POLICY #: PPB-NCBH-117 POLICY NAME: ISOLATION PRECAUTIONS EFFECTIVE: DECEMBER 2008

Transcription

1 POLICY #: PPB-NCBH-117 POLICY NAME: IOLATION PRECAUTION EFFECTIVE: DECEMBER 2008 NORTH CAROLINA BAPTIT HOPITAL, INCORPORATED POLICY AND PROCEDURE BULLETIN I. Description Describes the CDC-based isolation guidelines used to reduce the transmission of communicable diseases in the health care setting. 1

2 Table of Contents I. Description....1 II. Rationale..4 III. Policy.. 4 A. Principles of Isolation ource Host Transmission a. Contact Transmission b. Droplet Transmission... 5 c. Airborne Transmission d. Common Vehicle Transmission e. Vector-borne Transmission B. Fundamentals of Isolation Hand Hygiene and Gloving Patient Placement Transport of Infected Patients Masks, Respiratory Protection, Eye Protection, Face hields Gowns and Protective Apparel Patient Care Equipment and Articles Linen and Laundry Dishes, Glasses, Cups, and Eating Utensils Fans Visitors C. NCBH Isolation tandard Transmission-Based....8 D. Empiric...9 E. Guidelines for Isolation tandard...10 a. Hand Hygiene...10 b. Gloves c. Mask, Eye Protection, Face hield d. Gown e. Removal of Personal Protective Equipment f. Patient Care Equipment g. Linen h. Occupational Health and Bloodborne Pathogens i. Patient Placement j. Respiratory Hygiene / Cough Etiquette Airborne a. Patient Placement.. 12 b. Respiratory Protection...13 c. Patient Transport pecial Airborne

3 a. Patient Placement.. 14 b. Respiratory Protection.. 14 c. Gloves and Hand Hygiene d. Gown e. Protective Eyewear f. Patient Transport Droplet.. 14 a. Patient Placement...14 b. Masks c. Patient Transport Contact...15 a. Patient Placement b. Hand Hygiene c. Gloves d. Gown...15 e. Masks f. Patient Transport g. Patient Care Equipment h. Packaged Disposable Items i. Guidelines for Therapeutic Activities with Patients on Contact Protective a. Indication b IV. References...20 V. Reviewed/Approved by VI. Policy Revision Dates.. 20 Appendix 1: ynopsis of Types of and Patients Requiring for Disease and uspected Disease 21 Appendix 2: Isolation Quick Reference 25 Appendix 3: Type and Duration of Recommended for elected Infections and Conditions Appendix 4: hort Reference List for Discontinuation of Isolation 42 Appendix 5: equence for Donning and Removal of Personal Protective Equipment 45 Appendix 6: Respiratory yncytial Virus (RV) Guidelines for Pediatrics 46 Appendix 7: Management of Herpes Zoster (hingles) in the Clinics and on the NCBH Rehabilitation Unit 47 Appendix 8: Management of Patients with uspected Viral Hemorrhagic Fevers Due to Marburg, Ebola, and Crimean-Congo Hemorrhagic Fever Viruses 48 Appendix 9: MRA Positive Mother or Primary Care Giver of Patients in Neonatal Intensive Care Unit / 6IMN 50 Appendix 10: Isolation Guidelines for Infants and Mothers with Infectious Diseases 51 Appendix 11: Infection Prevention in the Nursery 53 Appendix 12: Isolation igns 54 3

