Isolation Precautions: Contact (Ambulatory) - CE

ALERT

Don appropriate PPE based on the patient’s signs and symptoms and indications for isolation precautions.

Avoid physical contact with the patient before donning appropriate PPE.^{undefined#ref1">1}

Wash hands with soap and water or use an alcohol-based hand rub (ABHR) immediately after removing all personal protective equipment (PPE).⁴

OVERVIEW

Infection prevention and control measures help ensure the protection of individuals, in a range of settings who may be vulnerable to acquiring an infection.

Infection-control practices that reduce and eliminate sources of infection transmission help protect patients and health care team members from disease. The health care team member is responsible for educating a patient about infection control. Knowledge of the infectious process, disease transmission, and critical thinking skills associated with the use of aseptic techniques and barrier protection is essential for both health care team members and patients.

Contact isolation can be divided into two subgroups: direct contact and indirect contact. Direct contact is when direct transmission occurs because microorganisms are transferred from one infected person to another without a contaminated intermediate object or person (e.g., cuts or abrasions in skin where blood or bodily fluids come in contact with mucous membranes, scabies-infested patient transfer to a health care team member with ungloved hands).³ Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person (e.g., patient care devices may transmit pathogens if devices contaminated with blood or bodily fluids are shared between patients; inadequately cleaned instruments used between patients before disinfection, such as endoscopes).³

Contact isolation applies to any person with signs of an illness easily transmitted by direct patient contact or by indirect contact with items in the patient’s environment. Illnesses requiring contact precautions may include those present with stool incontinence (e.g., norovirus, rotavirus, or Clostridium difficile), draining wounds, uncontrolled secretions, pressure injuries, or a generalized rash.

Standard precautions, or tier one precautions, assume that every patient is potentially infected or colonized with an organism that could be transmitted in the health care setting. The health care team member should apply standard precautions when caring for patients (Box 1).⁴ Standard precautions are the primary strategies for preventing infection transmission and apply to contact with blood, bodily fluids, nonintact skin, and mucous membranes, as well as equipment or surfaces contaminated with potentially infectious materials.

Tier two precautions include measures designed for the care of a patient who is known to be or suspected of being infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission (Table 1).⁴ Organisms may be transmitted by contact, droplet, or air, as well as by contact with contaminated surfaces. The three types of transmission-based precautions—airborne, droplet, and contact—may be combined for diseases that have multiple routes of transmission (e.g., chickenpox) (Table 1).⁴ Tier two precautions should be used with standard precautions. Additionally, more stringent precautions may be applied to specific outbreaks of a virus or bacteria.

Health care team members must participate in and practice rigorous training of current PPE recommendations, which include the systematic donning and doffing of PPE. Once in the procedure room, health care team members must keep PPE in place and continue to wear it correctly. Removing or adjusting PPE while in the procedure room puts health care team members at risk of contamination. Repeated training and practice are required.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Teach the patient the signs and symptoms of infections and provide instructions on when to seek additional care.
• Educate the patient about modes of infection transmission.
• Explain to the patient the methods of infection prevention.
• Educate the patient about possible exposure of other individuals before the diagnosis.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene.
   1. Review the patient’s medical history (if available) for possible indications and risk factors for illnesses associated with contact isolation precautions (e.g., presence of stool incontinence [e.g., norovirus, rotavirus, or Clostridium difficile], draining wounds, uncontrolled secretions, pressure injuries, or the presence of a generalized rash).
   2. Review the precautions for the specific isolation criteria, including the appropriate PPE to apply (Box 1) (Table 1).
   3. Review the patient’s laboratory test results, if applicable.
   4. Determine whether the patient has a known latex allergy.
   5. Provide proper equipment access and signage as needed.
2. Consider the types of care to be performed while in the patient’s room (e.g., medication administration, dressing change).
3. Prevent extra trips in and out of the room; gather all needed equipment and supplies before entering the room.
4. Provide dedicated medical equipment (i.e., stethoscope, blood pressure cuff, and thermometer) in the room.⁴
5. Choose a barrier protection that is appropriate for the type of isolation used and the organization’s practice (Box 1) (Table 1) (e.g., contact precautions: standard precautions plus gloves and gown).
6. Inspect PPE before donning. Ensure that the PPE is intact, that all required PPE and supplies are available, and that the correct size has been selected.
7. Perform hand hygiene.
8. Don an isolation gown.
   1. Ensure that the gown covers the torso from the neck to the knees and from the arms to the end of the wrists and that it wraps around the back.
   2. Pull the sleeves of the gown down to the wrists.
   3. Fasten the gown securely at the back of the neck and the waist (Figure 1).

