Isolation Precautions and Personal Protective Equipment (PPE)

Airborne Precautions: Airborne Infection Isolation Room

- 6 to 12 air changes per hour - Air is exhausted outside or through HEPA filter before recirculating - Negative air pressure directs the pathogen towards the exhaust - Keep the door closed other than when entering or exiting

Notes on safety (for doffing PPE)

- All PPE should be removed prior to leaving a patient's room unless you are wearing a respirator. - Respirators should only be removed outside the patient's room after the door is closed. - It is important to wash your hands or used alcohol based hand sanitizer after doffing PPE or if hands become contaminated while removing PPE.

Airborne Precaution: Immunization

- Any healthcare providers with increased susceptibility should not enter the room, for example during pregnancy or if they have not be immunized. - Vaccinate anyone who has had unprotected contact with the patient as soon as possible. Check on immunity status if boosters are needed.

Hand hygiene is performed

- Before and after coming into contact with a patient - Before and after donning or doffing gloves - After touching any potentially contaminated equipment, materials, or surfaces - When hands are visibly contaminated or soiled

Diagnoses requiring contact precautions

- Clostridium difficile (C. Diff) - Norovirus - Hepatitis A - if the patient is incontinent or wears briefs - Pediculosis - Head Lice - Scabies - Multi-Drug Resistant Organisms (MDROs) --- Methicillin-Resistant Staphylococcus Aureus: MRSA --- Vancomycin-Resistant Enterococci: VRE

Notes on safety (for donning PPE)

- Do not touch face while in PPE - Only touch necessary surfaces or objects - If gloves are torn or contaminated, replace them. - Always perform hand hygiene when removing PPE.

Sharps safety

- Don't recap needles with your hand - Don't pass uncapped needles to someone else - Always place used sharps in a sharps container for disposal

Cover-19 PPE Recommendations for Patients

- Everyone entering a healthcare facility should wear a face mask unless under age 2, having difficulty breathing, unconscious, or unable to remove the mask on their own. - Face masks with a valve are not effective at preventing spread of Covid-19.

Covid-19 PPE Recommendations for Providers:

- Healthcare providers should wear an N95 mask or equivalent respirator for contact with suspected or confirmed cases of Covid-19 and during aerosolizing procedures or surgeries. - Healthcare providers should wear a face mask or respirator throughout their shift - Perform hand hygiene before and after any contact with the face mask - Eye protection should be worn during patient care with any suspected or confirmed cases of Covid-19. Eye protection must cover the front and sides of the eyes. - Gown and gloves should be worn.

Diagnoses requiring airborne precautions

- Herpes Zoster or Varicella Zoster (shingles and chickenpox) - Rubeola (Measles) - Severe Acute Respiratory Syndrome - SARS - Variola- Smallpox - Tuberculosis

Covid-19 Patient Placement

- Home care is preferred if possible unless it is medically necessary for the patient to be hospitalized. - Maintain 6 foot social distancing between patients. - Limit the number of people in waiting rooms. Use physical barriers to guide and separate people. - Use separate or outdoor triage areas for patients with respiratory symptoms. - Limit visitors. - Cohort patients with Covid-19 into one unit away from patients without Covid-19. Designate providers to these areas to avoid room to room spread. - Place the patient in a AIIR room for any aerosol generating procedures. - Keep doors closed, especially during aerosolizing procedures.

Preventing occupational exposures

- Identify and provide safer medical devices that reduce or eliminate injuries from sharps - Involve health care workers in the selection process of these safer devices - Provide engineering controls for sharps disposal containers, self-sheathing needles, and other safety devices to reduce or eliminate sharps injuries - Educate employees regarding how to safely use these devices - Develop a sharps injury surveillance log

Diagnoses requiring droplet precautions

- Influenza - Meningitis - Haemophilusinfluenzae Type B - Neisseria meningitidis - Mumps - Parvovirus - Pertussis - Whooping Cough - Rhinovirus - Rubella - German measles - Group A Streptococcus - Strep Throat - Viral hemorrhagic fevers: Ebola

Contact Precautions: Patient Transport

- Only transport the patient outside of their room if medically required. - Keep any potentially contaminated or infected areas on the patient covered during transport - Remove contaminated PPE and perform hand hygiene prior to transporting the patient. - Don clean PPE to assist the patient at their destination.