4 II. Rationale The spread of communicable disease can be prevented by instituting control measures based upon the route of transmission. III. Policy A. Principles of Isolation Transmission of infection within a hospital requires 3 elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism. 1. ource Human sources of the infecting microorganisms in hospitals may be patients, personnel, or on occasion, visitors, and may include persons with acute disease, persons in the incubation period of a disease, persons who are colonized by an infectious agent but have no apparent disease, or persons who are chronic carriers of an infectious agent. Other sources of infecting microorganisms can be the patient s own endogenous flora (major source for healthcare-associated infections), which may be difficult to control, and inanimate environmental objects that have become contaminated, including equipment and medications. 2. Host Resistance among persons to pathogenic microorganisms varies greatly. ome persons may be immune to infection or may be able to resist colonization by an infectious agent; others exposed to the same agent may establish a commensal relationship with the infecting microorganism and become asymptomatic carriers; still others may develop clinical disease. Host factors such as age; underlying disease; treatments with antimicrobials, corticosteroids, or other immunosuppressive agents; irradiation; and breaks in the first line of defense mechanisms caused by such factors as surgical operations, anesthesia, and indwelling catheters may render patients more susceptible to infection. 3. Transmission Microorganisms are transmitted in hospitals by several routes, and the same microorganism may be transmitted by more than one route. There are five main routes of transmission: contact, droplet, airborne, common vehicle, and vector-borne. For the purpose of this policy, common vehicle and vector-borne transmission will be discussed only briefly, because neither plays a significant role in typical healthcare associated infections. a. Contact Transmission Contact transmission, the most important and frequent mode of transmission of healthcareassociated infections, is divided into 2 subgroups: direct-contact transmission and indirectcontact transmission. 1. Direct-contact transmission involves a direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person, such as occurs when a person turns a patient, gives a patient a bath, or performs other patient-care activities that require direct personal contact. Direct-contact transmission also can occur between two patients, with one serving as the source of the infectious microorganisms and the other as a susceptible host. 4

5 2. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, medical devices (e.g., blood pressure cuffs), or dressings. b. Droplet Transmission Droplet transmission, theoretically, is a form of contact transmission. However, the mechanism of transfer of the pathogen to the host is quite distinct from either direct- or indirect-contact transmission. Therefore, droplet transmission will be considered a separate route of transmission in this policy. Droplets are generated from the source person primarily during coughing, sneezing, and talking, and during the performance of certain procedures such as suctioning and bronchoscopy. Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance ( 3 feet) through the air and deposited on the host s conjunctivae, nasal mucosa, or mouth. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission; that is droplet transmission must not be confused with airborne transmission. c. Airborne Transmission Airborne transmission occurs by dissemination of either airborne droplet nuclei (small-particle residue [5 μm or smaller in size] of evaporated droplets containing microorganisms that remain suspended in the air for long periods of time) or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled by a susceptible host within the same room or over a longer distance from the source patient, depending on environmental factors; therefore, special air handling and ventilation are required to prevent airborne transmission. Microorganisms transmitted by airborne transmission include Mycobacterium tuberculosis and the rubeola and varicella viruses. d. Common Vehicle Transmission Common vehicle transmission applies to microorganisms transmitted by contaminated items such as food, water, medications, devices, and equipment. e. Vector-borne Transmission Vector-borne transmission occurs when vectors such as mosquitoes, flies, rats, and other vermin transmit microorganisms; this route of transmission is of less significance in hospitals in the United tates than in other regions of the world. B. Fundamentals of Isolation 1. Hand Hygiene and Gloving Hand hygiene is frequently considered the single most important measure to reduce the risks of transmitting microorganisms from one person to another or from one site to another on the same patient. Performing hand hygiene as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of infection control and isolation precautions. The scientific rationale, indications, methods, and products for hand hygiene have been delineated in healthcare publications (see Infection Control Policy: NCBH-119 Hand Hygiene, Use soap and water or an antiseptic agent (e.g., 2% CHG) and water after caring for patients with non-enveloped viruses (e.g., norovirus, adenovirus, polio) or C. difficile. In addition to hand hygiene, gloves play an important role in reducing the risks of transmission of microorganisms. Gloves are worn for three important reasons in hospitals. First, gloves are worn to provide a protective barrier and to prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. The wearing of gloves in specified circumstances to reduce the risk of exposures to 5