      Rationale: Donning a gown properly prevents the transmission of infection and provides protection if the patient has excessive drainage or discharge.

9. Don a procedure mask or face shield around the mouth and nose, if needed, based on the risk of exposure to bodily fluids.
   1. Secure the ties or elastic bands at the middle of the head and neck or the elastic ear loops around the ears.
   2. Fit the flexible band to the nose bridge
   .
   3. Ensure that the mask fits snugly on the face and below the chin.
10. Don eye protection (goggles or face shield), if needed, around the face and eyes based on the risk of exposure to bodily fluids. Adjust to fit.

    Rationale: Donning eye protection properly reduces the risk of exposure to microorganisms that may occur from splashing fluids.

11. Don gloves, bringing the glove cuffs over the edge of the gown sleeves (Figure 2).
12. Enter the patient’s room, close the door, and arrange the supplies and equipment that were brought into the patient’s isolation room.
13. Introduce yourself to the patient.
14. Verify the correct patient using two identifiers.
15. Explain the procedure and ensure that the patient agrees to treatment.
16. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
17. Provide designated care to the patient while maintaining isolation precautions.
    1. Keep hands away from own face.
    2. Limit touching surfaces in the room.
    3. Remove gloves when torn or heavily contaminated, perform hand hygiene, and don a clean pair of gloves.
    4. If additional supplies are needed, enlist another health care team member to hand in new supplies without entering the room.
18. Administer medications as ordered while maintaining precautions.
    1. Provide oral medication in a wrapper or cup and then discard the wrapper or cup in the proper trash receptacle in the patient’s room.

       Rationale: Single-use medication containers minimize the transfer of microorganisms.

    2. Wear gloves when administering injections.

       Rationale: Gloves act as a barrier to reduce the risk of exposure to blood.

    3. Discard disposable syringes and uncapped or sheathed needles in the proper sharps receptacle in the patient’s room.

       Rationale: Properly disposing of sharps reduces the risk of a needlestick injury.

    4. Place the reusable plastic syringe holder in a clean glove or, if used, on a towel for eventual removal and disinfection after leaving the patient’s room.
19. Collect any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.²
    2. Place the labeled specimen in a biohazard bag (Figure 3) and transport it to the laboratory immediately per the organization’s practice.
20. Discard linen, trash, and disposable items.
    1. Use single linen bags that are sturdy and impervious to moisture to contain soiled articles. Double-bag heavily soiled linen or heavy, wet trash if necessary.

       Ensure that linens or waste are totally contained to protect health care team members from exposure to infectious organisms.

    2. Tie the bags securely at the top with a knot (Figure 4).
21. Remove and disinfect all reusable pieces of equipment brought into the patient’s room using an organization-approved disinfectant and before it is used on another patient.

    Rationale: Disinfecting equipment after use decreases the risk of infection transmission.⁴

22. Inform the patient when you plan to return to the room. Ask whether the patient requires any personal care items or has any questions.
23. Discard supplies and remove PPE.

Option 1: Removal of PPE, if Using a Nondisposable gown

1. Remove gloves.

   If hands become contaminated during glove removal, immediately wash them with soap and water or use an ABHR.

   1. Using a gloved hand, grasp the palm area of the other gloved hand and peel off the first glove.
   2. Hold the removed glove in the gloved hand.
   3. Slide the fingers of the ungloved hand under the remaining glove at the wrist (Figure 5).
   4. Peel the second glove off over the first glove.

      Rationale: Properly removing gloves prevents contact with the contaminated gloves’ outer surface.

2. Discard gloves in the proper receptacle.
3. Remove the gown (Figure 6).
   1. Unfasten the gown’s neck ties and waist ties, taking care that the sleeves do not make contact with the body when reaching for the ties.
   2. Pull the gown away from the neck and shoulders, touching only the inside of the gown.
   3. Turn the gown inside-out and fold it into a bundle.

