3364-109-ISO-404

Name of Policy: Guidelines for Isolation Precautions in Hospitals I'!IL UNIVE!:\11 \'or

Policy Number: 3364-1 09-IS0-404 TOLEDO Department: Infection Control

Hospital Administration Medical Staff

Approving Officer: Chairman, Infection Control Committee Sr. Vice President & Executive Director, UTMC Chief of Staff

Responsible Agent: Infection Control Practitioner

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Scope: The University of Toledo Medical Center and its Medical Staff

Effective Date: 09/01/2011 Initial Effective Date: 7/111989

New policy proposal X Minor/technical revision of existing policy ----'-"--

---

Major revision of existing policy --- Reaffirmation of existing policy

(A) Policy Statement Specific protective measures must be instituted to prevent transmission of potentially pathogenic microorganisms between infected and non-infected persons.

(B) Purpose of Policy To prevent the spread of communicable and other infectious diseases within the hospital, special techniques must be followed when caring for the patient with a communicable disease and those patients whose immune systems are compromised. The procedures required are based on the following epidemiological factors:

1. The source of the infecting organisms. 2. The mode of transmission 3. The susceptible host.

(C) Procedure Types of precautions: Airborne, Contact and Droplet are to be used in addition to Standard Precautions(which must be followed with every patient, regardless of whether the disease has been identified or not)

Consider all waste from an isolation room as infectious and dispose of in red bag lined waste baskets.

Proper hand hygiene should be followed before and after every patient contact or contact with the patient environment. Hands should always be cleansed after glove removal.

Terminal cleaning (washing walls) is not indicated unless there is obvious contamination on the surfaces. The privacy curtains should be changed after every patient with contact precautions.

Airborne Precautions

Airborne Precautions are used to prevent the transmission of infections that are transmitted by droplet nuclei that can remain suspended in the air for considerable lengths of time and may be dispersed over long distances. Use this type of precautions for: Pulmonary tuberculosis- until 3 negative sputum smears are obtained Measles- for the duration of the illness Chicken Pox- until lesions are crusted (see also contact precautions) Herpes Zoster- disseminated in immune-compromised hosts- until lesions are crusted SARS-for the duration of the illness (see also contact precautions)

Policy 3364-109-IS0-404 Guidelines for Isolation Precautions in Hospitals Page2

Specific Procedures for Airborne precautions:

Placement of Patient: Use a private room with negative pressure ventilation

Or Use a portable HEPA filter in a private room with the door closed until one of the above rooms is available

Notifications: Place Airborne precautions sign on the door of the room ASAP, close the door.

Monitoring of Room If room has outward indicator, turn on and assure that the light is maintained in the green. If using portable HEPA filter, turn on high and position as close to the head of the bed as possible.

Malfunctions: If room is not functioning properly, place a tissue at the bottom of the door with the door closed. If the tissue is pulled in, the negative pressure is working. If the lights on the monitor are in the yellow or red, reposition the door, wait 30 seconds and the lights should return to green. If not, keep the door closed and notify Facilities Management Department ASAP by calling 5353 and identify the problem. A HEPA filter should be placed in the patient room until the negative pressure function is restored.

Respiratory Protection: All personnel entering the room must wear one of the following types of respiratory protection: N-95 respirator, N-100 respirator or a PAPR (Powered Air Purifying Respirator). These can be ordered by calling Materials Management Department. The P APR should be cleaned between users. PAPRs used by more than one person should be wiped down with the alcohol wipes on the inside and outside, and allowed to dry. Please see procedure: S-08-034 Respiratory Protection Program at http:/ /www.utoledo.edu/depts/safety/docs/S-08-034.pdf for training requirements for both N-95 respirators and P APRs.

Patient Considerations: Patient should remain in the room except under special circumstances. For tests that cannot be performed in the room, schedule patient for the last test or surgery of the day. All non-emergent surgeries should be delayed until the patient no longer requires precautions. Patients should be asked to cover their nose and mouth when coughing and sneezing with a tissue Limit visitors and do not allow young children to visit

Personal Protective Equipment Gloves and gown are not indicated, except as normally used for standard precautions or when used in conjunction with Contact Precautions

Equipment Stethoscope and blood pressure monitor: Cleanse after each use Thermometers: cleanse after each use Linen and dishes: No special precautions Sputum and other specimens: Handle as all others

Transport of patient Place a surgical mask on the patient during transport and in non-negative pressure enviroments to contain secretions; notify receiving department.

