Isolation Precautions: Airborne (Pediatric) - CE/NCPD

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 sanitizer immediately after removing all PPE.^{undefined#ref6">6}

Avoid physical contact with the patient with suspected or confirmed airborne pathogen before donning appropriate PPE.

Ensure that patients who require airborne isolation are placed in a negative-pressure airborne infection isolation room (AIIR). If an AIIR is not available, place a surgical mask on the patient.⁶

Airborne precautions are the highest level of isolation. Until an airborne-transmitted illness is diagnosed, airborne precautions represent the safest precautions.

OVERVIEW

Infection prevention and control measures help to ensure the protection of patients in a range of settings who may be vulnerable to acquiring an infection both in the general community and when receiving care because of health problems.

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.

For pediatric patients, airborne isolation precautions are used for rubeola (measles), chickenpox, tuberculosis (TB), and some coronaviruses.

Rubeola

Rubeola is a childhood illness that with vaccination was declared eliminated in the United States (US) in 2000.¹ This means that there were no endemic outbreaks. All cases could be traced to travel outside the US. With a growing fear of vaccination and an increasing number of unvaccinated pediatric patients, the cases of rubeola have risen in recent years.¹

Rubeola is a highly contagious illness with respiratory and dermatologic components. Prodromal signs and symptoms include high fever (as high as 40.5°C [105.0°F]),¹ malaise, cough, coryza, conjunctivitis, and Koplik spots. About 14 days¹ after exposure, a maculopapular rash develops, with a head-to-toe spread. Patients are considered contagious 4 days before the rash appears until 4 days¹ after the rash appears. The rubeola virus can live in the air for up to 2 hours.¹ Rubeola must be reported to the health department within 24 hours¹ of diagnosis. All health care team members and visitors must follow airborne isolation precautions regardless of immunity status.¹

Chicken Pox

Chicken pox is a highly contagious childhood illness with respiratory and dermatologic components. The incubation period is 14 to 16 days.³ Prodromal signs and symptoms include mild fever and malaise. The rash develops 1 to 2 days after the prodromal manifestations.³ The rash is highly pruritic and begins on the chest, back, and face, then spreading to the rest of the body. The rash starts as macular, becomes papular, and then vesicular. The vesicles are fluid filled and are contagious via the contact route. Symptoms generally last 4 to 7 days.³ The patient is contagious from onset of the prodrome (i.e., 1 to 2 days before the onset of the rash) until 4 days after all vesicular lesions have crusted over.³ Patients with chicken pox should be cared for in airborne isolation precautions by health care team members with documented immunity. Shingles, also a varicella infection, requires airborne isolation precautions if it is disseminated, the patient is immunosuppressed, or disseminated infection has not yet been ruled out.⁶

Tuberculosis

TB should be suspected in any patient who has a persistent cough lasting longer than 3 weeks accompanied by chest pain, bloody sputum, unexplained weight loss or loss of appetite, fever, chills, night sweats, malaise, or fatigue.⁴

Airborne Isolation

Airborne isolation precautions include an AIIR with special air-handling and ventilation capacity.⁶ Health care team members who care for patients on airborne isolation precautions should wear nonpowered air-purifying respirators (i.e., N95 [Figure 1]).⁶ These respirators are high-efficiency particulate masks that have the ability to filter 95% of very small (0.3 micron) airborne particles.²

N95 respirators must be fit-tested 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 use and repeated at least annually. Fit-testing must also be conducted whenever respirator design or facial changes that may affect a proper fit take place. A respirator that has not been fitted properly may leave unprotected gaps between it and the face, impairing its effectiveness.

If facial hair or unusual facial features make fitting a mask-type respirator properly difficult, a powered air-purifying respirator (PAPR) may be used. A PAPR has the same filtering properties as the mask-type respirator and is approved by national organization guidelines.⁴ This type of respirator covers the head and uses a blower to move air through the filter and into the face piece, helmet, or hood. A PAPR does not require fit-testing before use.

Using a respirator does not, on its own, fully protect a health care team member from acquiring an infection. Other infection-control practices, such as performing hand hygiene, isolating an infected patient, and using appropriate coughing etiquette are also important to minimize the risk of infection.

All organizations should have a procedure for removing their particular N95 or PAPR and preparing equipment for reprocessing (e.g., bagging for temporary storage before reprocessing, immediate reprocessing in the doffing area).

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 family.
• Incorporate play when explaining the use of PPE to a toddler or young child (e.g., superheroes).
• Give the patient and family information on the signs and symptoms of infections.
• Explain to the patient and family about strategies for infection prevention (e.g., hand hygiene, use of PPE).
• Emphasize to the family the importance of PPE despite exposure to the patient prior to admission.
• Explain to the family that both doors to the anteroom should never be open at the same time.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact.
2. Assess for signs and symptoms of airborne infections (e.g., rubeola, chicken pox).
3. Review the patient’s medical history, if available, for possible indications for isolation.
4. Review the precautions for the specific isolation criteria, including appropriate PPE to apply (Box 1) (Table 1).
5. Review the patient’s laboratory test results, if applicable.
6. Determine whether the patient has a known latex allergy.
7. Determine if the patient needs to be moved to a negative-pressure AIIR.

