroughly before transporting other patients. Clean the patient environment with Saniwipes or hosp. disinfectant. Change privacy curtain. Gloves, gown to assist patient on and off bed and stretcher. Wipe down pushing surface of bed/stretcher with bleach wipes. Cover patient with clean sheet. Remove gown, gloves prior to transport, wrash hands. Carry clean PPE to destination, don when assisting patient. Clean stretcher thoroughly before transporting other patients. Place yellow isolation mask on patient and transport as usual. Limit transports to essential procedures Clean rooms with bleach solution or bleach cloths. Change privacy curtain. Discharge cleaning as usual. Discharge cleaning Place yellow isolation mask on patient and transport as usual. Change privacy curtain Allow room to filter for 1 hour, then clean the environment with Sani-wipes or hosp. disinfectant. Change privacy curtain. Discharge cleaning as usual. Use soap and water for hand hygiene upon exiting room Hand Off Communication Communicate isolation needs to receiving department, agency, or facility. Document in patient chart. Communicate isolation needs to receiving department, agency, or facility. Document in patient chart. Communicate isolation needs to receiving department, agency, or facility. Document in patient chart. Communicate isolation needs to receiving department, agency, or facility. Document in patient chart. Room Requirements Private or cohort with another compatible patient: same gender, same organism. Infection Prevention at ext. 5006/5134 for assistance Private or cohort with another compatible patient: same gender, same organism. Infection Control ext 5006/5134 for assistance Private or cohort with another compatible patient: same gender, same organism. Infection Control ext 5006/5134 for assistance Private or cohort with another compatible patient: same gender, same organism. Infection Control ext. 5006/5134 for assistance Negative pressure rooms: 3223, 3225, 3227, 3229, 3176, 4176, 5176, 5179, 6186, 6190 Keep door closed at all times Revised: Oct., 2015

11 UNIVERSITY MEDICAL CENTER I M K t N IV I R S 1 1 V O f Isolation Guide for Inpatients T O I f I) O Type of precautions DC Isolation Scabies and Lice: 24 hours after treatment with scabicide or lice treatment. D After completion of treatment and no diarrhea for 48 hours. Note: A negative C diff test does not warrant discontinuing isolation. Discuss with Infection Prevention or Infectious Disease Physician 0roplet Meningitis: After 24 hours of appropriate antibiotic therapy or when found to be viral meningitis Influenza: after 7 days for suspected or confirmed influenza or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility. Airborne TB: when not symptomatic (coughing stops) and the results of three sputum smears for AFB have been reported as negative. Measles: When scabs are gone. Disseminated Herpes Zoster: When crusts are dry Mumps: 9 days after the onset of the swelling. Rubella: 7 days after the onset of the rash. Invasive Haemophilus disease: duration of illness. Pertussis: after 5 days of treatment. Facilities / Environmental Services Protection When you are in any area that could be the source of a fluid exposure, you should wear eye protection, in addition to these recommendations. Always wear gloves and gown when entering the patient room that is on contact precautions. Always wear gloves and gown when entering the patient room that is on contact precautions. Hands must be cleansed with soap and water upon exiting pt. room or environment. Wear a standard surgical mask when entering the room. This does not require fit testing. If you think you will have contact with any type of body fluids, you should wear gown and gloves. PAPR required Wear gown and gloves for contact precautions. Revised: Oct., 2015