Airborne Precautions - Patient Transport

- Only transport the patient outside of their room if medically required. - Patient should wear a mask during transport and follow Cough and Respiratory Hygiene etiquette. - If skin lesions are present, keep them covered to prevent aerosolization or direct contact

Droplet Precautions: Patient Transport

- Only transport the patient outside of their room if medically required. - Patient should wear a mask during transport and follow Cough and Respiratory Hygiene etiquette. - The nurse does not need to wear a mask during transport of the patient because the patient is masked.

Covid-19 CDC Recommendations for Healthcare Facilities and Patient Transport

- Patients should remain in the same room for the duration of their hospitalization if possible. - Perform procedures and tests in the patient's room whenever possible. Limit patient transport outside the room. - If a patient must be moved, make sure the receiving area has been given report and is prepared to receive the patient. - The patient should wear a mask during transport.

Droplet Precautions: Patient Placement

- Place patient in a single room if possible. - Cohort patients who have an infection by the same pathogen. - Avoid co-hortingwith a patient who is immunocompromised - Keep patients at least 3 feet apart and use a curtain to separate the beds - Change PPE and perform hand hygiene between contact with patient who are in the same room even if they are both on droplet precautions. - In ambulatory settings, place the patient in an examine room as soon as possible and instruct on Cough and Respiratory Hygiene etiquette.

Contact Precautions: Patient Placement

- Place patient in a single room if possible. - Cohort patients who have an infection by the same pathogen. - Avoid co-hortingwith a patient who is immunocompromised or has an open wound - Keep patients at least 3 feet apart and use a curtain to separate the beds - Change PPE and perform hand hygiene between contact with patients who are in the same room - In ambulatory settings, place the patient in an examine room as soon as possible

Airborne Precautions: Patient Placement

- Place patient in an Airborne Infection Isolation Room (AIIR). - If not immediately available, place the patient in a private room, mask the patient, and keep the door closed until transferred. In ambulatory settings, place the patient in an AIIR room as soon as possible. - If an AIIR room is not available, mask the patient and place them in an exam room as soon as possible. - The room should be left vacant at least one hour after the patient leaves the room to allow for full turnover of the air. - If necessary, in an outbreak, cohort patients who have an infection by the same pathogen away from other patients - Change PPE and perform hand hygiene between contact with patients who are in the same room even if they are both on airborne precautions.

Why are isolation precautions so important?

- Protecting yourself and others - Preventing or controlling outbreaks - Prevention of Healthcare Acquired Infections

What is the impact of HAIs (Healthcare Associated Infections)?

- There were 687,000 HAIs in hospitals in the USA in 2015 and 72,000 of those patients died during their hospitalization. - HAIs cost $28-$33 billion dollars in healthcare costs annually. - HAIs increase length of stay which contributes to increased costs.

Injection safety

- Use aseptic technique - Use needles, syringes, and IV administration supplies only once, and only on one patient - Use single dose vials when possible

Contact Precautions: Equipment

- Use disposable equipment for a patient on contact precautions or have equipment dedicated only to that patient. - If equipment must be used for another patient ensure that it is appropriately disinfected first. - Clean surfaces in the room at least daily.

It is recommended to use an alcohol-based handrub in the following situations:

- before direct contact with patients - after direct contact with patient skin - after contact with body fluids if hands are not visibly soiled - after removing gloves - before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement - before donning sterile gloves prior to an invasive procedure - if moving from a contaminated body site to a clean body site - after contact with objects contaminated by the patient. Keep in mind that handrubs are not appropriate for use with C. difficile infection.

PPE (personal protective equipment)

- covers clothing and skin to prevent contact with potentially infectious materials - is one time use and never shared between patients - Remove before leaving a patient's room - Hand hygiene is always performed after removing

Chemical methods of sterilization and disinfection

- ethylene oxide gas - chemical solutions

Types of PPE

- gloves - gown - face masks, eye protection, goggles, face shields

Methods of sterilization and disinfection

- physical - chemical

Physical methods of sterilization and disinfection

- steam - boiling water - dry heat - radiation

When collecting a specimen

- take care to prevent the outside of the container from becoming contaminated with any secretions or body fluids - place all laboratory specimens in plastic bags and seal the bags to prevent leakage during transportation - a red bag marked BIOHAZARD is used to dispose of trash that contains liquid or semiliquid blood or other potentially infective material (OPIM)

Handling and disposing of supplies

- used equipment may be disposed of after use or, if reusable, bagged according to facility policy, sent to a central cleaning area, and sterilized or disinfected. - double-bagging may be required if the single bag is not secure or is soiled on the outside. - a contaminated item must never be used for another patient. - all spills of body fluids or substances must be immediately cleaned with the appropriate chemical germicide or disinfectant.

