Isolation Precautions: Airborne (Ambulatory) - CE/NCPD

ALERT

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

Avoid physical contact with the patient with suspected or confirmed tuberculosis (TB) or other airborne pathogen before donning appropriate PPE.

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

OVERVIEW

Infection-control practices that reduce and eliminate sources of infection transmission help to 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 use of aseptic techniques and barrier protection is essential for both health care team members and patients.

According to the World Health Organization (WHO), airborne transmission of infectious pathogens occurs when droplets from the pathogen disseminate and remain infectious when suspended in the air over long distance and time.^{undefined#ref6">6} These pathogens can be spread via fine mist, dust, aerosols, or liquids. In most cases, the pathogen causes an inflammatory reaction of the upper airways, infecting the nose, sinuses, throat, and lungs.⁶ The result of this inflammatory reaction may cause sinus congestion, sore throat, and lower respiratory tract symptoms.

One of the most common airborne pathogens is TB. Current guidelines for preventing and controlling TB focus on detecting the infection early, preventing close contact with a patient who has active TB, and applying effective infection-control measures in the health care setting.² Other airborne pathogens include chickenpox, measles, and disseminated herpes zoster.

Health care team members who care for patients with suspected or confirmed infectious illness transmitted via the airborne route should ensure that these measures are taken to prevent airborne transmission:

• A mask should be placed on a patient who has suspected or confirmed infection with a pathogen transmitted by the airborne route.¹
• The patient should be appropriately placed in an airborne infection isolation room (AIIR).
• Health care team members who are susceptible to pathogens transmitted by the airborne route or who are immunocompromised should be restricted from entering the AIIR.
• PPE should be used appropriately, including National Institute for Occupational Safety and Health (NIOSH)-approved N95 respirator masks or higher level respirators, when health care team members are caring for patients in the AIIR.
• Transport of patients outside the AIIR should be limited unless medically necessary. If the patient needs to be transported for necessary medical treatment, the patient should wear a surgical mask and follow the respiratory hygiene/cough etiquette. Health care team members transporting patients to medically necessary treatments do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered.

Health care team members who don N95 respirator masks must be fit-tested in a reliable way to determine which size mask is appropriate and to ensure that the wearer knows when a good seal is achieved. Fit-testing must be performed before health care team members are required to wear the respirator in the workplace and must be repeated at least annually.⁴ Fit-testing must also be conducted whenever respirator design or facial changes that may affect a proper fit take place.⁴ A respirator that has not been fitted properly may leave unprotected gaps between it and the face, impairing its effectiveness.

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 airborne infection isolation to the patient.
• 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.
2. Review the patient for potential indications for isolation.
   1. Review the patient’s medical history (if available) for possible indications and risk factors for illnesses associated with droplet isolation precautions (e.g., influenza, adenovirus, rhinovirus).

      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. 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. Place a mask on the patient who is suspected or confirmed to be infected with a pathogen transmitted by the airborne route.
4. Place the patient in a negative-pressure AIIR, if available.² If an AIIR is not available, consult with an infection preventionist to determine if using supplemental air-cleaning technologies (e.g., portable high-efficiency particulate air [HEPA] filtration, ultraviolet germicidal irradiation [UVGI]) is necessary.²

   Rationale: An AIIR has at least 6 to 12 air exchanges per hour.²

   1. Provide proper equipment access and signage as needed. Label the door of the AIIR (as applicable).
   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. Dedicate medical equipment (e.g., stethoscope, blood pressure cuff, thermometer) to be used only with the patient.⁵
   5. Ensure that all health care team members entering the AIIR are wearing an N95 particulate respirator. Visitors of the patient should be offered respiratory protection and encouraged to wear it.
   6. Plan to perform diagnostic and treatment procedures in the isolation room (as applicable).
5. Restrict health care team members who are susceptible to pathogens transmitted by the airborne route or who are immunocompromised from entering the AIIR.
6. Use PPE appropriately, including NIOSH-approved N95 respirator masks or higher level respirators when caring for patients in AIIR.
7. Limit the transport of patients outside the AIIR, unless medically necessary. If the patient needs to be transported for necessary medical treatment, instruct the patient to wear a surgical mask and follow the respiratory hygiene and cough etiquette. Health care team members transporting patients to medically necessary treatments do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered.
8. Choose a barrier protection that is appropriate for the type of isolation used and the organization’s practice (Box 1) (Table 1) (e.g., airborne precautions: standard precautions plus an N95 respirator mask or powered air-purifying respirator [PAPR]).
9. 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.
10. Enter the designated area for donning PPE and prepare for entry into the AIIR isolation room (as applicable).

