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

ALERT

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

Don a gown that is impervious to moisture when there is a risk for excess soiling.^{undefined#ref2">2}

Perform hand hygiene with soap and water or use an alcohol-based hand sanitizer immediately after removing all PPE.²

Place patients who require airborne isolation in a negative-pressure airborne infection isolation room (AIIR).²

Ensure that the doors to the isolation room and the anteroom are never open at the same time.

OVERVIEW

When a patient has a known or suspected source of colonization or infection, specific infection prevention and control practices can reduce the risk of cross-contamination to other patients, family, visitors, and health care team members. Bodily fluids (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. Patients should be placed in isolation based on signs and symptoms until a diagnosis is confirmed.

Standard precautions, or tier one precautions, are used based on the assumption that every patient is potentially infected or colonized with a transmissible organism. Standard precautions are primary for preventing infection transmission and apply to contact with blood, bodily fluids, nonintact skin, mucous membranes, and equipment or surfaces contaminated with potentially infectious materials.

Respiratory hygiene and cough etiquette should be used by any person entering a health care facility with signs of respiratory infection (e.g., cough, congestion, rhinorrhea, increased production of respiratory secretions). Key elements of respiratory hygiene include proper hand hygiene, covering the mouth and nose with a tissue when coughing or sneezing, coughing or sneezing into the elbow, wearing a mask, and properly discarding used tissues.

Second tier precautions include protocols based on the route of transmission (Table 1).² 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, coronavirus) (Table 1).² More stringent precautions may be applied to specific outbreaks of a virus or bacteria.

Health care team members must participate in and practice rigorous training of current PPE recommendations, which include the systematic donning and doffing of PPE. Once in the isolation room, PPE must remain in place and be worn correctly. Removing or adjusting PPE while in the procedure room increases the risk of contamination. A breach may include skin exposure, a needlestick, or a tear in the PPE. The doffing process is a time of high risk, and a systematic procedure must be followed.²

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 that require isolation.
• 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 before 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. Review the patient's medical history for possible indications for isolation, such as risk factors for tuberculosis (TB), a major draining wound, diarrhea, or a purulent productive cough.
3. Review the precautions for the specific isolation criteria, including appropriate PPE to apply (Box 1) (Table 1).
4. Review the patient’s laboratory test results, if applicable.
5. Determine whether the patient has a known latex allergy.
6. Determine if the patient needs to be moved to a negative-pressure AIIR.

Preparation

1. Choose isolation precautions based on the patient’s signs and symptoms and 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 powered air-purifying respirator (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. Provide dedicated equipment (e.g., stethoscope, blood pressure cuff, thermometer) to be used only by the patient.²

PROCEDURE

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 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 surgical 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.

4. Don eye protection (i.e., goggles or face shield) 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.

5. Don gloves, bringing the glove cuffs over the edge of the gown sleeves (Figure 2).
6. Enter the patient’s room, close the door, 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 the patient agrees to treatment.
10. Provide 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.
11. Collect any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.¹
    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 linen, trash, and disposable items.

    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. 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 3).

15. Tie the bags securely at the top with a knot.
16. 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 it is used on another patient.

    Rationale: Disinfecting equipment after use decreases the risk of infection transmission. Using equipment that is dedicated for use only with the patient on isolation precautions further minimizes this risk.²

17. 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 the 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 (Figure 4).
   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 headband or earpieces. Discard eye protection in the proper container or place it 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 (Figure 5).
   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.

5. Place the gown in a designated laundry receptacle.
6. Remove the face mask.
   1. Remove the elastic loops from the ears and pull the mask away from the face or untie the bottom ties or grasp the elastics and then the top ties or elastics and pull the mask away from the face (Figure 6).
   2. Discard the mask in the proper receptacle.

      Do not touch the outer surface of the face 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 uniform.

7. Perform hand hygiene.
8. Leave the room and close the door. If an anteroom is used, ensure that both doors to the anteroom are never open at the same time.

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

1. Remove gown and gloves.

   If the hands become contaminated during glove removal, or any other step during 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 the outside of the gown only 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, touching 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.

   Rationale: The outside of the eye protection is contaminated. Handling as described allows removal without contaminating hands.

4. Remove the face mask.
   1. Remove the elastic loops from the ears and pull the mask away from the face or untie the bottom ties or grasp the bottom elastics and then the top ties or elastics and pull the mask away from the face (Figure 6).
   2. Discard the mask in the proper receptacle.

      Do not touch the outer surface of the face 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, contaminating the uniform.

5. Perform hand hygiene.
6. Leave the room and close the door. If an anteroom is used, ensure that both doors to the anteroom are never open at the same time.

Doffing the N95 Respirator or PAPR: Airborne Isolation

1. If the patient is in airborne isolation, remove the N95 respirator or PAPR after doffing all other PPE.
   1. 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, contaminating the uniform.

   2. 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.

      Use caution not to crush the mask. Do not leave the mask hanging around the neck.

   3. Remove, disinfect, and store the PAPR per the manufacturer’s instructions for use.
   4. Perform hand hygiene.
2. Leave the anteroom and close the door.

Completing the Procedure

1. Ensure that specimens have been transported to the laboratory per the organization’s practice.
2. Document the procedure in the patient’s record.

MONITORING AND CARE

1. 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 precautions.
• Breach of isolation precautions occurs.
• Health care team member contracts the infection.

DOCUMENTATION

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

REFERENCES

1. 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 (Level VII)
2. 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 READING

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