Sequence for Donning PPE

1. Gown - Should fully cover torso and arms - Fastens in the back of the neck and behind the waist 2. Mask or respirator - Secure the ties at the middle of the back of the head and behind the neck - it covers the mouth and the nose - Squeeze metal band to fit the bridge of the nose -Fit the mask so it is snug to the face and the chin - If you are wearing a respirator or N-95 mask ensure that it fits properly 3. Goggles and Face Shield - Place them over the eyes and ensure proper fit 4. Gloves - Place the gloves on and pull them up to cover the wrist of the gown so there is no gap between the gown and the gloves

Sequence for Doffing PPE

1. Gowns and Gloves - The outer gloves and front of gown are contaminated - Pull the front of the gown to break the ties behind the neck and waist. - Roll the gown down, turning it inside out. - Remove your gloves as you remove the gown, touching only the inside of the gloves or inside of the gown with bare skin. 2. Goggles or Face Shield - Remember the outside of the goggle or face shield are contaminated - Remove the goggles or face shield by lifting the back band off your head without touching the front. - Discard in appropriate container. 3. Mask or Respirator - Remember the front of the mask or respirator is contaminated - Remove the mask by lifting the elastic band off your head in the back without touching the front or pull to break ties. - Discard in appropriate container. 4. Wash your hands or used alcohol based hand sanitizer after doffing PPE or if hands become contaminated while removing PPE.

respiratory hygiene/cough etiquette

Applies to anyone with a respiratory infection or cold (nurses, visitors, patients, etc.) - Cover mouth and nose when coughing or sneezing - Dispose of tissues properly - Hand hygiene after contact with respiratory secretions - PPE - covers clothing and skin to prevent contact with potentially infectious materials - Wear a mask with a persistent cough - Sit away from others

Handling linens

Avoid contaminating other surfaces or the air, hold linens away from your body and don't shake them into the air

Covid-19 (SARS-CoV-2) CDC Recommendations

Covid-19 is thought to spread by respiratory droplets and may spread through the airborne route during aerosolizing procedures. Environmental services should not enter the room for cleaning immediately after it becomes empty. Allow enough time for air changes to remove infectious pathogens prior to cleaning.

Equipment and Environment

Follow facility policies for handling contaminated equipment and cleaning the environment - Wear PPE when handling contaminated equipment - Use appropriate cleaning agents and follow sterilization procedures - Clean surfaces that are likely contaminated - frequently touched surfaces or close to the patient - Use disinfectants that are appropriate for the pathogen

Contact Precautions: PPE

Gloves - use for skin contact with patient - use for touching any equipment or objects in the patient's environment Gown - wear for any direct contact with the patient or the patient's environment - Don gown and gloves when entering the room and doff gown and gloves prior to leaving the room. - Perform hand hygiene after removing PPE. - Avoid touching contaminated PPE or other surface with skin or clothing

Types of standard precautions

Hand Hygiene Use of Personal Protective Equipment (PPE) Respiratory Hygiene and Cough Etiquette Patient Placement Equipment for Patient Care Cleaning the Environment Handling Linens Injection Safety Sharps Safety

Healthcare Associated Infections

Infection developed during treatment for other conditions that were not present on admission

Neutropenic precautions

Isolation procedures to protect an immunocompromised patient from infections - Ensure that health care provider is healthy - Restrict visits from friends and family members who have colds or contagious illnesses - Avoid collection of standing water in the room (e.g., humidifiers) to prevent bacteria typically found in this water - Avoid plants and flowers—soil is a source of bacteria and mold - Follow hospital protocols regarding PPE for neutropenic precautions

Airborne Precautions: PPE

Masks - Place a mask on the patient - Wear a fit-tested N-95 mask or higher level respirator when entering the room. Perform hand hygiene after removing PPE Check CDC for pathogen specific recommendations.

