Transcript TRANSMISSION-BASED PRECAUTIONS FOR HOSPITALIZED …

TRANSMISSION-BASED
PRECAUTIONS FOR
HOSPITALIZED PATIENTS
Based On CDC Guidelines 2007
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2003 Guidelines
2007 Guidelines
The term “Nosocomial”
Healthcare Associated (HA)
Cough etiquette during flu season
Respiratory Hygiene/Cough Etiquette now a part of
Standard Precautions- year round
Negative Pressure (TB) Rooms
Airborne Infection Isolation Room (AIIR)
Categories: Airborne, Droplet, Contact and
RO (Resistant organism) Isolation
Airborne, Droplet and Contact
Precaution signsAirborne, Droplet, Contact, RO,
Stop –Childhood Illness
RO sign deleted
Contact sign now green
Yellow “hand wash soap and water only” added
All signs stay posted until terminal cleaning
completed
Family and visitors not encouraged to wear
N95 respirator when visiting a patient in
Airborne Infection Isolation
Families and visitors will be offered the N95
respirator mask-nursing will offer education on the
proper use as indicated
Family and visitors do not wear gowns and
gloves while visiting in a contact isolation
room
Family and visitors are encouraged to wear the
appropriate PPE when assisting with direct patient
care
CDC Guidelines 2007
New Name
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Transmission Based Precautions for
Hospitalized Patients
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To emphasize the reason for precautions
Method of transmission
Was titled Isolation Precautions for
Hospitalized Patients
Reasons Behind the Changes
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healthcare delivery has moved from primarily acute care
hospitals to other healthcare settings (e.g., home care,
ambulatory care, free-standing specialty care sites, longterm care)
the emergence of new pathogens (e.g., SARS and Avian
influenza in humans)
renewed concern for evolving known pathogens
(e.g., C. difficile, Noroviruses, community associated
MRSA)
CDC Guidelines 2007
Visitor Requirements
Hand Hygiene Upon Entering and Leaving the Room.
Airborne …An N95 mask will be offered
Droplet
…Standard mask will be offered
Contact
…Gown and gloves are encouraged
if visitors are assisting with direct
patient care
Updated P&P #05300 Transmission Based Precautions
Standard Precautions
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Prevents contact with blood or other potentially infectious
materials.
Involves Hand Hygiene and glove use as the most
important procedure for prevention of infection.
Wear gloves when:
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Handling blood, body fluids, excretions & secretions
Surfaces, materials & objects are visibly soiled with them
Contact with non-intact skin (includes rashes) and mucous
membranes is expected.
Wear facial protection when face likely to be splashed
with blood or body fluids.
Wear gowns when clothing may become soiled with body
fluids, blood, secretions or excretions.
Hand Hygiene
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Alcohol based hand gel is more effective than
soap and water on most organisms
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Hands visibly soiled must be washed with soap
and water
Precautions for Clostridium difficile include:
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Use before and after each patient
Apply product to palm of one had and rub hands together
Cover all surfaces of hands and fingers until hands are dry
Fast acting and cause less skin irritation than soap and water
Performing handwashing with only soap and water
C. Diff is a spore that is NOT killed by alcohol based hand gel
Teach visitors about importance of proper hand
hygiene
Hand Hygiene: Gloves and Fingernails
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The use of gloves does not eliminate the need for hand
hygiene
Likewise, the use of hand hygiene does not eliminate the
need for gloves
Gloves
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Artificial fingernails or extenders are not permitted for
staff having direct contact with patients
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Reduce hand contamination by 70-80%
Prevents cross-contamination
Protects patients and health care personnel from infection
Artificial fingernails are defined as “the application of a product to
the nail to include but not limited to acrylic, overlay, tips,
extensions, gels or silk wraps.
Keep all natural nail tips less than ½ inch long.
See P&P 05704.99 for further information.
Initiation of Transmission-Based
Precautions
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Physician’s responsibility:
 indicate infectious disease that is known or suspected
Nurse responsibility:
 initiates appropriate precautions as indicated by
laboratory or clinical results or physician diagnosis
 notifies admitting physician if not already informed.
Infection Prevention personnel:
 may be consulted for clarification when appropriate
 has authority to supersede the patient's physician
decision regarding need for precautions when the
safety of patients, personnel, or visitors is a concern.
Patient Placement
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When possible, patients with highly transmissible or epidemiologically
important microorganisms are placed in a private room with hand
washing and toilet facilities.