Preparation

1. Choose isolation precautions that are appropriate for the patient’s signs and symptoms or diagnosis (Box 1) (Table 1).
   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 PAPR
2. Provide proper PPE access and signage as needed.
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 by the patient.⁶

PROCEDURE

PAPR Option

Donning PPE

1. Enter the designated area for donning PPE and prepare for entry into the isolation room as applicable.
2. Perform hand hygiene.
3. 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.
4. 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.
5. Don a fluid-resistant gown if the patient is also in contact isolation.
6. If a PAPR (Figure 2) with an external belt-mounted blower will be used, attach the tubing and don a belted blower unit. Ensure that the blower and tubing are outside the gown to ensure proper airflow.
7. Don gloves, pulling the cuffs over the sleeves of the gown.
8. Don 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.⁶
   2. For a PAPR with an external belt-mounted blower unit 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.
9. Verify the integrity of the PPE. Extend the arms, bend at the waist, and go through a range of motion that is sufficient for delivering patient care.
10. Enter the patient’s isolation room, close the door, and arrange the supplies and equipment.
11. Introduce yourself to the patient and family.
12. Verify the correct patient using two identifiers.
13. Explain the procedure to the patient and family and ensure that they agree to treatment.
14. Provide designated care to the patient while maintaining 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 clean gloves.
15. Collect any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.⁵
    2. Place the labeled specimen in a biohazard bag.
16. At the door, have another health care team member hold a separate biohazard bag into which the bagged specimen is placed.

    Rationale: This prevents contamination of the outside of the biohazard bag.

17. Discard supplies.

    At the completion of the procedure, ensure that all choking hazards (e.g., syringe caps, port caps, adhesive bandages, bits of tape, twist-off caps from saline bullets) are removed from the patient’s linens and placed in the appropriate receptacle.

18. After providing patient care, doff PPE in a designated area by the door or in an anteroom. If an anteroom is in use, leave the isolation room and close the door to doff PPE.

Doffing PPE Option 1: Removal of PPE, if Using a Reusable Gown

1. Remove gloves.

   If hands become contaminated during glove removal, or any other step in the PPE doffing procedure, immediately perform hand hygiene.

   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.
   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 PAPR with an external belt-mounted blower.
   1. Remove the headpiece while still connected to the belt-mounted blower and filter unit.

      If a PAPR with a self-contained filter and blower unit inside the helmet is used, remove the 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 container designated for the collection of PAPR components for disinfection.
4. Remove the gown.
   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 gown directly into a designated laundry receptacle.
5. Perform hand hygiene.
6. Leave the anteroom and close the door. Ensure that both doors to the anteroom are never open at the same time.
7. Ensure that specimens have been transported to the laboratory per the organization’s practice.
8. Document the procedure in the patient’s record.

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

1. Remove gown and gloves.

   If hands become contaminated during glove removal, or any other step in the PPE doffing procedure, immediately perform hand hygiene.

   1. Grasp the gown in the front and pull it away from the body so that the ties break. Touch only the outside of the gown 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. Touch 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 the PAPR with an external belt-mounted blower.
   1. Remove the headpiece while still connected to the belt-mounted blower and filter unit.

      If a PAPR with a self-contained filter and blower unit inside the helmet is used, remove the 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 container designated for the collection of PAPR components for disinfection.
4. Perform hand hygiene.
5. Leave the anteroom and close the door. Ensure that both doors to the anteroom are never open at the same time.
6. Ensure that specimens have been transported to the laboratory per the organization’s practice.
7. Document the procedure in the patient’s record.

N95 Respirator Option

Donning PPE

1. 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.

2. Don the N95 respirator (Figure 1) and complete a fit check.
   1. Check the respirator before donning it to ensure that there is no damage or tears and that the straps are in good condition.
   2. Place the mask 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 of the head.
   4. Adjust the mask for a secure and 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.
      1. Inhale rapidly and ensure that the mask 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 mask edges.
   7. Repeat the fit-check.
3. Don eye protection (i.e., goggles or face shield), if needed, around the face and eyes. Adjust to fit.

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

4. Don gloves, pulling the cuffs over the sleeves of the gown.
5. Verify the integrity of the ensemble. Extend the arms, bend at the waist, and go through a range of motion that is sufficient for delivering patient care.
6. Enter the patient’s room and arrange the supplies and equipment.
7. Introduce yourself to the patient and family.
8. Verify the correct patient using two identifiers.
9. Explain the procedure to the patient and family and ensure that they agree to treatment.
10. Provide designated care to the patient while maintaining 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 clean gloves.
    4. If supplies are needed, enlist another health care team member to hand in new supplies without entering the room.
11. Collect any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.⁵
    2. Place the labeled specimen in a biohazard bag.
12. At the door, have another health care team member hold a separate biohazard bag into which the bagged specimen is placed.