Policy 3364-1 09-IS0-404 Guidelines for Isolation Precautions in Hospitals Page3

Cleaning Routine cleaning should be performed, with staff wearing the proper respiratory protection At discharge, the room or HEP A filter should run for 1 hour before entering without proper respiratory protection. Cleaning may be performed sooner if staff wears appropriate respiratory protection. Re-useable instruments should be thoroughly cleaned using hospital approved disinfectant before using on another patient

Contact Precautions

Contact precautions are used to prevent the transmission of infections that are transmitted by bacteria or other organisms that can be transmitted by direct contact with the patient's skin or other mucous membranes, or by indirect contact with the patient's environment. Use this type of precautions for: Contact precautions are used to prevent the transmission of infections that are transmitted by bacteria or other organisms that can be transmitted by direct contact with the patient's skin or other mucous membranes, or by indirect contact with the patient's environment. Use this type of precautions for: Antibiotic resistant organisms - resistant gram negative organisms such as resistant E. coli, resistant

Klebsiella pneumoniae, resistant Pseudomonas aeruginosa, and Acinetobacter that are only susceptible to one antibiotic class or no antibiotics. However, methicillin resistant Staphylococcus aureus (MRSA) and Vancomycin resistant enterococcus (VRE) are NOT included.

Chickenpox- (Also see Airborne precautions)- until lesions are crusted over Clostridium Difficile Colitis- until diarrhea has stopped Conjunctivitis- Acute viral- for the duration of the illness Group A streptococcal necrotizing fasciitis- until culture negative (see also droplet precautions Scabies- For 24 hours after therapy is initiated

Specific Procedures for Contact precautions:

Placement of Patient: Use a private room or in high census times, may cohort with other patient with same organism

Notifications: Place Contact precautions sign on the door of the room ASAP, door may remain open. Call Infection Control at 5006 to notify of patient in isolation

Personal Protective Equipment Respiratory protection is not needed except when used in conjunction with Airborne or Droplet Precautions. All personnel entering the room must wear gloves and gown. Gowns are not to be worn out of the room except when involved with the transport that will necessitate contact with the patient during the transport, (such as during resuscitation). Clean gowns are found in the yellow hamper outside the door. Gowns are not to re-used, and are to be placed in the blue linen hamper in the room after use. All linen is handled the same, no special procedures are needed for linen

Patient Considerations: Patient should remain in the room For tests that cannot be performed in the room, schedule patient for the last test or surgery of the day. All non-emergent surgeries should be delayed until the patient no longer requires precautions, if possible. Limit visitors; instruct them how to protect themselves by wearing gloves and washing hands. If participating in care of patient, instruct them to wear the gown

Personal Protective Equipment Gloves and gown are indicated, mask or respirator if used in conjunction with Airborne or Droplet Precautions

Policy 3364-109-IS0-404 Guidelines for Isolation Precautions in Hospitals Page4

Equipment If possible, dedicate equipment to the room

}>- Stethoscope and blood pressure monitor: Cleanse after each use }>- Thermometers: cleanse after each use }>- Linen and dishes: No special precautions }>- Sputum and other specimens: Handle as all others

Transport of patient Place clean sheet over patient during transport. Clean gurney or wheel chair before and after each transport. Wash hands after removing gloves and other personal protective equipment.

Cleaning Re-useable instruments should be thoroughly cleaned using hospital approved disinfectant before using on another patient Routine cleaning should be performed, with staff wearing the proper personal protective equipment. For clostridium difficile, staff should use approved bleach disinfectant for cleaning.

At discharge, leave the sign until the room is cleaned. The room may be cleaned as usual.

Droplet Precautions

Droplet Precaution are used to prevent the transmission of infections that are transmitted by bacteria or other organisms that can be transmitted by means of inhalation of large particle droplets that are produced when coughing, sneezing, or talking. Use this type of precautions for:

Meningitis, meningococcemia and meningococcal pneumonia for 24 hours after the initiation of appropriate therapy.

Influenza-duration of illness Mumps- for 9 days after the onset of swelling Parvovirus-duration of illness Rubella-for 7 days after onset of rash

Specific Procedures for Droplet precautions:

Placement of Patient: Use a private room

Notifications: Place Droplet precautions sign on the door of the room ASAP, door may remain open

Personal Protective Equipment Surgical masks should be worn when within three feet of the patient. Gowns are not indicated except as needed for standard precautions and if used in conjunction with Contact Precautions.

Patient Considerations: Patient should remain in the room For tests that cannot be performed in the room, schedule patient for the last test or surgery of the day. All non-emergent surgeries should be delayed until the patient no longer requires precautions, if possible. Limit visitors; instruct them how to protect themselves by wearing mask within three feet of the patient.

Equipment If possible, dedicate equipment to the room

}>- Stethoscope and blood pressure monitor: Cleanse after each use

Policy 3364-1 09-IS0-404 Guidelines for Isolation Precautions in Hospitals Page 5

~ Thermometers: cleanse after each use ~ Linen and dishes: No special precautions ~ Sputum and other specimens: Handle as all others; for CSF samples, label and hand carry to lab.

Transport of patient Have patient wear surgical mask. Clean cart or wheel chair before and after each transport. Wash hands after removing gloves and other Personal protective equipment.

