Affinity Health Services, Inc.
Title of Policy: Transmission-Based Precautions
Location of Policy: Infection Control Manual
Effective Date: February 2005
Prepared by: CWM
Revision Dates: May 2006, November 2007
Total Pages: 4
Attachments:
Approved by: MES
Transmission-Based Precautions
Highlights
Objectives
Policy Statement
It is the policy of this organization to use appropriate infection control precautions at all
times. Standard Precautions will be used in the care of all residents. Individuals who are
documented or suspected to have infections or communicable diseases that can be
transmitted to others will be cared for utilizing the appropriate type of Transmission-Based
Precautions.
There are three categories of Transmission-Based Precautions: Contact Precautions, Droplet
Precautions, and Airborne Precautions. Transmission-Based Precautions are used when the
route(s) of transmission is (are) not completely interrupted using Standard
Precautions alone. For some diseases that have multiple routes of transmission
(e.g., SARS), more than one Transmission-Based Precautions category may be
used. When used either singly or in combination, they are always used in
addition to Standard Precautions.
The facility will make every effort to use the least restrictive approach to managing
individuals with potentially communicable infections. Whenever possible, precautions shall
be used that do not involve physical and/or social isolation of the resident. Isolation shall
only be used when transmission cannot be reasonably prevented by less restrictive measures.
The objectives of this policy are to;
1. provide facility staff with concrete, empirically-based standards that will protect
residents, employees, and visitors from transmission or cross-infection of
communicable or infectious diseases;
2. establish procedures conforming to the most current knowledge available;
3. eliminate unnecessary, ineffective, or inefficient infection control practices, and;
4. identify specific diseases, microorganisms, and conditions that require precautions,
in addition to universally accepted Standard Precautions.
Policy Interpretation and Implementation
Transmission-Based
Isolation Precautions
1.
Transmission-Based Precautions will be used whenever measures more stringent
than Standard Precautions are needed to prevent the spread of infection.
Types of TransmissionBased Isolation Precautions
2.
Based on CDC definitions, three types of Transmission-Based Precautions
(airborne, contact, and droplet) have been established. *
Airborne Precautions
Airborne Precautions
In addition to Standard Precautions, implement Airborne Precautions for anyone
who is documented or suspected to be infected with microorganisms transmitted by
airborne droplet nuclei (small-particle residue [5 microns or smaller in size] of
evaporated droplets containing microorganisms that remain suspended in the air
and can be widely dispersed by air currents within a room or over a long distance).
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Examples of Infections
Requiring Airborne
Precautions
a. Examples of infections requiring Airborne Precautions include, but are not
limited to:
(1) Measles (rubeola virus)
(2) Chickenpox (Varicella virus )(including disseminated zoster)
(3) Tuberculosis
(4) And possibly SARs-CoV
Resident Placement During
Airborne Precautions
b. Resident Placement
(1) If necessary and if such a room is available, place the resident in a private
room that meets the following criteria:
(a)
(b)
(c)
Monitored negative air pressure in relation to the surrounding areas;
Six (6) to twelve (12) air changes per hour;
Appropriate discharge of air outdoors or monitored high efficiency
filtration of room air before the air is circulated to other areas of the
facility.
(2) Keep the room door closed and the resident in the room.
(3) If there is not a room in the facility that meets these criteria, then cohort
the individual with someone else who is infected with the same
microorganism.
(4) If neither is possible and isolation is necessary, place the individual in a
private room (a room with no one else in it).
(5) If isolation in a negative pressure room is essential to prevent transmission
of the illness (for example, with active TB), transfer the individual to a
setting that can provide the appropriate kind of isolation room.
c. Respiratory Protection
Respiratory Protection
During Airborne
Precautions
Resident Transport During
Airborne Precautions
Signs to Use to Alert Staff
of Airborne Precautions
(1) All individuals must wear respiratory protection when entering the room.
(2) Anyone who is susceptible (i.e., not immune) to measles (rubeola) or
varicella (chickenpox) may not enter the room of someone who has, or is
suspected of having, these infections.
d. Resident Transport
(1) The resident should only leave an isolation room when absolutely
essential.
(2) Someone who is on Airborne Precautions, should wear a mask when
leaving the room or coming into contact with others. Depending on the
organism, a special filtration mask may be necessary.
e. Signs will be used to alert staff of the implementation of airborne precautions,
while respecting the resident’s privacy.
f. Place a sign at the doorway instructing visitors to report to the nurses’ station
before entering the room.
.
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Transmission Based Precautions
Contact Precautions
Contact Precautions
In addition to Standard Precautions, implement Contact Precautions for residents
known or suspected to be infected or colonized with microorganisms that can be
transmitted by direct contact with the resident or indirect contact with
environmental surfaces or resident-care items in the resident’s environment.