 If private room not available and the patient does not use a bedpan:
 patient not to use a community bathroom
 place dedicated commode at bedside
 if commode must be used for another patient, clean it thoroughly
with approved hospital disinfectant (arms, seat, bucket, legs) and
allow to dry
A private room for source patient:
 has poor hygienic habits
 cannot assist in maintaining infection control precautions
When a private room is not available:
 may be placed with appropriate roommates: i.e. patients infected or
colonized with the same microorganism can share a room
 staff use appropriate barriers between patient contacts.
 postoperative patient should not share a room with a patient who has
a draining wound
Airborne Precautions
Airborne precautions sign
Childhood diseases stop sign
Place on door if patient has a childhood
illness, e.g. measles, mumps or chicken pox
Airborne Precautions Diseases
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Tuberculosis, confirmed infectious case - diagnosed with
pulmonary or laryngeal TB by positive culture.
Tuberculosis, suspected infectious case - a respiratory
specimen is positive for AFB, or the physician indicates TB
is highly possible.
Large draining tuberculosis wounds with culture swabs
that are positive for AFB, or the physician indicates TB is
highly possible.
Rubeola virus (Measles), confirmed or suspected.
Chickenpox, confirmed or suspected.
Disseminated Varicella zoster, confirmed or suspected.
(Disseminated zoster is diagnosed when the patient has
30 or more lesions out side of the affected dermatome.)
Airborne Precautions Diseases
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Localized Varicella zoster in immunocompromised patient.
SARS (Severe Acute Respiratory Syndrome) confirmed or
suspected infectious case. (See Attachment A)
Viral Hemorrhagic Fevers
Other unusual viruses or bacteria suspected of being
transmitted via airborne route.
Specifications of Airborne Precautions
Specifications - ROOM
 Room will have negative air pressure in relation to
corridor. Keep door closed. (See Attachment D for
specific rooms).
 Nursing unit personnel should notify Engineering
department that the negative air pressure room needs to
be monitored daily, unless the nursing unit already
monitors routinely.
 In the event negative air pressure is lost, contact
Engineering to initiate back-up support to sustain negative
air pressure in Airborne Infection Isolation Room.
 When no Airborne Infection Isolation Room is available,
contact Infection Prevention for further assistance and
place a standard mask on the patient.
Specifications of Airborne Precautions
Specifications - SIGN
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Post Airborne Precautions sign outside of the room.
When Airborne Infection Isolation precautions are discontinued, the room
should remain closed with the sign posted until the air inside is totally
exchanged.
Specifications - MASK/Hood
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Masks for Airborne precautions (N95 Particulate Filter Respirator) are
specially designed to filter particles the size of the TB organism. This mask
is to be worn by all health care workers.
The N95 mask must be fit tested annually to ensure mask fits properly.
Those who fail the fit testing will wear a hood/PAPR (personal powered airpurifying respirator with a HEPA filter).
The N95 mask may be worn more than once as long as the mask is clean,
dry and intact.
The mask must be worn each time the room is entered and removed after
leaving the room.
Place a regular mask on patient during transport (N95 mask is not
necessary)
Duration of Airborne Precautions
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Suspected TB patient may be removed from precautions if
the respiratory specimen fails to show AFB and the
physician rules out active TB.
For confirmed cases of TB, precautions are maintained
until three (3) sputum AFB smears, taken at least 8 hours
apart, with at least one being an early a.m. specimen, are
negative.
For confirmed cases of Chickenpox, precautions are
maintained until lesions are crusted over.
Droplet Precautions Diseases
Droplet Precautions Diseases
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Mumps
Rubella*
Parvovirus
Meningococcal disease (meningitis)
Pertussis
Mycoplasma pneumoniae
Pneumonic plague
Diphtheria, pharyngeal
Respiratory Syncytial Virus (RSV)
Rhinovirus
SARS-associated coronavirus
Streptococcus
Influenza, confirmed or strongly suspicious
* = childhood illness.
Specifications & Duration of Droplet
Precautions
Specifications
 Private room, door closed.
 Standard mask is worn when in the room.
 Post "Droplet Precautions" sign outside patient room.
 Post Childhood Illness ("Stop") sign when a patient has
any disease in the list that is preceded by an *.
 Personnel who are immune to the * diseases do not need
to wear a mask.
Duration of Precautions
 Refer to table in Attachment A in policy #05300.