6 bloodborne pathogens is mandated by the OHA Bloodborne Pathogens final rule. econd, gloves are worn to reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive or other patient-care procedures that involve touching a patient s mucous membranes and non intact skin. Third, gloves are worn to reduce the likelihood that hands of personnel contaminated with microorganisms from a patient or a fomite can transmit these microorganisms to another patient. In this situation, gloves must be changed between patient contacts and hand hygiene performed after gloves are removed. Wearing gloves does not replace the need for hand hygiene, because gloves may have small, unapparent defects or may be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves and perform hand hygiene between patient contact is an infection control hazard. 2. Patient Placement Appropriate patient placement is a significant component of isolation precautions. A private room is important to prevent direct- or indirect-contact transmission when the source patient has poor hygienic habits, contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission of microorganisms (i.e., infants, children, and patients with altered mental status). A patient with highly transmissible or epidemiologically important microorganisms is placed in a private room with hand hygiene and toilet facilities, to reduce opportunities for transmission of microorganisms. A private room with appropriate air handling and ventilation is particularly important for reducing the risk of transmission of microorganisms from a source patient to susceptible patients and other persons in hospitals when the microorganism is spread by airborne transmission. 3. Transport of Infected Patients Limiting the movement and transport of patients infected with virulent or epidemiologically important microorganisms and ensuring that such patients leave their rooms only for essential purposes reduces opportunities for transmission of microorganisms in hospitals. When patient transport is necessary, it is important that (1) appropriate barriers (e.g., masks, impervious dressings) are worn or used by the patient to reduce the opportunity for transmission of infectious microorganisms to other patients, personnel, and visitors and to reduce contamination of the environment; (2) personnel in the area to which the patient is to be taken are notified of the impending arrival of the patient and of the precautions to be used to reduce the risk of transmission of infectious microorganisms; and, (3) patients are informed of ways by which they can assist in preventing the transmission of their infectious microorganisms to others. 4. Masks, Respiratory Protection, Eye Protection, Face hields Various types of masks, goggles, and face shields are worn alone or in combination to provide barrier protection. A mask that covers both the nose and the mouth, and goggles or a face shield are worn by hospital personnel during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions to provide protection of the mucous membranes of the eyes, nose, and mouth from contact transmission of pathogens. The wearing of masks, eye protection, and face shields in specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by the OHA Bloodborne Pathogens final rule. A surgical mask generally is worn by hospital personnel to provide protection against spread of infectious large-particle droplets that are transmitted by close contact and generally travel only short distances (up to 3 ft.) from infected patients who are coughing or sneezing. An N-95 respirator (prior fit-testing required) is worn by personnel to provide protection against infectious small-particle droplets (< 5 μm) that can remain suspended in the air for long periods of time (e.g., droplet nuclei of Mycobacterium tuberculosis). An N-95 respirator is also worn when patients have smallpox, monkeypox, viral 6

7 hemorrhagic fever (VHF), AR-CoV, and avian influenza. Patients leaving the BMTU should wear an N100 respirator if cleared by physician. 5. Gowns and Protective Apparel Various types of gowns and protective apparel are worn to provide barrier protection and to reduce opportunities for transmission of microorganisms in hospitals. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. Gowns that are treated to make them impermeable to liquids, leg coverings, boots, or shoe covers provide greater protection to the skin when splashes or large quantities of infective material are present or anticipated. The wearing of gowns and protective apparel under specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by the OHA Bloodborne Pathogens final rule. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from patients or items in their environment to other patients or environments. When gowns are worn for this purpose, they are removed before leaving the patient s environment, and hand hygiene is performed. 6. Patient Care Equipment and Articles Many factors determine whether special handling and disposal of used patient-care equipment and articles are prudent or required, including the likelihood of contamination with infective material; the ability to cut, stick, or otherwise cause injury (needles, scalpels, and other sharp instruments [sharps]); the severity of the associated disease; and the environmental stability of the pathogens involved. ome used articles are enclosed in containers or bags to prevent inadvertent exposures to patients, personnel, and visitors and to prevent contamination of the environment. Used sharps are always placed in puncture-resistant containers. Guidelines for the disposal of medical waste are provided in the Infection Control Policy: Management of Regulated and Non-Regulated Waste, NCBH-138, Contaminated, reusable critical medical devices or patient-care equipment (i.e., equipment that enters normally sterile tissue or through which blood flows) or semicritical medical devices or patient-care equipment (i.e., equipment that touches mucous membranes) are sterilized or disinfected (reprocessed) after each use to reduce the risk of transmission of microorganisms to other patients; the type of reprocessing is determined by the article, its intended use, and the manufacturer s recommendations. Noncritical equipment (i.e., equipment that touches intact skin) contaminated with blood, body fluids, secretions, or excretions is cleaned and disinfected after each patient use. The Infection Control Policy entitled, Disinfection of Non-Critical Medical Devices/Equipment, NCBH detailed guidelines to ensure appropriate disinfection/sterilization of equipment and devices. Only those supplies essential for a patient s care should be kept in the patient s room. At the time of patient discharge, unused items may be saved and used for another patient including the supplies of those patients on Contact. However, the supplies must be discarded and not used if: 1) the item is visibly soiled, 2) if a packaged item has been opened or the integrity of the package has been compromised, or 3) the patient on Contact was located in the Burn Center. 7. Linen and Laundry Although soiled linen may be contaminated with pathogenic microorganisms, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms to patients, personnel, and environments. All linen should be considered potentially contaminated and handled with tandard. Isolation linen does not require 7