Cleaning Re-useable instruments should be thoroughly cleaned using hospital approved disinfectant before using on another patient. Routine cleaning should be performed, with staff wearing the proper personal protective equipment. At discharge, leave the sign until the room is cleaned. The room may be cleaned as usual.

References: Recommendations for Isolation Precautions in Hospitals: Hospital Infection Control Practices Advisory Committee, MMWR 2004, Guidelines for Isolation Precautions in Hospitals, 2007; APIC Text of Infection Control and Epidemiology, Volume II, Scientific and Practice Elements, 2005

UTMC Titberculosis Exposure Control Plan and Bloodborne Pathogens Plan

Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee

Approved by: Review/Revision Date: 5/18/81 7/28/2008 8/16/82 11/14/2008 Bl2~ ln 11/21/83 5/23/2011

Date 5/21/84 08/22/2011 7/15/85

01 ( '-li ( l1 6/30/86 6/16/87 8/88

Date 10/4/88 8/7/89

~ 8/10/90 11/4/91 9/14/94 e 6/2/97 5/1/99 4/15/02

Scott Scarborough, PhD Sr. Vice President & Executive Director, UTMC

Review/Revision Completed By: 4/21/05 Infection Control Committee

Next Review Date: 08/22/2014 Policies Superseded by This Policy: 31 :IS0-404


Synopsis of Types of Precautions and Patients Requiring the Precautions: Appendix A

Standard Precautions- Use Standard Precautions for the care of all patients Airborne Precautions - In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include:

Measles Varicella (including disseminated zoster)t Tuberculosis:j: SARS Use both contact and airborne

Droplet Precautions - In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include:

Invasive Haemophilus injluenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis Other serious bacterial respiratory infections spread by droplet transmission, including:

Diphtheria (pharyngeal) Mycoplasma pneumonia Pertussis Pneumonic plague Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children

Serious viral infections spread by droplet transmission, including: Adenovirust Influenza Mumps Parvovirus B 19 Rubella

Contact Precautions - In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include:

Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance Enteric infections with a low infectious dose or prolonged environmental survival, including:

Clostridium difficile For diapered or incontinent patients: enterohemorrhagic Escherichia coli 0157:H7, Shigella, hepatitis A, or rotavirus

Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children Skin infections that are highly contagious or that may occur on dry skin, including:

Diphtheria (cutaneous) Herpes simplex virus (neonatal or mucocutaneous) Impetigo Major (noncontained) abscesses, cellulitis, or decubiti Pediculosis SARS Use both contact and airborne precautions Scabies Staphylococcal furunculosis in infants and young children Zoster (disseminated or in the immunocompromised host)t

Viral/hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, or Marburg)*


Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent Transmission of Epidemiologically Important Pathogens Pending Confirmation of Diagnosis*

Clinical Syndrome or Conditiont

Diarrhea Acute diarrhea with a likely infectious cause in an incontinent or diapered patient , Diarrhea in an adult with a history of recent antibiotic use

Meningitis Rash or exanthems, generalized, etiology unknown

Petechial/ecchymotic with fever Vesicular

Maculopapular with coryza and fever Respiratory infections

Cough/fever/upper lobe pulmonary infiltrate in an HIV -negative patient or a patient at low risk for HIV infection Cough/fever/pulmonary infiltrate in any lung location in a HIV-infected patient or a patient at high risk for HIV infection (23) Paroxysmal or severe persistent cough during periods of pertussis activity Respiratory infections, particularly bronchiolitis and croup, in infants and young children

Risk of multi drug-resistant microorganisms

Potential Pathogens;

Enteric pathogens

Clostridium difficile Neisseria meningitidis

Neisseria meningitidis Varicella

Rubeola (measles)

Mycobacterium tuberculosis

Mycobacterium tuberculosis

Bordetella pertussis Respiratory syncytial or parainfluenza virus

History of infection or colonization with multi drug-resistant organisms II Resistant bacterial! Skin, wound, or urinary tract infection in a patient with a recent hospital or Resistant bacterial! nursing home stay in a facility where multidrug-resistant organisms are prevalent

Skin or Wound Infection Abscess or draining wound that cannot be covered Staphylococcus aureus,

group A streptococcus

Empiric Precautions

Contact

Contact Droplet

Droplet Airborne and Contact Airborne

Airborne

Airborne

Droplet Contact

Contact Contact

Contact

t Patients with the syndromes or conditions listed below may present with atypical signs or symptoms ( eg, pertussis in neonates and adults may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgment. t The organisms listed under the column "Potential Pathogens" are not intended to represent the complete, or even most likely, diagnoses, but rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out. These pathogens include enterohemorrhagic Escherichia coli 0157:H7, Shigella, hepatitis A, and rotavirus. IIResistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical or epidemiological significance.

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3364-109-ISO-404