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Apr.18.2020

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Isolation Precautions: Personal Protective Equipment - CE

ALERT

Don a gown that is impervious to moisture when there is a risk for excess soiling.^{undefined#ref3">3}

Wash hands or use an alcohol-based hand rub (ABHR) immediately after removing all personal protective equipment (PPE).³

Place patients who require airborne isolation in a negative-pressure airborne infection isolation room (AIIR).³

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

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 must assess the need for barrier precautions for each planned task and for each patient, regardless of the diagnoses. 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.

Published guidelines for isolation precautions contain recommendations based on current epidemiologic information regarding disease transmission in health care settings. Although primarily intended for patients in acute care, these recommendations can be applied to patients in subacute care or long-term care facilities. 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 patients (Box 1) Box 1 .³ Standard precautions are the primary strategies for preventing infection transmission and apply to contact with blood, body fluids, nonintact skin, and mucous membranes, as well as 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 (i.e., 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.

Second tier precautions include transmission-based precautions designed for the care of a patient who is known or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission (Table 1) Table 1 .³ Organisms may be transmitted by contact, droplet, or airborne route or by contact with contaminated surfaces. The three types of transmission-based precautions—airborne, droplet, and contact—may be combined for diseases that have multiple routes of transmission (e.g., chickenpox) (Table 1) Table 1 .³ Whether used singly or in combination, the precautions should be employed in conjunction with standard precautions.

EDUCATION

Explain the purpose of the isolation to the patient and family.
Instruct the family on precautions to take when entering an isolation room.
Demonstrate to the family how to put on and take off the PPE, as applicable.
Teach the patient and family appropriate use of barrier techniques for home care, as applicable.
Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

Review the patient’s medical history for possible indications of isolation, such as risk factors for TB, a major draining wound, diarrhea, or a purulent productive cough.
Review the precautions for the specific isolation criteria, including appropriate PPE to apply (Box 1) (Table 1).
Review the patient’s laboratory test results, if applicable.
Determine whether the patient has a known latex allergy.
Review the patient’s medical record or confer with colleagues regarding the patient’s emotional state and reaction and adjustment to isolation.
Determine if the patient needs to be moved to a negative-pressure AIIR.

Preparation

Provide proper PPE access and signage as needed.
Prevent extra trips in and out of the room; gather all needed equipment and supplies before entering the room.
Dedicate medical equipment (i.e., stethoscope, blood pressure cuff, and thermometer) to be used only by the patient.³
Choose a barrier protection that is appropriate for the type of isolation used and the organization’s practice (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 a N95 respirator or powered air-purifying respirator (PAPR)

PROCEDURE

Perform hand hygiene.
Don a 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 wrist.
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.
Don either a procedure mask or a fitted N95 respirator around the mouth and nose.
1. Secure the ties or elastics at the middle of the head and neck or the elastic ear loops around the ears.
2. Fit the flexible band to the nose bridge.
3. Ensure that the mask fits snugly on the face and below the chin.
4. If using a PAPR, follow the manufacturer’s instructions for use.
  Rationale: Donning the correct mask properly reduces the risk of exposure to airborne microorganisms or exposure to microorganisms from splashing fluids.
Don eye protection (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.
Don gloves, bringing the glove cuffs over the edge of the gown sleeves (Figure 2).
Enter the patient’s room and arrange the supplies and equipment.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Explain the procedure to the patient and ensure that he or she agrees to treatment.
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 a clean pair of gloves.
Administer medications while maintaining precautions as ordered.
1. Provide oral medication in a wrapper or cup and then discard the wrapper or cup in the proper trash receptacle within the patient’s room.
  Rationale: Single-use medication containers minimize the transfer of microorganisms.
2. Wear gloves when administering injections.
  Rationale: Gloves act as a barrier to reduce the risk of exposure to blood.
3. Discard disposable syringes and uncapped or sheathed needles in the proper sharps receptacle.
  Rationale: Properly disposing of sharps reduces the risk of a needlestick injury.
4. Place the reusable syringe holder in a clean glove or on a paper towel for eventual removal and disinfection after leaving the patient’s room, if used.
Assist the patient with hygiene, encouraging him or her to ask questions or express concerns about the isolation. Provide informal teaching at this time to ensure that the patient understands the purpose of the isolation.
Rationale: Hygiene practices further minimize the transfer of microorganisms. Assisting the patient with hygiene provides quality time with the patient and an opportunity to reinforce patient education.

Avoid allowing the isolation gown to become wet. Carry the wash basin outward, away from the gown, and do not lean against a wet tabletop.

Rationale: Moisture allows organisms to travel through the gown to the uniform underneath.
Collect any ordered specimens.
1. In the presence of the patient, label the specimen per the organization’s practice.²
2. Prepare the specimen for transport. Place the labeled specimen in a biohazard bag (Figure 3).
Discard linen, trash, and disposable items.
1. Use single 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 (Figure 4).
2. Tie the bags securely at the top with a knot.
Remove all reusable pieces of equipment and thoroughly disinfect reusable equipment brought into the room. Ensure that equipment is disinfected with an organization-approved disinfectant when it is removed from the room and before use on another patient.
Rationale: Disinfecting equipment after use decreases the risk of infection transmission. Using equipment that is dedicated only for use with the patient on isolation precautions further minimizes this risk. ³
Resupply the room as needed. Have other health care team members hand in new supplies, if needed.
Rationale: Limiting trips in and out of the room reduces exposure of the patient and health care team members to microorganisms.
Inform the patient when you plan to return to the room. Ask whether the patient requires any personal care items or has any questions.
Remove PPE before exiting the patient room except for the N95 respirator or PAPR (if worn). Remove the N95 respirator or PAPR after leaving the patient’s room and closing the door.