8 special bagging. Fluid-resistant bags are used for wet contaminated linen to prevent potential leaking of body fluids through the bags. 8. Dishes, Glasses, Cups, and Eating Utensils No special precautions are needed for dishes, glasses, cups, or eating utensils. Reusable dishes and utensils can be used for patients on isolation precautions. 9. Fans Fans are prohibited in rooms of patients on isolation precautions. 10. Visitors Visitors may not eat or drink in rooms of patients on Airborne or Droplet. Prison Guards may not eat or drink in the rooms of patients on Airborne, Droplet, or Contact. The above eating and drinking restrictions do not apply to Pediatrics. C. North Carolina Baptist Hospital Isolation There are three tiers of NCBH Isolation. In the first and most important tier are those precautions designed for the care of all patients, regardless of their diagnosis or presumed infection status. Implementation of these tandard is the primary strategy for successful healthcare associated infection control. In the second tier are precautions designed only for the care of specified patients. These additional transmission-based precautions are for patients known or suspected to be infected by epidemiologically important pathogens spread by airborne or droplet transmission or by contact with skin or contaminated surfaces. The third tier Protective is designed for the protection of the immunosuppressed patient whose resistance to infection is impaired due to treatment or disease. 1. tandard tandard apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; (3) nonintact skin; and (4) mucous membranes. tandard are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. 2. Transmission-Based Transmission-based precautions are designed for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond tandard are needed to interrupt transmission in hospitals. There are four types of Transmission-Based : pecial Airborne, Airborne ; Droplet ; and Contact. They are combined for diseases that have multiple routes of transmission. When used either singularly, or in combination, they are used in addition to tandard. a. pecial Airborne pecial airborne precautions are designed to reduce the risk of airborne transmission of infectious agents transmitted by the airborne route and also by contact with mucous membranes. These precautions require the use of an N-95 respirator, eye protection (e.g., goggles), gloves, and gown to enter the room. pecial Airborne are used for patients with AR-CoV, smallpox, monkeypox, viral hemorrhagic fevers (VHF; e.g., Congo-Crimean, Lassa, Ebola, Marburg, Argentine, Bolivian), and avian influenza. As with Airborne, special air handling and ventilation are required (see below). b. Airborne 8

9 Airborne precautions are designed to reduce the risk of airborne transmission of infectious agents. Airborne transmission occurs by dissemination of either airborne droplet nuclei (smallparticle residue [5 μm or smaller in size] of evaporated droplets that may remain suspended in the air for long periods of time) or dust particles containing the infectious agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled by or deposited on a susceptible host within the same room or over a longer distance from the source patient depending on environmental factors; therefore, special air handling and ventilation are required to prevent airborne transmission. Airborne apply to patients known or suspected to be infected with epidemiologically important pathogens that can be transmitted by the airborne route. c. Droplet Droplet precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (larger than 5 μm in size) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking and during the performance of certain procedures such as suctioning and bronchoscopy. Transmission via large-particle droplets requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only short distances, usually 3 ft. or less, through the air. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission. Droplet apply to any patient known or suspected to be infected with epidemiologically important pathogens that can be transmitted by infectious droplets. d. Contact Contact precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients, bathe patients, or perform other patient-care activities that require physical contact. Direct-contact transmission also can occur between two patients (e.g., by hand contact), with one serving as the source of infectious microorganisms and the other as a susceptible host. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient s environment. Contact apply to specified patients known or suspected to be infected or colonized (presence of microorganism in or on patient but without clinical signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. 3. Protective NCBH provides medical care to variety of patients who may have impaired resistance to infection. Immunosuppression may be due to underlying disease such as HIV and leukemia as well as treatments such as organ transplant and chemotherapy. In order to provide an environment as safe as possible for the immunosuppressed patient, a protocol of Protective is followed. D. Empiric Patients with a known or suspected communicable disease (e.g., TB, pertussis, invasive meningiococcal disease) should be placed on the appropriate isolation precautions as per NCBH policy and CDC guidelines. Any nurse or physician may initiate isolation precautions; however, only a physician or Infection Control practitioner may discontinue isolation precautions. Once a communicable disease requiring isolation has been ruled out, empiric isolation precautions may be discontinued. If a 9

