A Nurse’s Guide to Isolation Precautions
A Nurse’s Guide to Isolation Precautions
by Mackenzie Thompson
Life Saver, NHCPS
posted on Apr 18, 2017, at 8:15 pm
Nurses are among the most impacted by patients with infections or illnesses that warrant additional precautions. Thus, these health care professional need to understand the epidemiology of the most common infections, how to address unique isolation needs and how they relate back to best practices and delivery on successful treatment outcomes.
How Often Are Patients Suffering From Illnesses Requiring Isolation?
This depends on the type of illness being referenced. In general, up to 7 percent of patients, or 10 percent in developing countries, may contract a health-care associated infection, including infections that would have been prevented through the use of appropriate isolation precautions, reports the World Health Organization (WHO).
Among these, influenza and C. diff remain the most prevalent. However, a common component of infections that warrant isolation is their ease of transmission and access to other people that lack immune system strength to fend off the infection.
In other words, nurses may have strong immune systems, which help them avoid infection while working in a health facility. However, other patients may be immunocompromised, so not following isolation guidelines with one patient may result in the transmission of diseases to other patients while providing care.
Consider the needs of patients that have an existing bloodborne illness, such as HIV or hepatitis B. While these infections are transmitted through direct contact of blood, semen or vaginal fluids, requiring universal precautions, as explained in our BBP: Bloodborne Pathogens course, they may not require additional isolation measures. However, each patient is different, and depending on the severity of the diagnosis, particularly in cases where HIV has progressed to acquired immune deficiency syndrome (AIDS), isolation precautions may be warranted to prevent exposing the patient to common pathogens, such as a cold.
New, emerging pathogens, such as multi-drug resistant organisms (MDROs) and increasing rates of meningitis, reports the Centers for Disease Control and Prevention (CDC), contribute to the increased vigilance in managing and reducing transmission rates. Meanwhile, sudden outbreaks of deadly, highly infectious diseases, such as Ebola, have spurred the creation of additional isolation measures, up to and including measures that preventing all health professionals from becoming exposed to the Ebola-containing room.
Clearly, trying to simply follow universal precautions when working with patients on isolation is dangerous.
For example, water-proof gowns, hazardous-material (hazmat) suits face shields, masks for both droplet and airborne contaminates, such as the N95 mask used to prevent tuberculosis transmission, shoe coverings and negative-pressure rooms may be used to reduce transmission risk.
Clearly, trying to simply follow universal precautions when working with patients on isolation is dangerous. Isolation precautions fall into one of five categories, which include the following:
- Contact precautions
- Droplet precautions
- Airborne precautions
- Neutropenic precautions
- Radiation precautions
For nurses, knowing the difference between these precaution sets is essential to providing superior care and ensuring their personal safety and the safety of patients, family members and visitors to the care facility.
Contact Isolation Precautions
Common reasons for contact isolation include illnesses with a high-risk transmissibility, such as C. diff, Herpes simplex virus, scabies, MRSA or even fungal infections.
Contact isolation precautions revolve around the most common method of transmission for pathogens, direct or indirect contact. Direct contact transmission is the result of transference of pathogens from one person to another person with a contaminated intermediary, such as floor or table.
For example, blood or blood-containing fluids that come into contact with the mucus membranes of a caregiver or enter the body via cuts or abrasions are considered direct contact. Indirect contact involves an intermediary for transmission, such as using an oral thermometer between patients with using barriers or probe covers.
The simplest way to remember contact isolation precautions lies in preventing direct contact with the patient or surfaces in the room if there is a reasonable chance that you will encounter blood or blood-containing bodily fluids.
1. Wear Gloves
Gloves prevent direct transmission to the hands, but they are not impervious. Double-gloving does not necessarily provide better protection against an organism. In addition, gloves do not provide protection against accidental exposure due to needle sticks. Therefore, take care when wearing gloves to prevent their tearing or damaging while providing care. If they do tear or rip, wash your hands and put on a near pair before continuing with providing patient care.
2. Use a Face Shield if Splashing Is Likely
Splashing body fluids may include removing an intravenous (IV) line too quickly, resulting in the brief propulsion of blood into the air, which may end up in a nurse’s face. In this case, a face shield is appropriate. Similarly, a face shield may be necessary when providing perineal care, cleaning of the genitals.
3. Wear a Mask if Splashing Into the Face Is Likely
Masks are commonly listed under droplet or airborne precautions. However, they may be necessary when providing care if splashing is likely and a face shield is not fully effective.
For example, masks can provide protection if splashing may come from the bottom up. In other words, masks can prevent splashing of bodily fluids near the chin or mouth.
4. Shoe Covers May Be Necessary
Patients on contact isolation precautions represent a risk to other patients. One of the most forgotten aspects of contact isolation precautions is shoe covers. Some pathogens, such as C. diff and HIV can live on surfaces outside the body for days or until the next cleaning. Throughout the day, blood or blood-containing fluids may fall to the floor. While most of these cases are cleaned up immediately, the pathogen may survive. Thus, it could realistically be on the soles of your shoes, heading into the next room without proper protection.
Shoe covers may also benefit staff when caring for patients that have a bloodborne infection if blood or blood-containing fluids are likely to fall atop the shoes. For example, vomit may contain blood, and shoe covers may be necessary.
5. Perform Hand Washing
Hand hygiene is often used interchangeably with handwashing. In other words, an alcohol-based hand sanitizer may be used in lieu of handwashing provided hands are not visibly soiled. Due to increased risk of transmission of pathogens while on contact precautions, hand sanitizer should never be used as a substitute for hand washing. Hand sanitizers may be used after hand washing at the discretion of the health care professional.