CONTACT
PRECAUTIONS
GOWN
GLOVES
REQUIRED UPON ENTRY BY ALL HEALTHCARE WORKERS
VISITORS SHOULD CHECK WITH THE NURSE BEFORE ENTERING
___________________________________________________
VISITANTES DEBEN DE REPORTARSE CON LA ENFERMERA
ANTES DE ENTRAR
Contact
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Diseases or Colonization/Infection with Microorganisms Requiring
Precautions
Diseases may be transmitted via direct and indirect contact
With direct contact microorganisms are transferred from
one infected person to another person (without a
contaminated intermediate object or person)
Examples of Direct contact transmission between patients
and healthcare personnel include:
 blood or other blood-containing body fluids from a patient
directly entering a caregiver’s body through contact with a
mucous membrane or breaks (i.e., cuts, abrasions) in the skin.
Contact Precautions Diseases
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Scabies
Pediculosis
Shingles, localized
Congenital Rubella
Diphtheria, cutaneous
Furunculosis, Staphylococcus
Rotavirus
Impetigo
RSV
Major draining wounds (Staph/Strep) not contained in dressing
Hemorrhagic fevers*
Clostridium difficile*
MRSA*
VRE*
ESBL* and organisms labeled MDRO*
*lab will notify the nursing unit when these organisms are identified
Contact Precautions
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Private room door may be open
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Contact Sign will be posted
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In addition “Clean Hands with Soap and Water Only”
sign may be posted for patients with C difficile
Patients with the same resistant organism during
current admission may be cohorted in the same
room
Gown/gloves will be worn upon entering the room
Please contact the AL for appropriate placement
Contact Precautions
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The patient may leave the room to ambulate, but must clean their
hands using the waterless alcohol-based hand sanitizer or wash
their hands with soap and water before ambulating.
Patients infected with Clostridium Difficile must wash their hands
with soap and water.
 a) Patient should limit contact with the environment when
outside the transmission-based precautions room.
 b) Patient must wear a clean hospital gown over the gown they
are wearing.
 c) Failure to comply with policy will restrict patient to their room
Patient Equipment & Supplies
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Use disposable (single patient) BP cuff, stethoscope and
thermometer. Keep the equipment in the patient room
during use, and send home with patient when discharged.
Send single use items and any items that cannot be wiped
with hospital approved disinfectant home with the patient
or discard the items upon discharge (gauze dressings, etc.)
If patients are being cohorted one patient may use the
bathroom toilet and the other will use a bedside commode
dedicated to the patient
Isolation Supplies-”PPE Supply Stations”
Personal Protection Equipment
(PPE) Supply Containers are
placed outside rooms of
patients requiring
transmission based
precautions
Unit will be stocked
appropriately with hospital
items (not magazines, books,
etc.) and not overstocked
Following patient discharge
the supplies will be removed
and the holder will be cleaned
with hospital approved
disinfectant and will be stored
in the designated area
(determined by each patient
care unit)
For rooms in which the patient requires Contact
Precautions due to C diff this sign will be posted and
left in place until terminal cleaning performed
Please
Clean Hands with Soap
and Water only
Duration of Contact Precautions-MRSA
MRSA –
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Maintain precautions for positive culture or swab
during current hospitalization.
If an attempt has been made to eradicate
colonization/ infection, the patient may be
screened for continued colonization/infection at
the physician’s discretion.
Culture/swab must be taken after patient has
completed antibiotic therapy for MRSA and the
first culture/swab must be obtained no sooner
than 48 hours after completion of therapy.
Infection Prevention will review these cases on an
individual basis.
Duration of Contact Precautions-VRE
 Isolation precautions should remain in use until there
are VRE negative culture results on at least three
consecutive occasions, at least a week apart.
 Cultures are to be obtained from the original body
site(s) if possible, and from stool or rectal swab.
Duration of Contact PrecautionsOther Organisms
Precaution for other resistant organisms may
be discontinued on a case by case basis
Readmission of a Patient With
Resistant Organisms
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Check face sheet under “IC section” for
 MRSA
 VRE
 Gram
negative rods
Readmission of the patient with a known history of
resistant organism colonization/infection- MRSA
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MRSA known patients who are not on antibiotics specific for treatment of
MRSA may be candidates for screening to see if colonization exists
Swab nares and perineum (Refer to the Decision Tree for patients Readmitted with the IC: MRSA.)