10 communicable disease requiring isolation is confirmed, isolation should be continued for the duration defined by NCBH policy and CDC guidelines. E. Guidelines for Isolation Maintaining uniform standards of isolation practice within NCBH is essential to protect patients and those responsible for their care from acquiring communicable diseases. It is the responsibility of the physician to recognize the need for isolation and to indicate the appropriate type of isolation precautions to be followed. Isolation precautions should be instituted empirically as described in section IV, Empiric use of Airborne, Droplet, or Contact, and in Appendix 3. The physician may consult with an Infection Control Professional if desired. When the need is demonstrated, isolation procedures may be instituted by a nurse or Infection Control Professional prior to the action by a physician. Termination of isolation requires a physician s order or the recommendation of Hospital Epidemiology. Every member of the direct healthcare team has the responsibility to observe proper procedures and to teach them to those individuals coming in contact with the patient who are not familiar with isolation techniques. The patient and their family should also be instructed regarding the need for isolation precautions to promote compliance. The appropriate Isolation Precaution sign (pecial Airborne, Airborne, Droplet, Contact, Protective) should be placed in a readily visible location outside of the patient s room. The signs should be readily available in all areas where patients requiring isolation are seen. No card is necessary for tandard. 1. tandard Use tandard, or the equivalent, for the care of all patients. a. Hand Hygiene Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Perform hand hygiene 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 perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites. An alcohol-based hand hygiene product may be used if hands are not visibly soiled or contaminated with blood or other potentially infectious materials (OPIM). New Born Nursery please refer to Appendix 11: Infection Prevention in the Nursery. b. Gloves Wear latex 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, and perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environments. elect gloves with barrier durability appropriate for the task: latex, or if allergic to latex, nitrile gloves, when handling blood or other potentially infectious material (OPIM) (e.g., CF pleural fluid, peritoneal fluid, semen, vaginal secretion); vinyl gloves for activities unlikely to involve contact with blood or OPIM. c. Mask, Eye Protection, Face hield 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. Wear mask and eye protection for patients on pecial Airborne. 10

11 d. 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. elect a gown that is appropriate for the activity and amount of fluid likely to be encountered. Carefully remove a soiled gown so clothes are not contaminated. Gowns should be removed promptly when no longer needed and should be properly disposed of. Disposable gowns may not be used more than once. Perform hand hygiene to avoid transfer of microorganisms to other patients or environments. e. Removal of Personal Protective Equipment Refer to Appendix 5 for sequence of PPE removal. f. 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 single use items are discarded properly. Refer to Disinfection of Non-Critical Medical ervices / Equipment Policy NCBH (appendix A) for details on approved cleaning of patient care equipment. g. 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. h. Occupational Health and Bloodborne Pathogens (For additional guidelines, see Infection Control Policy: NCBH-142, Bloodborne Pathogen Exposure Control Plan, 1. 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. Use needle-less devices when available in accordance with the Bloodborne Pathogen Exposure Control Plan 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, which are located as close as practical to the area in which the items are used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area. 2. Use mouthpieces, resuscitation bags or other ventilation devices as an alternative to mouthto-mouth resuscitation methods in areas where the need for resuscitation is predictable. 11

