Isolation Precautions: Airborne (Ambulatory) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

OVERVIEW

Pathogens may be transmitted by one of three routes: contact (including contact with contaminated surfaces), droplet, or airborne. The transmission-based precautions—airborne, droplet, and contact—may be used alone or in combination for diseases that have multiple routes of transmission (e.g., chickenpox) (Table 1).^{undefined#ref3">3} Whether used alone or in combination, these isolation precautions should be employed in conjunction with standard precautions (Box 1). Precautions include measures designed for the care of a patient who is known to be or suspected of being infected or is colonized with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission (Table 1).³

Airborne transmission happens when tiny particles (i.e., smaller than 5 microns) in the air carry infectious pathogens over time and distance (e.g., spores of Aspergillus or the bacteria that cause tuberculosis). These particles can transmit infection to others if breathed in through the nose or mouth. They can also contaminate environmental sources (e.g., food, water, medications, surfaces) even if the infected person is not in the immediate area.³ Airborne-transmitted pathogens are able to hang in the air for long periods of time and travel on air currents of fine mist, dust, aerosols, or liquids.³

Airborne precautions require special air handling and ventilation, such as an airborne infection isolation room (AIIR) and National Institute for Occupational Safety and Health (NIOSH)-approved filtering facepiece respirators (FFRs) (e.g., N95) or higher-level respirators, to prevent the spread of infectious pathogens. Use of these precautions should be outlined in the organization’s respiratory protection program.³ The level of respirator protection is determined by the efficiency of the filter material and how well the facepiece fits or seals to the face. The most common types of respirators in health care organizations are FFRs (e.g., nonpowered [filtering or elastomeric] respirators, also called N95 respirators [Figure 1]) and powered air-purifying respirators (PAPRs).² PAPRs may be used in aerosol-generating procedures or when the respirator user is not able to wear a tight-fitting respirator.

Health care team members who wear FFRs (e.g., N95) must be fit tested to determine which size respirator is appropriate and to make sure that a good seal is achieved.² Fit testing must be done before team members are required to wear the FFRs in the workplace, and they must be fit tested at least annually.² Fit testing must also be conducted whenever respirator design or team member facial changes may affect a proper fit.² An FFR that has not been correctly fitted may have unprotected gaps between it and the face, impairing its effectiveness.

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Explain the purpose of airborne isolation to the patient and any precautions that the family should take when entering the patient’s room.
• Teach the patient about modes of infection transmission.
• Teach the patient about possible exposure of other individuals before the diagnosis.
• Remind the patient to cover the mouth with a tissue when coughing and to wear a disposable surgical mask when leaving the room.

PROCEDURE

1. Review the patient’s medical record for potential indications for isolation.
   1. Review the patient’s medical history (if available) for possible indications and risk factors for illnesses associated with airborne isolation precautions (e.g., Mycobacterium tuberculosis, rubeola monkeypox, smallpox, measles, chickenpox).³

      Rationale: The mode of transmission for an infectious microorganism determines the type and degree of precautions used.

   2. Review the precautions for the specific isolation criteria, including appropriate personal protective equipment (PPE) to apply (Table 1).
   3. Review the patient’s laboratory test results, if applicable.
   4. Determine whether the patient has a known latex allergy.
   5. Put up airborne isolation signs on the patient’s room and anteroom, as applicable.
2. Collaborate with other health care team members regarding the patient’s emotional state and reaction and adjustment to airborne isolation (as needed).
3. Get the necessary disposable or dedicated equipment, supplies, and labels before going into the patient’s room to reduce the risk of transmitting infectious pathogens.

   Rationale: Using equipment that is disposable or dedicated for use only with the patient on isolation precautions minimizes the risk of infection transmission to other patients.³

4. Be sure to have all the needed PPE in the correct sizes and check that it is intact before putting it on, including a NIOSH-approved FFR or higher-level respirator when caring for a patient in an AIIR.
5. Go into the designated area for putting on PPE (e.g., anteroom).
6. Clean hands.
7. Put on PPE, as applicable (Figure 2).^1,3
8. If using a NIOSH-approved FFR or higher-level respirator (Figure 1):