Examples of Infections
Requiring Contact
Precautions
a. Examples of infections requiring Contact Precautions include, but are not
limited to:
(1) Gastrointestinal, respiratory, skin, or wound infections or colonization
with multi-drug resistant organisms (e.g., VISA, VRSA, VRE);
(2) Diarrhea associated with Clostridium difficile;
(3) Enterohemorrhagic Escherichia coli 0157:H7;
(4) Shigella;
(5) Hepatitis A;
(6) Diarrhea associated with Rotavirus;
(7) Abscesses, cellulitis, or decubiti with noncontained drainage;
(8) Pediculosis;
(9) Scabies;
(10) Cutaneous Zoster;
(11) Viral/Hemorrhagic Conjunctivitis; and
(12) Viral Hemorrhagic Infections (Ebola, Lassa, Marburg).
b. Resident Placement
Resident Placement During
Contact Precautions
(1) A single-patient room is preferred but when that is not available then
consultation with the infection control personnel to assess the various risks
associated with other placement options that would include keeping the
patient with the existing roommate an cohorting.
(2) For existing residents developing conditions requiring Contact
Precautions, allow them to remain in the room in which they were
originally housed.
(3) For new admissions, cohort the individual with someone who does not
have indwelling tubes, catheters, or open wounds; or
(4) Isolate the individual in a private room if it is not feasible to contain
drainage, excretions, blood or body fluids (e.g., the individual is
incontinent on the floor, or wanders and touches others).
(5) In multi-patient rooms, >3 feet spatial separation between beds is advised
to reduce the opportunities for inadvertent sharing of items between the
infected/colonized patient and other patients.
Gloves and Handwashing
During Contact Precautions
c. Gloves and Handwashing
(1) In addition to wearing gloves as outlined under Standard Precautions, wear
gloves (clean, non-sterile) when entering the room.
(2) While caring for a resident, change gloves after having contact with
infective material (for example, fecal material and wound drainage). Wash
hands or use sanitizer gel between these glove changes.
(3) Remove gloves before leaving the room and wash hands immediately with
an antimicrobial agent or a waterless antiseptic agent.
(4) After removing gloves and washing hands, do not touch potentially
contaminated environmental surfaces or items in the resident’s room.
Gowns During Contact
Precautions
d. Gown
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(1) In addition to wearing a gown as outlined under Standard Precautions,
wear a gown (clean, nonsterile) when entering the room if you anticipate
that your clothing will have substantial contact with an actively infected
resident, with environmental surfaces, items in the resident’s room, or if
the actively infected individual is incontinent, has diarrhea, an ileostomy, a
colostomy, or wound drainage not contained by a dressing.
(2) Remove the gown before leaving the resident’s environment.
(3) After removing the gown, do not allow clothing to contact potentially
contaminated environmental surfaces.
Resident Transport During
Contact Precautions
e. Resident Transport
(1) For individuals with skin lesions, excretions, secretions, or drainage that is
difficult to contain, maintain precautions to minimize the risk of
transmission to other residents and contamination of environmental
surfaces or equipment.
Resident-Care Equipment
During Contact Precautions
f. Resident-Care Equipment
(1) When possible, dedicate the use of non-critical resident-care equipment
items such as a stethoscope, sphygmomanometer, bedside commode, or
electronic rectal thermometer to a single resident (or cohort of residents) to
avoid sharing between residents.
(2) If use of common items is unavoidable, then adequately clean and
disinfect them before use for another resident.
Signs Used to Alert Staff of
Contact Precautions
g. Signs will be used to alert staff and visitors of the implementation of
Transmission-Based Precautions, while respecting the privacy of the resident.
Place a sign at the doorway instructing visitors to report to the nurses’
station before entering the room.
Droplet Precautions
Droplet Precautions
In addition to Standard Precautions, implement Droplet Precautions for an individual
documented or suspected to be infected with microorganisms transmitted by droplets (largeparticle droplets [larger than 5 microns in size] that can be generated by the individual
coughing, sneezing, talking, or by the performance of procedures such as suctioning).
Examples of Infections
Requiring Droplet
Precautions
Droplet Precautions are intended to prevent transmission of pathogens spread through close
respiratory or mucous membrane contact with respiratory secretions. Because these
pathogens do not remain infectious over long distances in a healthcare
facility, special air handling and ventilation are not required to prevent droplet
transmission.
a. Examples of infections requiring Droplet Precautions include, but are not
limited to:
(1) Invasive Haemophilus influenzae type B disease including meningitis,
pneumonia, epiglottitis and sepsis;
(2) Invasive Neisseria meningitidis disease, including meningitis, pneumonia,
and sepsis;
(3) Mycoplasma pneumonia;
(4) Influenza, B.pertussis, adenovirus, rhinovirus;
(5) Mumps;
(6) Rubella;
b. Resident Placement
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Resident Placement During
Droplet Precautions
(1) A single-patient room is preferred but when that is not available then
consultation with the infection control personnel to assess the various risks
associated with other placement options that would include keeping the
patient with the existing roommate and cohorting.