Swabs will be submitted for rapid molecular diagnostic testing or traditional
culture, depending upon specific entity procedures and the results will be
reviewed by the lab
If results are negative the nurse can contact Infection Prevention who will
remove the MRSA coding on the admit facesheet IC code field
Patients with wounds will be cleared on an individual basis by Infection
Prevention.
Note: at this time (2008) PCR testing is only performed on MRSA
readmissions. Other organisms are screened via cultures
Readmission of the patient with a known
history of VRE
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Patients with a history of VRE place them in Contact
Precautions and obtain orders for VRE screening
cultures and off antibiotic
If VRE culture results on at least three consecutive
occasions, at least a week apart are negative the
nurse will notify Infection Prevention to remove the
patient from precautions
Cultures are to be obtained from the original body
site(s) if possible, and from stool or rectal swab.
Visitors
Visitors in the Transmission-Based Precautions Rooms
All visitors should be instructed to perform hand hygiene before and after patient contact.
Visitors in rooms of patients with Clostridium difficile should be instructed to wash their
hands with soap and water.
Airborne Precautions for the TB patient: For visitors, offer a TB mask and instruct on its
use prior to the visitor entering the negative pressure room.
The patient will need to wear a standard mask in the presence of children.
The patient will wear a standard mask when outside the negative pressure room.
Droplet Precautions: Visitors should wear the standard mask.
Contact Precautions:
Gowns and gloves are encouraged if participation in direct patient care is anticipated.
If the patient has Lice or Scabies, the patient’s physician should be alerted to the need to
assess the household members for the need for treatment of the same condition.
Animals are not permitted in transmission-based precautions rooms except as stipulated in
The SHC policy #05625, Animals in the Workplace.
Airborne Infection Isolation and Room
Exchanges
Following Discharge of a Patient Requiring Airborne Precautions,
the door must be left closed for the period of time indicated below
Regular Patient Room
Regular Patient Treatment room
90 minutes
90 minutes
Airborne Designated Patient Room
30 minutes
Medical Air Unit
OR Suite
30 minutes
30 minutes
(AIIR)
MRSA Screening of the Previously
Positive Patient
January 2008
Objectives
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Identify patients with a previous history of
Methicillin-resistant Staphylococcus Aureus
(MRSA) colonization
Perform the screening procedures for
obtaining appropriate specimens prior to
or upon admission to the hospital
admission hospital
Demonstrate proper specimen collection
technique
Brief History of MRSA
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Over the last decade, MRSA has increased from
38% of Staph aureus infections to greater than
60% of infections
Penicillin became available in the 1940Penicillin
1940’’
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Within ten years, Staph aureus began to develop
resistance
90% of community acquired and hospital acquired
Staph aureus infections are resistant to the penicillin
infections class drugs
Methicillin is the test for penicillin resistance
Isolation Utilization
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Appropriate use of isolation is an important
tool to help decrease transmission of MRSA
between patients and staff
Isolation impacts patients and staff through:
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Increased financial costs (supplies, blocked
beds)
High emotional costs (to patient)
Workflow disruption (donning isolation gear)
MRSA Statistics
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Patients with MRSA infections have:
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Double the mortality rate of other blood
stream infections
Longer hospital length of stay
Annual cost of treatment of MRSA infections
in US hospitals is $3.2 – 4.2 billion
Setting for Screening
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Screening occurs at initial point of entry to
our system:
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Emergency Department
Pre-anesthesia Admission Evaluation Service
(PAES) for elective surgical patients
Triage
Any other nursing unit
Scope of Supervision
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MRSA Screening is a Procedure that is
implemented by a physician order.
All patients with a history of MRSA are
screened on entry to the hospital
PCR Technology vs. Cultures
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PCR (polymearase chain reaction)
identifies DNA fragments of a specific
bacteria; in this case, MRSA. The test
results can be obtain very quickly i.e.
within hours.
Cultures are specimens placed in a media
which feeds a specific bacteria allowing it
to grow and usually takes up to 3 days to
identify MRSA.
Screening Procedure
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Step One: Determine history of MRSA by
asking the patient if:
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They have ever had MRSA
If so, have they received treatment for MRSA
within the past 48 hours
Step Two: Determine history of MRSA by:
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Review the Infection Control (IC) field on
patient’s face sheet
Screening Procedure
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Step Three: Inquire
whether the patient has
received any of the
following antibiotics
within the past 48 hours
 Bactrim
 Vancomycin
 Doxycycline
 Linezolid
 Tetracycline
 Daptomycin
 Rifampin
 Clindamycin
 Mupirocin
 Tigarcycline
If the patient has received any of the above medications, NO further
screening is required & place patient in Contact Precautions.