Option 1: Removal of PPE, if using a nondisposable or disposable gown
1. Remove gloves.
  If hands become contaminated during glove removal, immediately wash hands or use an ABHR.
  1. Using a gloved hand, grasp the palm area of the other gloved hand and peel off the first glove.
  2. Hold the removed glove in the gloved hand.
  3. Slide the fingers of the ungloved hand under the remaining glove at the wrist (Figure 5).
  4. Peel the second glove off over the first glove.
    Rationale: Properly removing gloves prevents contact with the contaminated gloves’ outer surface.
2. Discard gloves in the proper container.
3. Remove eye protection from the back by lifting the head band or earpieces.
4. 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.
5. Remove gown (Figure 6).
  1. Unfasten the gown's neck ties and waist ties, taking care that the sleeves do not make contact with the body when reaching for the ties.
  2. Pull the gown away from the neck and shoulders, touching the inside of the gown only.
  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.
6. Place the gown in a laundry bag or discard disposable gown in the proper container.
7. Remove mask. Remove the elastic from the ears and pull the mask away from the face (Figure 7) or grasp the bottom ties or elastics and then the top ties or elastics and pull the mask away from the face.
  Do not touch the outer surface of the mask.
  
  Rationale: The front of the mask is contaminated. Touching only the elastic or mask strings protects ungloved hands from contamination. Untying the bottom mask string first prevents the top part of the mask from falling down over the health care team member's uniform.
8. Discard the mask in the proper container.

Perform hand hygiene.

Leave the room and close the door, if the patient is in a negative-pressure AIIR.

If the patient is in airborne isolation, remove the N95 respirator or PAPR.

To remove the mask, grasp the bottom ties or elastics and then the top ties or elastics and pull the mask away from the face.
Do not touch the outer surface of the mask.

Rationale: The front of the mask is contaminated. Touching only the elastic or mask strings protects ungloved hands from contamination. Untying the bottom mask string first prevents the top part of the mask from falling down over the health care team member's uniform.
If the patient is on contact and airborne isolation, discard the N95 respirator in the proper waste container.
Rationale: Humidity, dirt, and crushing reduce the efficiency of the mask.
Place the reusable N95 respirator in a labeled paper bag for reuse by the same person. N95 respirators can be reused when supplies are limited (e.g., influenza pandemics or widespread outbreaks of other respiratory illnesses).¹
Rationale: Reusable storage bags keep equipment contaminant free and should be labeled to prevent more than one person from wearing the mask. A damaged or crushed mask may not seal properly.

Use caution not to crush the mask. Do not leave the mask hanging around the neck.
Remove, disinfect, and store the PAPR per the manufacturer’s instructions for use.
Perform hand hygiene.

Immediately transport the specimen to the laboratory.

Document the procedure in the patient's record.

MONITORING AND CARE

Ensure that the patient has had sufficient opportunity to discuss health problems, course of treatment, or other topics important to him or her while in the isolation room.
Continually monitor the patient’s and family’s understanding of ongoing isolation. Offer opportunities for them to ask questions.

EXPECTED OUTCOMES

Patient asks for information about disease transmission.
Patient explains the purpose of isolation and cooperates with precautions.

UNEXPECTED OUTCOMES

Patient avoids social and therapeutic discussions.
Patient does not cooperate with precautions.

DOCUMENTATION

Education
Procedures performed
Patient’s response to social isolation
Evidenced or suspected breach of isolation precautions
Unexpected outcomes and related nursing interventions

PEDIATRIC CONSIDERATIONS

Isolation creates a sense of separation from family and a loss of control. A strange environment may add to any confusion the child feels during isolation. A preschool-age child is unable to understand the cause and effect relationship for isolation. Older children may be able to understand the cause, but they still may be frightened.
A child requires simple explanations, for example, “You need to be in this room to help you get better.”
Ensure that the child’s family is actively involved in any explanations.
All isolation precautions should be shown to the child. Health care team members should let the child see their faces before applying a mask so that the child does not become frightened.

OLDER ADULT CONSIDERATIONS

Isolation can be a concern for older adults, especially those who have signs and symptoms of confusion or depression. Many older adults become confused when they are confronted with a health care team member using barrier precautions or when left in a room with the door closed. The need for closing the door (negative-pressure AIIR), along with the patient's safety and additional safety measures, should be assessed.
Older adults should be assessed for signs of depression, such as loss of appetite or a decrease in verbal communication. If necessary, the health care team should be consulted for appropriate interventions.

HOME CARE CONSIDERATIONS

Although isolation precautions followed in a health care facility are not directly applicable to home care, caregivers should be aware of potential sources of contamination in the home.

REFERENCES

Centers for Disease Control and Prevention (CDC). (2018). Pandemic planning: Recommended guidance for extended use and limited reuse of N95 filtering facepiece respirators in healthcare settings. Retrieved March 11, 2020, from https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html (Level VII)
Joint Commission, The. (2020). National patient safety goals effective January 2019. Hospital accreditation program. Retrieved March 11, 2020 from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2020.pdf (Level VII)
Siegel, J.D. and others. (2007, updated 2019). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved March 11, 2020, from https://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf (Level VII)

Adapted from Perry, A.G., Potter, P.A., Ostendorf, W.R. (Eds.). (2018). Clinical nursing skills & techniques (9th ed.). St. Louis: Elsevier.

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