12 i. 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. j. Respiratory Hygiene / Cough Etiquette As a tandard Precaution, emphasize the importance of respiratory hygiene / cough etiquette to help decrease transmission of AR-CoV, influenza, and other respiratory pathogens. 1. Provide surgical masks to all patients with symptoms of a respiratory illness. Provide instructions on the proper use and disposal of masks. 2. For patients who cannot wear a surgical mask, provide tissues and instructions on when to use them (i.e., when coughing, sneezing, or controlling nasal secretions), how and where to dispose of them, and the importance of hand hygiene after handling this material. 3. Provide hand hygiene materials in waiting room areas, and encourage patients with respiratory symptoms to perform hand hygiene. 4. Designate an area in the waiting room where patients with respiratory symptoms can be segregated (ideally by at least 3 feet) from other patients who do not have respiratory symptoms. 5. Place patients with respiratory symptoms in a private room (preferred) or cubicle as soon as possible for further evaluation. 6. Implement use of surgical or procedure masks by health care personnel during the evaluation for patients with respiratory symptoms such as coughing and/or sneezing. 7. Consider the installation of Plexiglas barriers at the point of triage or registration to protect health care personnel from contact with respiratory droplets. 8. If no barriers are present, instruct registration and triage staff to remain at least 3 feet from unmasked patients and to consider wearing surgical masks during respiratory infection season. 9. Continue to use Contact. For patients with respiratory symptoms such as coughing and/or sneezing use also surgical or procedure masks. Continue to use masks until it is determined that the cause of symptoms is not an infectious agent that requires precautions beyond tandard. 2. Airborne In addition to tandard, use Airborne for patient known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue 5 μm 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). If the room is equipped with a rheostat or switch, ensure it is set to negative pressure. a. Patient Placement 1. Place the patient in a specially ventilated private room. Keep the room door closed and the patient in the room. Contact Infection Control at or pager for a listing of Airborne Isolation Rooms. 2. Perform a tissue test to assess negative pressure at least daily and document results on the patient record. To perform the tissue test: Hold a thin single-ply strip of tissue along the 12

13 bottom of the door at the corridor. The tissue should be drawn under the door towards the room. If the tissue is blown away from the door or falls straight to the floor, the room is not negative pressure and Maintenance should be notified to correct the problem as soon as possible. While waiting, a HEPA unit should be ordered from Engineering and placed inside the patient s room at the door. Engineering stores, maintains and installs portable HEPA units. These units move 700 cubic feet of air per minute, or 42,000 cubic feet of air per hour. OHA requires 6 air exchanges per hour. When a known or suspected TB patient has been in a room with a portable HEPA unit, the door should be closed and the room blocked for an adequate period of time to protect subsequent patients as well as staff without respirators. Fluoroscopy Room #20, for example, is 3000 cubic feet (20 ft x 15 ft x 10 ft). o, 42,000 (# of cubic ft of air per hour a HEPA unit can move) / 3,000 (size of #20 Fluoroscopy Room) = 14 ((# of air exchanges per hour). ince OHA requires only 6 air exchanges per hour, we divide 14 * 6 =.43 hours. o it takes about 30 minutes to clear a room the size of Fluoroscopy Room #20 of infectious organisms once the isolated patient is removed. Call Infection Control at or pager if guidance is needed in determining the need for a portable HEPA unit or the time needed to clear the air from a room after their use. HEPA units have been permanently installed in Peds Clinic, Dialysis unit, and #20 Fluoroscopy Room in Radiology b. Respiratory Protection 1. Wear respiratory protection (N-95 respirator for personnel; surgical mask for visitors) when entering the room of a patient with known or suspected infectious tuberculosis. usceptible persons should not enter the room of patients known or suspected to have measles (rubeola) or varicella (chickenpox) 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 (N-95 respirator). All persons regardless of their immune status to measles (rubeola) or varicella need to wear respiratory protection. 2. Disposable TB respirators may be used as long as the respirator continues to pass the fit check and the exterior surface has not become contaminated. Damaged or visibly soiled respirators should be immediately disposed of in a regular waste receptacle. Respirators should be immediately disposed of following each use when the patient is on Contact. c. 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. 3. pecial Airborne In addition to tandard, use pecial Airborne for patients known or suspected to be infected with microorganisms transmitted by the airborne route and also by contact with mucous membranes of the eyes, nose, and mouth. In particular, use pecial Airborne for patients with known or suspected AR-CoV infection, smallpox, monkeypox, VHF (e.g., Lassa, Ebola, Marburg, Argentine, Bolivian), and Avian influenza. Call Infection Control immediately at or pager for specific instructions if these organisms are suspected. The following is a brief outline of basic concepts. 13

