Isolation Precautions: Contact (Ambulatory) - CE

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

Perform hand hygiene with soap and water or use an alcohol-based hand rub (ABHR) immediately after removing all PPE.^{undefined#ref5">5}

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.¹

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).⁴ Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person (e.g., patient care devices transmitting pathogens if devices contaminated with blood or bodily fluids are shared between patients; inadequately cleaned instruments used between patients before disinfection, such as endoscopes).⁴

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 all patients regardless of risk or presumed infection status (Box 1).⁵ 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 contact with 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 to be infected or is colonized with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission (Table 1).⁵ Organisms may be transmitted by one of the 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).⁵ Whether used alone or in combination, these isolation precautions should be employed in conjunction with standard precautions.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the purpose of the isolation to the patient and any precautions that the family should take when entering the isolation room.
• 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 before patient contact.
2. Review the patient for potential indications for isolation.⁵
   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).

      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 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 PPE access and signage as needed.
   6. Review the patient’s record or confer with other health care team members regarding the patient’s emotional state and reaction and adjustment to isolation (as needed).
3. Prevent extra trips in and out of the room; gather all needed equipment, labels, and supplies before entering the isolation room.
4. Dedicate medical equipment (e.g., stethoscope, blood pressure cuff, and thermometer) to be used only by the patient in isolation.

   Rationale: Using equipment that is dedicated for use only with the patient on isolation precautions minimizes the risk of infection transmission to other patients.⁵

5. Choose a barrier protection that is appropriate for the type of patient isolation (e.g., contact, droplet, airborne infection isolation precautions) to be used per the organization’s practice (Box 1) (Table 1).^2,5
6. Inspect PPE before donning PPE. 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 at 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 mask with 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. Adjust the flexible band so that it is snug 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), as needed. Place over 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. Bring the glove cuffs over the wrists 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 the correctly designated isolation precautions to limit the spread of contamination.
    1. Keep hands away from the face.
    2. Limit touching surfaces in the patient care area.
    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 standard and isolation precautions.
    1. Provide oral medication in a wrapper or cup and then discard the wrapper or cup in the proper trash receptacle in the isolation 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 isolation room.
    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, as applicable.
19. Obtain and label any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.³
    2. Place the labeled specimen in a biohazard bag 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. Secure bags at the top with a knot or tape per the organization’s practice.
21. Remove and disinfect all reusable pieces of equipment brought into the patient’s room using an organization-approved disinfectant before they are used on another patient.

    Rationale: Disinfecting equipment after use decreases the risk of infection transmission.⁵

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 before exiting the patient’s room.

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

If hands become contaminated during PPE removal, immediately perform hand hygiene with soap and water or use an ABHR.

1. Remove gloves.
   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 remaining gloved hand.
   3. Slide the fingers of the ungloved hand under the remaining glove at the wrist or cuff (Figure 3).
   4. Peel the second glove off over the first glove.
   5. Discard gloves in the appropriate waste receptacle.

      Do not touch the outer surface of the gloves; it is considered contaminated.

2. Remove the eye protection (e.g., goggles) or face shield.
   1. Remove eye protection or face shield from the back of the head by lifting the headband or earpieces up and over the head.

      Do not touch the outer surface of the eye protection or face shield; it is considered contaminated.

   2. Discard the eye protection or face shield in the appropriate waste receptacle or place it in an organization-designated receptacle for disinfection.
3. Remove the gown (Figure 4).
   1. Unfasten the gown’s neck ties or VELCRO^® closure and waist ties, ensuring that the gown sleeves do not come into contact with the body when reaching for the ties or VELCRO.
   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 or roll the gown into a bundle.
   4. Place the gown in the appropriate soiled linen receptacle.

      Do not touch the front surface or sleeves of the gown; it is considered contaminated.

4. Remove the mask or mask with face shield.
   1. Grasp the bottom ties or elastics of the mask or mask with face shield, then the top ties or elastics and pull the mask away from the face (Figure 5A).

      Do not touch the outer surface of the mask or mask with face shield; it is considered contaminated.

   2. Discard the mask or mask with face shield in the appropriate waste receptacle (Figure 5B) or place it in an appropriate receptacle for disinfection.
5. Perform hand hygiene.

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

If hands become contaminated during any part of the PPE removal, immediately perform hand hygiene with soap and water or use an ABHR.

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

      Do not touch the front surface or sleeves of the gown or outside of the gloves; it is considered contaminated.

   4. Place the gown and gloves in the appropriate waste receptacle.
2. Remove eye protection (e.g., googles) or face shield.
   1. Remove eye protection or face shield from the back of the head by lifting the headband or earpieces up and over the head.

      Do not touch the outer surface of the eye protection or face shield; it is considered contaminated.

   2. Discard eye protection or face shield in the appropriate waste receptacle or place in an organization-designated receptacle for disinfection.
3. Remove the mask or mask with face shield.
   1. Grasp the bottom ties or elastics of the mask or mask with face shield, then the top ties or elastics of the mask or mask with face shield (Figure 5A).

      Do not touch the front of the mask or mask with face shield; it is considered contaminated.

   2. Discard the mask or mask with face shield in the appropriate waste receptacle (Figure 5B).
4. Perform hand hygiene.

Completing the Procedure

1. Ensure that the patient has had sufficient opportunity to discuss health problems, course of treatment, or other topics important to the patient while in the isolation room.
2. Continually monitor the patient’s and family’s understanding of ongoing isolation precautions.
3. Perform hand hygiene.
4. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Patient can explain purpose of isolation and cooperates with specific isolation 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 of PPE correctly.

UNEXPECTED OUTCOMES

• Patient does not cooperate with specific isolation 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 of PPE correctly.

DOCUMENTATION

• Education
• Procedures performed
• Evidence or suspected breach of isolation precautions (as applicable)
• 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 pediatric patients may be able to understand the cause, but they still may be frightened.
• A pediatric patient 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 patient’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. Evaluate the need for closing the door (negative-pressure airborne isolation infection room [AIIR]), along with the patient’s safety needs.

REFERENCES

1. Centers for Disease Control and Prevention (CDC). (2016). Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Retrieved October 13, 2022, from https://www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf (classic reference)* (Level VII)
2. Centers for Disease Control and Prevention (CDC). (n.d.). Personal protective equipment (PPE) sequence. Retrieved October 13, 2022, from https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf (Level VII)
3. Joint Commission, The. (2022). National Patient Safety Goals for the ambulatory health care program. Retrieved October 13, 2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_ahc_jan2022.pdf (Level VII)
4. Joint Commission, The. (2022). National Patient Safety Goals for the hospital program. Retrieved October 13, 2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_hap_jan2022.pdf (Level VII)
5. Siegel, J.D. and others. (2007, updated 2022). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved October 13, 2022, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level VII)

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

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