      Rationale: The front of the gown and sleeves are contaminated. Removing the gown as described prevents contact with the contaminated front of the gown.

4. Place the nondisposable gown in a laundry bag.
5. Remove the eye protection and mask or face shield. Remove the elastic from the ears and pull the mask away from the face (Figure 7A) or grasp the bottom ties or elastics and then the top ties or elastics and pull the mask away from the face.

   Do not touch the outer surface of the mask or face shield.

   Rationale: The front of the mask is contaminated. Touching only the elastic or mask strings protects ungloved hands from contamination. Untying the bottom mask string first prevents the top part of the mask from falling down over the health care team member’s uniform.

6. Discard the eye protection and mask or face shield in the proper receptacle (Figure 7B) or place it in an appropriate receptacle for disinfection.
7. Perform hand hygiene.

Option 2: Removal of PPE, if Using a Disposable Gown

1. Remove gown and gloves.

   If hands become contaminated during glove removal, immediately wash hands with soap and water or use an ABHR.

   1. Grasp the gown in the front and pull it away from the body so that the ties break, touching the outside of the gown only with gloved hands.
   2. While removing the gown, fold or roll it inside-out into a bundle, peeling off the gloves at the same time, touching only the inside of the gloves and gown with bare hands.

      Rationale: The front of the gown and sleeves are contaminated. Removing the gown as described prevents contact with the contaminated front of the gown.

2. Discard the gown and gloves in the proper receptacle.
3. Remove eye protection and mask or face shield. Remove the elastic from the ears and pull the mask away from the face (Figure 7A) or grasp the bottom ties or elastics and then the top ties or elastics and pull the mask away from the face.

   Do not touch the outer surface of the mask or face shield.

   Rationale: The front of the mask is contaminated. Touching only the elastic or mask strings protects ungloved hands from contamination. Untying the bottom mask string first prevents the top part of the mask from falling down over the health care team member’s uniform.

4. Discard eye protection and mask or face shield in the proper receptacle (Figure 7B) or place in an appropriate container for disinfection.

   Rationale: The outside of the eye protection is contaminated. Handling as described allows removal without contaminating hands.

Completing the Procedure

1. Perform hand hygiene.
2. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Patient can explain purpose of isolation and cooperates with precautions.
• No evidence of suspected breach of isolation precautions exists.
• Health care team members are free from infection.
• Health care team members perform donning and doffing correctly.

UNEXPECTED OUTCOMES

• Patient does not cooperate with precautions.
• Evidence of suspected breach of isolation precautions exists.
• Health care team member contracts the infection.
• Health care team members do not perform donning and doffing correctly.

DOCUMENTATION

• Education
• Procedures performed
• Evidence or suspected breach of isolation precautions
• Unexpected outcomes and related interventions
• Evaluation findings communicated to the clinical team leader per the organization’s practice

PEDIATRIC CONSIDERATIONS

• Isolation creates a sense of separation from family and a loss of control. A strange environment may add to the confusion that the pediatric patient feels during isolation. A preschool-age patient is unable to understand the cause-and-effect relationship for isolation. Older patients may be able to understand the cause, but they still may be frightened.
• A pediatric patients requires simple explanations, for example, “You need to be in this room to help you get better.”
• 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 child’s anxiety regarding PPE.

OLDER ADULT CONSIDERATIONS

• Many older adults 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 for closing the door (negative-pressure airborne isolation infection room [AIIR]), along with the patient’s safety and additional safety measures, should be evaluated.

REFERENCES

1. Centers for Disease Control and Prevention (CDC). (2015). Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Retrieved July 19, 2021, from https://www.cdc.gov/hai/pdfs/guidelines/ambulatory-carechecklist_508_11_2015.pdf (classic reference)* (Level VII)
2. Joint Commission, The. (2021). National Patient Safety Goals^® for the ambulatory health care program. Retrieved July 19, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_ahc_jan2021.pdf (Level VII)
3. Joint Commission, The. (2021). National Patient Safety Goals^® for the hospital program. Retrieved July 19, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_hap_jan2021.pdf (Level VII)
4. Siegel, J.D. and others. (2007, updated 2019). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved July 19, 2021, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level VII)

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports