Isolation Precautions: Personal Protective Equipment (Ambulatory) - CE/NCPD

ALERT

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

Place patients who require airborne isolation in a negative-pressure airborne infection isolation room (AIIR).^{undefined#ref3">3}

Perform hand hygiene with soap and water or use an alcohol-based hand rub (ABHR) immediately after removing all PPE.³

OVERVIEW

When a patient has a known or suspected source of colonization or infection, health care team members must follow specific infection prevention and control practices to reduce the risk of cross-contamination to other patients and health care team members. Body substances (e.g., feces, urine, mucus, wound drainage) contain potentially infectious organisms. Isolation or barrier precautions include the appropriate use of PPE, such as a gown, mask, eye protection, and gloves. Health care team members should evaluate the need for barrier precautions for each planned task and for each patient, regardless of the patient’s diagnosis. Increased attention to the prevention of blood-borne pathogens and airborne pathogens, such as tuberculosis (TB), has led to the stressed importance of barrier protection by the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA).³

Published guidelines for isolation precautions contain recommendations based on current epidemiologic information regarding disease transmission in health care settings. Organizations should modify the recommendations based on their specific needs and as dictated by federal, state, or local regulations.³

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).³ 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. The strategy for respiratory hygiene and cough etiquette applies to any person with signs of respiratory infection (e.g., cough, congestion, rhinorrhea, increased production of respiratory secretions) when entering a health care facility. Key elements of respiratory hygiene education for health care team members, patients, and visitors include covering the mouth and nose with a tissue when coughing and properly discarding used tissues.

Tier two precautions include transmission-based 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).³ Organisms 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).³ 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 an isolation room.
• Teach the patient appropriate use of barrier techniques for home care, as applicable.
• 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.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene before patient care.
2. Review the patient for potential indications for isolation.
   1. Review the patient’s medical history (if available) for possible indications of isolation, such as risk factors for TB, a major draining wound, diarrhea, or a purulent productive cough.

      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 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. Determine if the patient needs to be moved to a negative-pressure AIIR.
   6. Provide proper PPE access and signage as needed.
   7. 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, 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.³

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).^1,3
   1. Contact precautions: Standard precautions plus gloves and gown
   2. Droplet precautions: Standard precautions plus a mask
   3. Airborne precautions: Standard precautions plus an N95 respirator or powered air-purifying respirator (PAPR)
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.

Donning of PPE

1. Perform hand hygiene.
2. 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.

3. Don either a procedure mask, a mask with face shield, or a fitted N95 respirator mask around the mouth and nose.
   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.
   4. If using a fitted N95 respirator mask, follow the manufacturer’s instructions for use and complete a user seal check.
      1. Check the N95 respirator mask before donning it to ensure that there is no damage or tear and that the straps are in good condition.
      2. Place the N95 respirator over the nose, mouth, and chin. Ensure that the bottom flap is pulled out completely, if applicable.
      3. Secure the lower elastic strap at the top of the neck and the upper elastic strap above the ears at the back or top of the head.
      4. Adjust the N95 respirator for a comfortable fit.
      5. Place the fingertips on each side of the metal nosepiece. Beginning at the bridge of the nose, move down the cheeks and mold the flexible nosepiece to create a snug fit.

         Avoid pinching the nosepiece, which may result in an improper fit.

   5. Perform a fit check of the N95 respirator mask.

      Rationale: Donning the correct mask properly reduces the risk of exposure to airborne microorganisms.

4. Don eye protection (goggles or face shield), as needed. Place over the face and eyes and adjust to fit.

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

5. Don gloves. Bring the glove cuffs over the wrists of the gown sleeves (Figure 2).
6. Enter the patient’s room, close the door, and arrange the supplies and equipment brought into the patient’s isolation room.
7. Introduce yourself to the patient.
8. Verify the correct patient using two identifiers.
9. Explain the procedure and ensure that the patient agrees to treatment.
10. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
11. 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.
12. 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 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 a reusable syringe holder, if used, in a clean glove or on a paper towel for eventual removal and disinfection after leaving the patient’s room, as applicable.
13. Obtain and label 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 and transport it to the laboratory immediately per the organization’s practice.
14. 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.
15. Remove and disinfect all reusable pieces of equipment brought into the patient’s room using an organization-approved disinfectant before they were used on another patient.

    Rationale: Disinfecting equipment after use decreases the risk of infection transmission.³

16. Inform the patient when you plan to return to the room. Ask whether the patient has any questions before leaving the room.
17. Discard supplies and remove PPE before exiting the patient’s room, except for the N95 respirator mask (if worn). Remove the N95 respirator mask after leaving the patient’s room and closing the door.

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

If hands become contaminated at any time 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 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 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 the inside of the gown only.
   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 and then the top ties or elastics and pull the mask away from the face (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) or place it in an appropriate receptacle for disinfection.
5. Perform hand hygiene.
6. If the patient is in a negative-pressure AIIR, leave the room and close the door before removing the N95 respirator or PAPR (as applicable).

Removal of N95 Respirator Mask

1. If the patient is in airborne isolation, leave the negative-pressure AIIR and close the door.
2. Remove the N95 respirator mask.
   1. Remove the N95 respirator by grasping the bottom elastics and then the top elastics and pull the mask away from the face.

      Do not touch the outer surface of the N95 respirator mask.

      Rationale: The front of the N95 respirator is contaminated. Touching only the elastic or N95 respirator strings protects ungloved hands from contamination.

   2. Discard the N95 respirator in the proper waste receptacle or store per the organization’s practice.

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., 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 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.
5. If the patient is in a negative-pressure AIIR, leave the room and close the door before removing the N95 respirator mask (as applicable).

Removal of N95 Respirator Mask

1. If the patient is in airborne isolation, leave the negative-pressure AIIR and close the door.
2. Remove the N95 respirator mask.
   1. Remove the N95 respirator by grasping the bottom elastics and then the top elastics and pull the mask away from the face.

      Do not touch the outer surface of the N95 respirator mask.

      Rationale: The front of the N95 respirator is contaminated. Touching only the elastic or N95 respirator strings protects ungloved hands from contamination.

   2. Discard the N95 respirator in the proper waste receptacle or store per the organization’s practice.

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 an infection.
• Health care team members do not perform donning and doffing of PPE correctly.

DOCUMENTATION

• Education
• Procedures performed (as applicable)
• Evidence of 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.
• 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 pediatric patients may be able to understand the cause, but they still may be frightened.
• 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.

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 AIIR), along with the patient’s safety needs.

REFERENCES

1. Centers for Disease Control and Prevention (CDC). (n.d.). Personal protective equipment (PPE) sequence. Retrieved October 8, 2023, from https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf (Level VII)
2. Joint Commission, The. (2023). National Patient Safety Goals for the ambulatory health care program. Retrieved October 8, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_ahc_jan2023.pdf (Level VII)
3. Siegel, J.D. and others. (2007, updated 2023). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved October 8, 2023, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level VII)

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

Published: November 2023

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