Donning PPE: PAPR Option

1. Perform hand hygiene.
2. If a PAPR with a self-contained filter and blower unit integrated inside the helmet will be used, put on the belt and battery before donning the impermeable gown so that the belt and battery unit are under the gown.
3. Don a fluid-resistant or impermeable gown (Figure 1).
   1. Ensure that the gown is large enough to allow for unrestricted movement.
   2. 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.
   3. Pull the sleeves of the gown down to the wrists to cover the cuffs of the gloves.
   4. Wrap the back of the gown and tie the gown securely at the neck and at the waist.
4. If a PAPR with an external belt-mounted blower (Figure 2) will be used, attach the tubing and don a belted blower unit. Ensure that the blower and tubing are outside of the gown to ensure proper airflow.
5. Don a respirator. Put on a PAPR with a full-face shield, helmet, or headpiece.
   1. For a PAPR with a self-contained filter and blower unit inside the helmet, use a single-use (disposable) hood that extends to the shoulders and fully covers the neck. Ensure that the hood covers all of the hair and the ears and that it extends past the neck to the shoulders.⁵
   2. For a PAPR with an external belt-mounted blower unit (Figure 2) and attached reusable headpiece, use a single-use (disposable) hood that extends to the shoulders and fully covers the neck. Ensure that the hood covers all of the hair and the ears and that it extends past the neck to the shoulders.
6. Don gloves, bringing the glove cuffs over the edge of the gown sleeves (Figure 3).
7. Verify the integrity of the PPE ensemble. Extend the arms, bend at the waist, and go through a range of motion that is sufficient for delivering patient care.
8. Enter the patient’s isolation room and close the door. Arrange the supplies and equipment brought into the patient’s isolation room as needed.
9. Introduce yourself to the patient.
10. Verify the correct patient using two identifiers.
11. Explain the procedure and ensure that the patient agrees to treatment.
12. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
13. 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 clean gloves.
    4. If additional supplies are needed, enlist another health care team member to hand in new supplies without entering the room.
14. 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, if used, on a towel for eventual removal and disinfection after leaving the patient’s room, as applicable.
15. Obtain and label any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.⁴
    2. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
16. 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 and 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.
17. 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

18. Inform the patient when you plan to return to the room. Ask whether the patient requires any personal care items or has any questions.
19. Remind the patient to cover the mouth with a tissue when coughing and to wear a disposable surgical mask when leaving the room.

    Rationale: Covering the mouth with a tissue when coughing helps prevent the spread of infection to other patients and to health care team members. The mask prevents particles from the patient’s respiratory tract from being released into shared air. Patients should not wear a respirator because it does not prevent expulsion of droplet nuclei into shared air.

20. Discard supplies, leave the isolation room, close the door, and doff PPE.

Doffing PPE: PAPR Option

1. Inspect PPE for visible contamination, cuts, or tears before starting the doffing process.
   1. If a glove is visibly soiled, cut, or torn, remove and discard the gloves, perform hand hygiene with ABHR on bare hands, and don clean gloves.
   2. If no visible contamination, cuts, or tears are identified on the outer surfaces of the gloves, remove and discard the gloves, and perform hand hygiene with ABHR on bare hands.
   3. If a cut or tear is detected on a glove, immediately review and follow the organization’s practice for occupation exposure risk.
2. Remove gloves.

   If hands become contaminated at any time during PPE removal, immediately perform hand hygiene 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 remaining gloved hand.
   3. Slide the fingers of the ungloved hand under the remaining glove at the wrist or cuff (Figure 4).
   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.

3. Remove the PAPR with an external belt-mounted blower.
   1. Remove the headpiece while still connected to the belt-mounted blower unit (Figure 2). This step may require help from the doffing assistant.

      If a PAPR with a self-contained blower unit inside the helmet is used, remove the surgical hood and wait until later in the procedure to remove the integrated components.

   2. Remove the belt-mounted blower unit and place all reusable PAPR components in an area or organization-designated receptacle for the collection of PAPR components for disinfection.
   3. Disinfect the inner gloves with either an Environmental Protection Agency (EPA)-registered disinfectant wipe or ABHR.
4. Remove and discard the gown (Figure 5) in the appropriate receptacle.
   1. Depending on the gown design and the location of the fasteners, untie the fasteners or gently break the fasteners.
   2. Avoid contact of the scrubs or disposable garments with the outer surface of the gown during removal.
   3. Pull the gown away from the body, rolling it inside out and touching only the inside of the gown.

      Rationale: The front of the gown and sleeves are contaminated.

5. Perform hand hygiene and don gloves.
6. Remove the PAPR.
   1. For a PAPR with a self-contained filter and blower unit inside the helmet, remove the hood and wait until the very end of the procedure to remove the integrated components.
   2. For a PAPR with a belt-mounted blower unit, remove all reusable PAPR components and place them in an area or receptacle designated for the collection of PAPR components for disinfection.
7. Perform a final inspection for any indication of contamination and immediately change into clean surgical scrubs or disposable garments if contamination is identified.

   Rationale: The final inspection is a key step to ensuring health care team members’ safety.

8. Perform hand hygiene.
9. Document the procedure in the patient’s record.

Donning PPE: N95 Respirator Option

1. Perform hand hygiene.
2. Don a fluid-resistant or impermeable gown.
   1. Ensure that the gown or coverall is large enough to allow unrestricted movement.
   2. 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.
   3. Pull the sleeves of the gown down to the wrists.
   4. Fasten the gown securely at the back of the neck and at the waist (Figure 1).
3. Don a fitted N95 respirator mask (Figure 6) 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.