MRSA Screening Exclusion Criteria
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MRSA Screening Not Indicated if the
patient has a(n):
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Active infection with MRSA
Previous MRSA infection (within the past 48
hours) treated with antibiotics
NO FURTHER screening is necessary
MRSA Specimen Collection
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Prior to obtaining, verify if specimens were
collected pre--admission (ED,PAES,
Physicians office)
Collect specimens from nares and
perineum if no open wounds are present.
Appearance of MRSA
MRSA Specimen Collection
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If the patient has an open wound, swab:
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If the patient has a tracheostomy or tubes/drains,
swab:
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Nares
Perineum
Wound
Lesions
Abscesses
Nares
Perineum
Tube exit sites
Notify the Infection Control Practitioner by phone
or mail that specimens have been collected
Collecting Nares Specimen
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Educate patient
Have the patient sit facing you
Use both swabettes provided
One per nostril
Swab UP TO the anterior fold
only
Gently swab in a circular
fashion FIVE times
Collecting Perineum Specimens
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Educate patient
Have the patient lie comfortably in bed,
with legs apart
Use one swabette for swabbing the
perineum and place in culture tube.
Take swabette attached to the red handle
and swab the skin in a zigzag fashion 5
times between the genitalia and anus.
Specimen Labeling and Disposition
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Replace the swabettes in the tube, sealing it
with the red handle cap
Label the specimen tube at the bedside with:
Patient ID information (i.e. Name, MR,
Billing#)
Specimen site (nares & perineum, etc.)
Collected by ________, RN
Date
Time
Place in biohazard plastic bag
Specimen Labeling and Disposition
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Label specimen bag
with the patient
identification sticker
Send specimen to
lab
How to Order in Carecast
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Go to Orders in Carecast & enter “MRSA”
in the Non Med Orders field
Then Select “MRSA mol”
How to Order in Carecast
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Select “perineum” under Source; “nares”
also available for selection
How to Order in Cerner
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Add an order &
search for “MRSA”.
Select “MRSA
Molecular Amp”.
 Enter
required
fields as
appropriate.
Prescheduled Surgery Screening
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Prior to prescheduled surgery, the PAES nurses
screen patients who are able to come to the
PAES clinic and collect specimens from the
nares, and perineum when indicated.
If unable to collect all needed specimens, the
PAES nurse places a Physician Order Sheet on
the patient’s chart indicating which sites still
need a specimen collected.
Patient Education on Screening
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If the specimen is obtained prior to
hospital admission, the PAES RN will notify
the surgeon of all positive results if results
are available prior to the day of surgery
If the final results are unavailable upon
admission, the patient is placed in
isolation, pending results of screening
Screening Results
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The Infection Control Practitioner reviews the
results of all screens
If all PCR or culture results are negative, the
MRSA designation is removed from the patient
face sheet by the Infection Control Practitioner
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The patient will no longer require isolation
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Only 1 negative culture/PCR from each site is
necessary
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If the results return on the weekend, notify the
Infection Control Practitioner so that the
designation can be removed from the face sheet
Further Tests During Hospitalization
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If the results are positive, the patient
remains in isolation
Infection Control Practitioner may order
additional specimens to further assess
colonization
Contact Precaution Guidelines
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Patients are to be placed in a private room
Patients can ambulate in the halls,
however they must perform hand hygiene
before and after leaving the room and not
be allowed in other patient care areas.
For mother/baby isolation, the mother and
infant will remain in isolation together.
Benefits of Screening
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Current screening of patients with a
history of MRSA results in 30 - 40%
clearance rate – meaning these patients
are no longer infected or colonized and do
not need isolation
Screening makes a difference for our
patients and the care they receive
References/Credits
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Submitted:
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Gina Newman, RN, Infection Control
Practitioner, SMH
Shannon Oriola, RN, CIC Infection Control
Practitioner, SMMC
Joan Ausloos, RN, PAES, SMH
Bobbie Bochichio, RN, PAES, SMH
Susan Moore, RN, Senior Specialist, SMH
Monee Gagliardo, RN, Infection Control
Practitioner, SMBHW