   Make sure to be fit tested before use of an N95 or higher-level respirator.³

   1. Do a seal check of the FFR.
      1. Inhale rapidly and ensure that the FFR collapses slightly.
      2. Exhale and use the hands to check for leaks around the face.
         1. Adjust the nosepiece if there are air leaks around the nose.
         2. Adjust the straps along the sides of the head if there are air leaks at the N95 respirator edges.
      3. Repeat the seal check (as needed).
   2. If using a PAPR (Figure 3), follow the manufacturer’s instructions for use (IFU).
9. Verify the integrity of the PPE. Extend the arms outward and upward, bend at the waist, and go through a range of motions that are similar to those moves used for patient care.
10. Enter the patient’s room and close the door.
11. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
12. Review the patient’s previous experience and knowledge of airborne isolation precautions and understanding of the care to be provided.
13. Use environmental and transport measures while providing patient care, as applicable (Table 1).
14. Discard supplies, leave the patient’s room, and close the door.
15. Remove all reusable pieces of equipment brought into the patient’s room.
16. Inspect PPE for visible contamination, cuts, or tears before removal.
    1. If a glove is visibly soiled, cut, or torn, remove and throw away gloves, clean hands, and put on clean gloves.
    2. If no visible contamination, cuts, or tears are found, remove and throw away gloves, and clean hands with an alcohol-based hand rub (ABHR) on bare hands.
    3. If a cut or tear is found on a glove, follow the organization’s practice for occupational exposure risk.
17. Remove PPE in the correct sequence depending on the type of gown used before leaving the designated area for removing PPE (Figure 4)(Figure 5).^1,3
18. Remove the PAPR (if used) per the manufacturer’s IFU.
19. Do a final look for any indication of contamination on attire; immediately change attire if contamination is identified.
20. Leave the designated area for removing PPE (e.g., anteroom) and close the door.
21. Clean hands.
22. Clean the patient’s room and reusable patient care items as appropriate (Table 1).

EXPECTED OUTCOMES

• Health care team members put on and take off PPE correctly.

UNEXPECTED OUTCOMES

• Health care team members do not put on or take off PPE correctly.

DOCUMENTATION

• Education
• Evidence of or suspected breach of isolation precautions (as applicable)
• Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

• All isolation precautions should be shown to pediatric patients. Health care team members should let pediatric patients see their faces before applying masks so that patients do not become frightened.
• For preschool-age and school-age patients, making a game out of wearing the mask (e.g., superheroes) can lessen the patient’s anxiety regarding PPE.

OLDER ADULT CONSIDERATIONS

• Older adults may become confused when they are confronted with a health care team member using barrier precautions or when left in a room with the door closed. The need to close the door should be evaluated (negative-pressure AIIR), along with the patient’s safety needs.

REFERENCES

1. Centers for Disease Control and Prevention (CDC). (n.d.). PPE sequence. Retrieved November 25, 2024, from www.cdc.gov/healthcare-associated-infections/media/pdfs/ppe-sequence-p.pdf?CDC_AAref_Val=https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
2. National Institute for Occupational Safety and Health (NIOSH). (2015, updated 2022). Hospital respiratory protection program toolkit: Resources for respirator program administrators. Retrieved November 25, 2024, from https://www.cdc.gov/niosh/docs/2015-117/pdfs/2015-117revised042022.pdf?id=10.26616/NIOSHPUB2015117
3. Siegel, J.D. and others. (2007, updated 2024). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved November 25, 2024, from https://www.cdc.gov/infection-control/media/pdfs/guideline-isolation-h.pdf?CDC_AAref_Val=https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf

ADDITIONAL READINGS

Centers for Disease Control and Prevention (CDC). (2018). A guide to air-purifying respirators. Retrieved November 25, 2024, from https://www.cdc.gov/niosh/docs/2018-176/pdfs/2018-176.pdf

Centers for Disease Control and Prevention (CDC). (2022). The National Personal Protective Technology Laboratory (NPPTL): Healthcare respiratory protection resources. Retrieve November 25, 2024, from https://www.cdc.gov/niosh/npptl/hospresptoolkit/default.html

Centers for Disease Control and Prevention (CDC). (2024). NIOSH-approved particulate filtering facepiece respirators. Retrieved November 25, 2024, from https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html

Clinical Review: Kerrie L. Chambers, MSN, RN, CNOR, CNS-CP(E)

Published: January 2025