(2) Cohort residents with the same infection with the same microorganism; or.
(3) Maintain at least 3 feet of space between the infected resident and other
residents and visitors.
(4) Special air handling and ventilation are unnecessary and the door to the
room may remain open.
Masks During Droplet
Precautions
c. Masks
Resident Transport During
Droplet Precautions
d. Resident Transport
Signs Used to Alert Staff of
Droplet Precautions
(1) In addition to Standard Precautions, wear a mask when working within 3
feet of the resident.
(1) Limit movement of resident from the room to essential purposes only.
(2) If transport or movement from the room is necessary, place a mask on the
infected individual to minimize dispersal of droplets.
e. Signs will be used alert staff and visitors of the implementation of Droplet Precautions,
while protecting the privacy of the resident. Place a sign at the doorway instructing visitors
to report to the nurses’ station before entering the room.
Syndromic and Empiric Applications of Transmission-Based
Precautions
Pending Laboratory
Confirmations
Diagnosis of many infections requires laboratory confirmation. Since laboratory tests,
especially those that depend on culture techniques, often require two or more days for
completion. The facility will implement the following guidelines:
1. Transmission-Based Precautions must be implemented while test results are pending
based on the clinical presentation and likely pathogens.
2. Use of appropriate Transmission-Based Precautions at the time a patient develops
symptoms or signs of transmissible infection, or arrives at a healthcare facility for care,
reduces transmission opportunities.
3. While it is not possible to identify prospectively all patients needing Transmission-Based
Precautions, certain clinical syndromes and conditions carry a sufficiently high risk to
warrant their use empirically while confirmatory tests are pending.
Discontinuation of Transmission-Based Precautions
Discontinuation
1. Transmission-Based Precautions remain in effect for limited periods of time (i.e., while
the risk for transmission of the infectious agent persists or for the duration of the illness).
2. For most infectious diseases, this duration reflects known patterns of persistence and
shedding of infectious agents associated with the natural history of the infectious process
and its treatment.
3. For some diseases (e.g.,pharyngeal or cutaneous diphtheria, RSV), Transmission-Based
Precautions remain in effect until culture or antigen-detection test results document
eradication of the pathogen and, for RSV, symptomatic disease is resolved .
4. For other diseases, (e.g., M. tuberculosis) state laws and regulations, and healthcare
facility policies, may dictate the duration of precautions.
5. In immunocompromised patients, viral shedding can persist for prolonged periods of time
(many weeks to months) and transmission to others may occur during that time; therefore,
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the duration of contact and/or droplet precautions may be prolonged for many weeks.
6. The duration of Contact Precautions for patients who are colonized or infected with
MDROs remains undefined by CDC and remains an unresolved issue. (Management of
Multidrug-Resistant Organisms in Healthcare Setting, 2006 CDC)
The LTC facility will implement the following guidelines in regard to
implementation or discontinuation of Contact Precautions:
a. Follow Standard Precautions during all resident encounters.
b. Will consider the individual resident’s clinical situation and prevalence
or incidence of MDRO in the facility when deciding whether to
implement or modify Contact Precautions in addition to Standard
Precautions for a resident infected or colonized with a target MDRO.
c. For relatively healthy residents (e.g. mainly independent) follow
Standard Precautions, making sure that gloves and gowns are used for
contact with uncontrolled secretions, pressure ulcers, draining wounds,
stool incontinence, and ostomy tubes/bags.
d. For ill residents (e.g. those totally dependent upon staff for healthcare
and ADL’s, ventilator-dependent) and those residents whose infected
secretions or drainage cannot be contained, use Contact Precautions in
addition to Standard Precautions.
e. For MDRO colonized or infected residents without draining wounds,
diarrhea, or uncontrolled secretions, establish ranges of permitted
ambulation, socialization, and use of common areas based on their risk
to other resident and on the ability of the colonized or infected resident
to observe proper hand hygiene and other recommended precautions to
contain secretions and excretions.
f.
The facility protocols include individual policies and procedures for target
MDRO’s and MRSA. ( e.g. MRSA, VRE, C-Diff, etc)
* Additional resources for Transmission Based Precautions is part of the Infection Control
Manual as “CDC Isolation Precautions Table 1 Synopsis of Type of Precautions and
Patients Requiring the Precautions”
References
OBRA
Regulatory
Reference Numbers
Related Documents
483.65(a)(b)(c) F 441; F 442; F 444; F 445
See also: Management of Multi-Drug Resistant Organisms in HealthcareSettings 2006
Standard Precautions
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