6. Report Any Possible Exposure Immediately
The final step in addressing contact precautions is understanding the importance of reporting possible exposure. This includes accidental needle sticks or known exposure to blood or blood-containing fluids via mucus membranes or other entryways to the body.
Droplet Isolation Precautions
Illnesses spread by droplets include and are not limited to influenza, rhinovirus, pertussis and group A streptococcus.
Droplet isolation precautions are used when pathogens are small enough to be dispersed into the air when coughing or sneezing. However, they do settle on surfaces, and some pathogens may also be transmitted via direct contact. So, droplet isolation precautions should include the use of all appropriate measures as identified in the section entitled, “Contact Isolation Precautions.” Additional isolation measures included under droplet precautions include the following:
1. Wear A Mask
The typical, yellow-colored mask used for procedures is essential to preventing droplet transmission. The mask should be applied before opening the door to a patient’s room, and should only be removed upon exiting the room.
2. Wear Goggles
The use of goggles to prevent droplet transmission via the eyes may depend on the specific policies of your facility. In many cases, a facility may require the use of a face shield and routine procedure mask in lieu of goggles.
3. Remove PPE and Perform Hand Washing After Completing Care and Leaving the Room
As with contact precautions, you should wash your hands with warm soap and water upon leaving the patient’s room.
There is not a standard distance that defines how far a droplet-borne pathogen may travel. Experts describe it as a “relatively short distance,” such as three feet. However, the higher concentration of droplet-borne pathogens in patient rooms may require the use of masks upon entry regardless of the distance to the patient.
Droplet size is key to determining if an infection falls under droplet or airborne precautions. Generally, droplets are defined as being greater than 5 µm in size, meaning their size enables long-term suspension in the air. Thus, transmission can be prevented by using a basic, protective mask. However, smaller size particles may penetrate these masks, pushing the level of precautions into the next category, airborne precautions.
Airborne Isolation Precautions
Common airborne infections include spores or desiccated nuclei of pathogens, such as spore of Aspergillus and tuberculosis.
Airborne isolation precautions are used to prevent transmission of droplet-borne pathogens of less than 5 µm and those that may be disseminated within a facility over distances more than 10 feet. In addition, droplet-borne or contact-based infections that desiccate, or dry out, on a surface can be aerosolized in an environment, increasing transmissibility.
Airborne pathogens also have an increased infective rate. In other words, transmissibility increases as these infectious agents spread throughout a facility to those that have not been in the same room as an infected patient or hand indirect or direct contact with such patient. Therefore, special care must be taken to prevent their transmission, including these steps.
1. The Patient Should Be in a Negative-Pressure Room
A negative-pressure room maintains a lower pressure via the ventilation system that prevents airborne pathogens form exiting the room through an opened door. This is comparable to the effect of a mild vacuum or feeling air rush into an enclosed when opening the doors.
2. Wear an Appropriate Respirator
Due to the decreased size of the infectious agents in airborne illnesses, such as spores or dried, aerosolized nuclei, a higher-level respirator is needed to prevent their inhalation. The respirator should have an NIOSH rating of N95 or higher, and the respirator should be applied prior to entering the patient room. Otherwise known as a “duck-billed” mask, the respirator should adhere to the face without obstruction. Therefore, caregivers wearing heavy makeup or those with excess facial hair may be susceptible to infection via airborne pathogens.
3. Dispose of PPE in the Adjunct Room, Not Another Patient’s Room
Most negative-pressure rooms have an adjunct room for donning PPE prior to entry. This room is part of the specialized ventilation system, and all PPE used in a negative-pressure room should be left on until the caregiver is within this room, having closed the patient’s primary room door. Handwashing should be completed within this room, and the specialized air ventilation system will draw airborne pathogens, explains the CDC, into the patient’s room and through external air filters.
Neutropenic and Radiation Precautions
Neutropenic precautions are used when a patient has a low number of neutrophils in their immune system, making them immunocompromised. Neutropenic precautions may be used for patients that have AIDS or who are on immunosuppressants.
Neutropenic precautions are comparable to contact precautions in reverse. For example, you may need to wear gloves or other appropriate PPE to prevent bringing contaminates into the patient’s room. In addition, fresh fruits or vegetables should not be included with patient meals. Neither flowers nor live gifts of any kind should be brought into the room. Wash your hands immediately prior to entering the room as well.
Protect Yourself, Your Patients and Your Family From Infection by Getting the Training You Need.
Radiation precautions are also similar to neutropenic precautions because radiation may result in neutropenia too. However, radiation precautions also mean that all materials brought into a patient’s room must stay for the duration or until removed by an appropriate person, such as a custodial member of nuclear medicine.
Depending on the level of radiation used, including the use of radiopharmaceuticals, reports the University of Iowa, time limits may be imposed for visitors and caregivers in both daily and weekly maximums. In addition, gowns, shoe covers or other PPE equipment may be required. The appropriate member of nuclear medicine will provide an exposure-guideline chart that will placed aside the patient’s door. Due to privacy laws, this chart may contain protected health information, and it may be placed inside the top shelf of the appropriate isolation cart.
Protect Yourself, Your Patients and Your Family From Infection by Getting the Training You Need.
Isolation precautions are only part of the battle in preventing the spread of infection in your role as a health care professional. Understanding bloodborne pathogens is critical to making the most out of this article on isolation precautions. In the interim, by taking these steps, you can help stop the spread of infection now.