Droplet Precautions: PPE

Masks - Place a mask on the patient - Wear a mask whenever entering the patient's room or environment Face shields or goggles and gowns are generally not needed for droplet precautions Perform hand hygiene after removing PPE

Hand hygiene

Most important step in infection prevention - use soap and water if hands are visibly soiled with bodily fluids, blood, or another contaminant - alcohol based hand-sanitizer can be used if hands are not visibly soiled

Factors influencing choice of sterilization and disinfection

Nature of organisms present - all supplies, linens, and equipment in a health care setting should be treated as if the patient were infectious. Some organisms are easily destroyed, whereas others can withstand certain common sterilization and disinfection methods. Number of organisms present - the more organisms present on an item, the longer it takes to destroy them. Type of equipment - equipment with small lumens, crevices, or joints requires special care. Certain articles that may be damaged by various sterilization and disinfection methods require special handling. Intended use of equipment - the need for medical or surgical asepsis influences the preparation and cleaning of equipment. In the home, it may be safe to use equipment and supplies that are clean, but most health care facilities use sterilized articles for patient care. Available means for sterilization and disinfection - the choice of chemical or physical means of sterilization and disinfection depends on the nature and number of organisms, the type and intended use of the equipment, and the availability and practicality of the means. Table 24-3 lists the types of methods for sterilization and disinfection. Time - time is a key factor when sterilizing or disinfecting articles. Failure to follow the recommended time periods is grossly negligent.

Reporting accidental exposures

Nurses are accountable for their own safety. Any needlestick injury or accidental exposure to blood or body fluids must be reported immediately so that appropriate interventions can be used. - Immediate management of the exposure site—wash the exposed area immediately with warm water and soap, flush mucous membranes, or irrigate eyes - Immediate, detailed report of the incident to the facility, with likely completion of an incident or injury report Baseline testing of the source person first, with permission, to determine HCV (Hepatitis C), HBV (Hepatitis B), and HIV status (rapid HIV Ab testing preferred) - Baseline testing of the exposed person indicated with positive results from the source person; note if the exposed person is considered immune to HBV with documented positive titer and requires no further testing or follow-up - Postexposure prophylaxis (PEP), if recommended - Follow-up testing as recommended—can be at 6 weeks, 3 or 4 months, 6 months, and/or 12 months, depending on the exposure - Counseling sessions regarding safe practices to protect self and others

Why are standard precautions used?

Protect yourself - the patient may have infections you don't know about Prevent the spread of infections to other patients

Patient placement

Transmission of infection factors into placement decisions - Consider route of transmission - Some patients may require a single-patient room - Co-hortingpatients with similar infections

Droplet precautions

Used for pathogens transmitted through respiratory droplets by coughing, sneezing, and talking. - Use of PPE - Patient Transport - Patient Placement

Airborne Precautions

Used for pathogens transmitted through small particles in the air such as aerosolized respiratory secretions or pathogens on dust particles. - They can infect through contact with the nose, mouth, or eyes. - Face-to-face contact is not required for transmission since the pathogen can travel through the air. - Use of PPE - Patient Transport - Patient Placement - Immunizations

Standard precautions

infection prevention measures that apply to every patient regardless of the potential infection status of the patient

Contact Precautions

practices used to prevent spread of disease by direct or indirect contact - Use of PPE - Patient Transport - Equipment for Patient Care - Patient Placement

Sterilization

process that completely destroys all microbial life, including spores - performed on equipment that is entering a sterile portion of the body

Disinfection

process used to destroy microorganisms; destroys all pathogenic organisms except spores - used when preparing the skin for a procedure or cleaning a piece of equipment that does not enter a sterile body part

Gloves

protects against contact with blood, body fluids, mucous membranes, or broken skin - are not a substitute for good hand hygiene - worn only once and discarded appropriately according to facility policy - then hands are thoroughly decontaminated with meticulous hand hygiene - when there is a possibility of soiling the hands with body fluids, gloves must be worn

ace masks, eye protection, goggles, face shields

protects against splashing or spraying of body fluids - - help prevent the wearer from inhaling large-particle aerosols, which usually travel short distances (about 3 ft), and small-particle droplet nuclei, which can remain suspended in the air and travel longer distances - protect the patient from the respiratory secretions of the health care worker - they discourage the wearer from touching the eyes, nose, and mouth, thus limiting contact of organisms with mucous membranes

Gowns

protects skin and clothes from contamination - worn to prevent soiling of the health care worker's clothing by the patient's blood and body fluids - they provide barrier protection and are donned immediately before entering the patient's room - if a gown becomes heavily soiled or moistened with blood or body fluids when caring for a patient, remove it, perform thorough hand hygiene, and put on a clean gown

transmission-based precautions

used in addition to standard precautions - When more protection is needed, transmission based precautions are used based on how the infection is transmitted. -- Contact -- Droplet -- Airborne