    Rationale: This prevents contamination of the outside of the biohazard bag.

13. Discard supplies.

    At the completion of the procedure, ensure that all choking hazards (e.g., syringe caps, port caps, adhesive bandages, bits of tape, twist-off caps from saline bullets) are removed from the patient’s linens and placed in the appropriate receptacle.

14. After providing patient care, doff PPE in a designated area by the door or in an anteroom. If an anteroom is in use, leave the isolation room and close the door to doff PPE.

Doffing PPE Option 1: Removal of PPE, if Using a Reusable Gown

1. Remove gloves.

   If hands become contaminated during glove removal, or any other step in the PPE doffing procedure, immediately perform hand hygiene.

   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.
   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 eye protection from the back by lifting the headband or earpieces. Discard eye protection in the proper container 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.

4. Remove the gown.
   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 gown directly into a designated laundry receptacle.
5. Don clean gloves.
6. Remove the N95 respirator.
   1. Tilt the head slightly forward.

      Rationale: Tilting the head forward aids the doffing process and minimizes the risk of contamination.

   2. Grasp the bottom elastic strap first and then the top elastic strap.
   3. Remove them without touching the front of the N95 respirator.

      Rationale: Avoiding touching the front of the N95 respirator aids the doffing process and minimizes the risk of contamination.

   4. Discard the N95 in the proper trash receptacle.
7. Remove and discard gloves, taking care not to contaminate the bare hands during the removal process.
8. Perform hand hygiene.
9. Leave the anteroom and close the door. Ensure that both doors to the anteroom are never open at the same time.
10. Ensure that specimens have been transported to the laboratory per the organization’s practice.
11. Document the procedure in the patient’s record.

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

1. Remove gown and gloves.

   If hands become contaminated during glove removal, or any other step in the PPE doffing procedure, immediately perform hand hygiene.

   1. Grasp the gown in the front and pull it away from the body so that the ties break. Touch only the outside of the gown 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. Touch 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 from the back by lifting the headband or earpieces. Discard the eye protection in the proper receptacle.
4. Don clean gloves.
5. Remove the N95 respirator.
   1. Tilt the head slightly forward.

      Rationale: Tilting the head forward aids the doffing process and minimizes the risk of contamination.

   2. Grasp the bottom elastic strap first and then the top elastic strap.
   3. Remove them without touching the front of the N95 respirator.

      Rationale: Avoiding touching the front of the N95 respirator aids the doffing process and minimizes the risk of contamination.

   4. Discard the N95 in the proper trash receptacle.
6. Remove and discard gloves, taking care not to contaminate the bare hands during the removal process.
7. Perform hand hygiene.
8. Leave the anteroom and close the door. Ensure that both doors to the anteroom are never open at the same time.
9. Ensure that specimens have been transported to the laboratory per the organization’s practice.
10. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Remind the patient to cover the mouth with a tissue when coughing and to wear a disposable surgical mask when leaving the room.
2. Ensure that equipment is disinfected with an organization-approved disinfectant when it is removed from the room, before use on another patient.

EXPECTED OUTCOMES

• Patient and family cooperate with isolation precautions.
• No evidence of breach of isolation precautions occurs.
• Health care team members are free from infection.

UNEXPECTED OUTCOMES

• Patient and family do not cooperate with isolation precautions.
• Breach of isolation precautions occurs.
• Health care team member contracts an infection.

DOCUMENTATION

• Education
• Care provided
• Evidence of or suspected breach of isolation precautions
• Unexpected outcomes and related interventions

REFERENCES

1. Centers for Disease Control and Prevention (CDC). (2020). Measles (rubeola): For healthcare providers. Retrieved September 11, 2023, from https://www.cdc.gov/measles/hcp/index.html (Level VII)
2. Centers for Disease Control and Prevention (CDC). (2020). Proper N95 respirator use for respiratory protection preparedness. Retrieved September 11, 2023, from https://blogs.cdc.gov/niosh-science-blog/2020/03/16/n95-preparedness/ (Level VII)
3. Centers for Disease Control and Prevention (CDC). (2021, updated 2022). Chickenpox (varicella): For healthcare professionals. Retrieved September 11, 2023, from https://www.cdc.gov/chickenpox/hcp/index.html (Level VII)
4. Centers for Disease Control and Prevention (CDC). (2021). Core curriculum on tuberculosis: What the clinician should know (7th ed.). Retrieved August 31, 2022, from https://www.cdc.gov/tb/education/corecurr/pdf/CoreCurriculumTB-508.pdf (Level VII)
5. Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved September 11, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf
6. Siegel, J.D. and others. (2007, updated 2023). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved September 11, 2023, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level VII)

ADDITIONAL READINGS

Centers for Disease Control and Prevention (CDC). (n.d.). Sequence for putting on personal protective equipment (PPE). Retrieved September 11, 2023, from https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

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: Marlene L. Bokholdt, MS, RN, CPEN, TCRN, CEN

Published: October 2023