14 a. Patient Placement Place the patient in a specially ventilated private room. Keep the room door closed and the patient in the room. Monitor daily (and record results in the patient s record) via a tissue test for negative air pressure in relation to the surrounding areas. b. Respiratory Protection Wear respiratory protection when entering the room of a patient on pecial Airborne. An N-95 respirator should be worn by personnel. Visitors should use an N-95 respirator if the patient is known/suspected to have AR-CoV or smallpox. c. Gloves and Hand Hygiene In addition to wearing gloves as outlined under tandard, wear gloves when entering the room (clean, nonsterile gloves are adequate). Perform hand hygiene following the removal of PPE. d. Gown Wear a gown to enter the room. Use of an isolation gown is adequate if no fluid exposure is anticipated. Use a fluid resistant gown if fluid exposure is anticipated. Perform hand hygiene following the removal of PPE. e. Protective Eyewear Wear protective eyewear to enter the room. Goggles must be used for aerosol-generating procedures (e.g., suctioning, wound irrigation, inhalation therapy). f. Patient Transport Limit the movement and transport of the patient from 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. If the patient must be moved out of the room, consult the Infection Control Professional for your area or pager for advice regarding strategies to prevent exposures during transport. 4. Droplet In addition to tandard, use Droplet for a patient known or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets larger than 5 μm in size that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures). a. Patient Placement Place the patient in a private room. b. Masks In addition to tandard, wear a surgical mask when entering the room. c. Patient Transport 14

15 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. 5. Contact In addition to tandard, use Contact for specified patients known or suspected to be infected or colonized with epidemiologically important microoganisms 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. a. Patient Placement Place the patient in a private room. b. Hand Hygiene All staff will perform strict hand hygiene using an antibacterial product (chlorhexidine gluconate 2%) immediately after patient contact and after touching contaminated articles. An alcohol based hand hygiene product is acceptable for use unless the hands are contaminated with proteinaceous material or visibly soiled. Use soap (e.g., 2% CHG) and water when caring for patients with nonenveloped viruses (e.g., norovirus, adenovirus, polio) or C. diff.. c. Gloves In addition to wearing gloves as outlined under tandard, 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 perform hand hygiene immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and hand hygiene, 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. d. Gown In addition to wearing a gown as outlined under tandard, wear an isolation gown each time you enter the patient s room. Before leaving the patient s environment, carefully remove and properly dispose of the gown. Yellow isolation gowns are not to be reused. Ensure that clothing does not contact the contaminated gown or potentially contaminated environmental surfaces. Perform hand hygiene after gown removal. e. Masks All staff will wear a surgical mask when performing procedures that may generate droplets or aerosolization of infective material (e.g., suctioning, tracheal care, wound irrigation). Properly dispose of mask upon leaving the patient s room and perform hand hygiene. f. Patient Transport Limit the movement and transport of the patient from the room to essential purposes only. If the 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. g. Patient Care Equipment 15