   6. Perform a fit check of the N95 respirator mask.
      1. Inhale rapidly and ensure that the N95 respirator 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.
   7. Repeat the fit check (as needed).
4. Don eye protection (goggles or face shield), as needed. Place around 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 3).
6. Verify the integrity of the PPE ensemble. Extend the arms, bend at the waist, and go through a range of motion that is sufficient for delivering patient care.
7. Enter the patient’s room, close the door, and arrange the supplies and equipment brought into the patient’s isolation room.
8. Introduce yourself to the patient.
9. Verify the correct patient using two identifiers.
10. Explain the procedure and ensure that the patient agrees to treatment.
11. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
12. 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 clean gloves.
    4. If additional supplies are needed, enlist another health care team member to hand in new supplies without entering the room.
13. 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, if used, on a towel for eventual removal and disinfection after leaving the patient’s room, as applicable.
14. 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 (Figure 5) and transport it to the laboratory immediately per the organization’s practice.
15. 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.
16. 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

17. Inform the patient when you plan to return to the room. Ask whether the patient has any questions before leaving the room.
18. Remind the patient to cover the mouth with a tissue when coughing and to wear a disposable surgical mask when leaving the room.

    Rationale: Covering the mouth with a tissue when coughing helps prevent the spread of infection to other patients and to health care team members. The mask prevents particles from the patient’s respiratory tract from being released into shared air. Patients should not wear a respirator because it does not prevent expulsion of droplet nuclei into shared air.

19. Discard supplies, leave the isolation room, close the door, and doff PPE.

Doffing PPE: N95 Respirator Option

1. Inspect PPE for visible contamination, cuts, or tears before starting the doffing process.
   1. If a glove is visibly soiled, cut, or torn, remove and discard the gloves, perform hand hygiene with ABHR on bare hands, and don clean gloves.
   2. If no visible contamination, cuts, or tears are identified on the outer surfaces of the gloves, remove and discard the gloves, and perform hand hygiene with ABHR on bare hands.
   3. If a cut or tear is detected on a glove, immediately review and follow the organization’s practice for occupation exposure risk.
2. Remove gloves.

   If hands become contaminated at any time during PPE removal, immediately perform hand hygiene 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 remaining gloved hand.
   3. Slide the fingers of the ungloved hand under the remaining glove at the wrist or cuff (Figure 4).
   4. Peel the second glove off over the first glove.
   5. Discard gloves in the appropriate receptacle.

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

3. Remove eye protection (e.g., goggles of 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.
4. Remove and discard the gown in the appropriate receptacle.
   1. Depending on the gown design and the location of the fasteners, untie the fasteners or gently break the fasteners.
   2. Avoid contact of the scrubs or disposable garments with the outer surface of the gown during removal.
   3. Pull the gown away from the body, rolling it inside out and touching only the inside of the gown.

      Rationale: The front of the gown and sleeves are contaminated.

5. Remove the N95 respirator mask.
   1. Grasp the bottom elastic strap first and then the top elastic strap.
   2. Remove the elastic straps without touching the front of the N95 respirator.

      Rationale: The front of the N95 respirator is considered contaminated.

   3. Discard the N95 respirator in the appropriate receptacle.
6. Perform hand hygiene.
7. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• No evidence of suspected breach of isolation precautions exists.
• Health care team members are free from airborne-transmitted infectious illnesses.
• Health care team members perform donning and doffing of PPE correctly.
• Patient explains the purpose of isolation and cooperates with specific isolation precautions.

UNEXPECTED OUTCOMES

• Evidence of or suspected breach of isolation precautions exists.
• Health care team members contract an airborne-transmitted infectious illness.
• Health care team members do not perform donning and doffing of PPE correctly.
• Patient does not cooperate with specific isolation precautions.

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. 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

• 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. 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). (2016). Infection control: Transmission-based precautions. Retrieved October 8, 2023, from https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor_1564058235
2. Centers for Disease Control and Prevention (CDC). (2021). Core curriculum on tuberculosis: What the clinician should know (7th ed.). Retrieved October 8, 2023, from https://www.cdc.gov/tb/education/corecurr/pdf/CoreCurriculumTB-508.pdf (Level VII)
3. 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)
4. National Institute for Occupational Safety and Health (NIOSH). (2015, updated 2022). Hospital respiratory protection program toolkit: Resources for respirator program administrators. Department of Health and Human Services (DHHS) NIOSH publication number 2015-117. doi:10.26616/NIOSHPUB2015117revised042022 Retrieved October 8, 2023, from https://www.cdc.gov/niosh/docs/2015-117/pdfs/2015-117revised042022.pdf?id=10.26616/NIOSHPUB2015117
5. 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
6. World Health Organization (WHO). (2020). Transmission of SARS-CoV-2: implications for infection prevention precautions. Retrieved October 8, 2023, from https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions

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

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

Published: November 2023