16 When possible, dedicate the use of noncritical patient-care equipment to a single patient to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient. After use in the room of a patient on Contact, the parts of the portable x-ray machine that have been touched by the technicians or the patient or may have come into contact with contaminated items in the room will be cleaned with an EPA-approved disinfectant detergent. h. Packaged Disposable Items 1. Rooms should be stocked with limited amounts of disposable items such that they will be used within a short period of time (e.g., <24 hours). 2. Disposable sterile packaged items that are opened, damaged, wet, or visually contaminated (e.g., dry blood) should not be used and must be discarded. 3. upplies should be handled only with clean hands or clean gloves and should be stored in a drawer or far enough from the patient and water sources to prevent droplet contamination of the item (i.e., >3 feet away). 4. When a patient on Contact is transferred from the room or discharged, unused supplies that have been stored in accordance with item C, above, may be used for the next occupant. i. Guidelines for Therapeutic Activities with Patients on Contact Patients on Contact should remain in their rooms for all but essential purposes. As part of their rehabilitation, some patients need to exercise outside of their rooms, accompanied by a physical therapist, nurse, or other health care worker. The following precautions should be followed when the patient leaves the room for therapeutic purposes (e.g., physical therapy): 1. The patient will be accompanied by a therapist, nurse, or other healthcare worker when walking in the hallways. 2. Ideally, the patient should remain on their unit. The patient should not enter the room of any other patients. 3. The caregiver will don gloves and an isolation gown to enter the Contact room. If the gloves or gown become visibly soiled while assisting the patient in the room, they should be changed prior to leaving the room with the patient. 4. Prior to leaving the room, the patient will wash or have hands washed with assistance. oap with CHG or alcohol based hand hygiene product should be used. 5. The patient should don a clean hospital gown or isolation gown prior to leaving the room. 6. Dressings should be clean and should contain any wound drainage. 7. The patient should be instructed not to handle any items in the environment. The caregiver should avoid touching items in the environment. If it is necessary for the patient or caregiver to handle items, then the caregiver should thoroughly clean these items with an hospital-approved disinfectant detergent. Ideally, cleaning should be done prior to leaving the area; however, if this is not possible, then cleaning will be done after the patient has been returned to their room. 8. After returning the patient to the room, the healthcare worker must remove gown and gloves and perform hand hygiene. 16

17 9. Pediatric Patients on contact precautions for MRA, VRE, resistant pneumococci, and/or other multiple resistant bacteria including gram-neg. rods as determined by IC may spend time in the hallways and use the Playrooms/Lounge. Before doing so, they should: put on a clean gown, wash hands, wear mask if the isolate is known to be in sputum and/or they have known resp. disease (CF, etc.). Pediatric patients on contact precautions for all other causes such as respiratory tract infections including RV, enteric infections, skin infections/manifestations, and miscellaneous conditions or body sites will stay in their rooms. Patient s primary caregivers, who are rooming in, are NOT required to wear an isolation gown in the patient room or outside. However, they should be instructed to wash/disinfect their hands thoroughly before leaving the room, have restricted access to other areas in the unit/hospital (kitchen etc.), and cannot visit any other patients. hort time visitors should follow the isolation precautions by wearing a gown inside the patient room for the time of their visit. 10. Adult patients, especially elderly and long term patients, are sometimes allowed to sit outside of their rooms for socialization purposes. This is acceptable for patients on Contact, as long as they remain confined to their chair and remain just inside or just outside the doorway to their room, in a location where the Contact sign is visible. 11. The above terms do not apply to patients in airborne or droplet precautions as these precautions must be followed regardless of the patient s current location. j. When the infected site is the respiratory tract, instruct the patient to cough and expectorate into paper tissues. An appropriate receptacle for disposing of tissues must be provided to the patient. When the patient leaves their room, they must be able to manage their respiratory secretions in a manner to prevent droplet spread of organisms. A mask is not required unless necessary to control secretions, or unless a CF patient is on Contact. k. When the patient must be transported to another department, the following additional precautions should be taken: 1. Notify the receiving department that the patient is on Contact. 2. The receiving department must manage the patient in a manner to prevent the transmission of the resistant organisms to other patients or personnel. Ideally, patients on Contact will be seen at the end of the day or in a separate area. 3. The stretcher, wheelchair or other equipment used by the patient must be cleaned with an approved disinfectant prior to reuse. l. Patients colonized/infected in the respiratory tract with multiply-antibiotic resistant organisms (e.g., patient with B. cepacia or P. aeruginosa) will not undergo PT/OT at the same time/room with severely immunocompromised patients (e.g., leukemia or bone marrow transplant). m. If the patient is immunocompromised and requires Protective as well as Contact, all guidelines will be followed. For example, a mask may be indicated for the transplant patient for the first few weeks post transplant. All precautions to be taken will be indicated on the appropriate precaution card outside the patient s door. n. Patients who wish to visit other patients in the hospital must have approval from their attending physician and the attending physician of the other patient prior to visitation. o. All visitors must be instructed to follow Contact with special emphasis on handwashing. This is especially important, since many visitors interact with more than one patient and other patient s family members. Visitors must also be instructed that items are not to be 17