Isolation Guidelines


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  • Responsibilities for Carrying Out Isolation Precautions

    Prevention of infections is an important part of health care. Not only do we desire that hospitalization result in improvement of our patient's health, we wish to prevent patients from acquiring an illness as a result of the care provided. As such, prevention of health care-associated infections is an obligation of everyone involved in the delivery of health care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)states that individuals in the health care environment have the right to expect reasonable safety. To protect patients, visitors and personnel from spread of infections, a system of isolation precautions and procedures has been implemented. These procedures have been adapted from the most current recommendations of the Centers for Disease Control and Prevention. Standard Precautions must be used on all patients, whether or not the patient is on isolation precautions.

    An order must be written for isolation, at which time the unit secretary will order isolation equipment from Central Supply. Nursing personnel may begin a patient on isolation for known or suspected infection, but must obtain a physician's order within 24 hours. Per hospital protocol, infection prevention nurses may place patients in isolation or discontinue isolation. The decision of infection prevention practitioners supercedes a physician's decisions since it is felt that infection prevention practitioners are more conservative in their decisions than are physicians. Any disagreements regarding institution and discontinuation of isolation will be decided by the hospital epidemiologist as an officer of the Infection Prevention Committee and the Clinical Executive Committee. For questions during regular office hours, call the Infection Prevention Office at (601) 924-2188. After hours, page Dr. Nolan at 929-0946. If there is no answer, page the Infectious Diseases attending physician listed on the hospital call schedule.

    All personnel - physicians, nurses, students, technicians, housekeeping, dietary and any others - are responsible for complying with isolation guidelines, and tactfully calling observed departures in compliance to the attention of offenders. Physicians must observe precautions as all times; they are expected to lead by example. Hospital Policy, State and Federal Regulations all require compliance with Standard Precautions. Departures in compliance with Standard Precautions or Isolation Precautions should be reported to Hospital Administration via an incident report.

    Patients and their families also have a responsibility for abiding by isolation guidelines. Health care providers may facilitate this by explaining appropriate measures to the patient. To aid in patient education, printable information sheets regarding general isolation concepts, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus are available under "Isolation Guidelines" at this website. It is important for patients to wash their hands after touching infective material or contaminated articles.

    Abiding by isolation guidelines is the responsibility of us all. Neglect of isolation guidelines by a few negates the conscientious efforts of many.

    Introduction to isolation

    Each category of isolation is designated by a sign on the patient's door. Laminated isolation signs should be available at all patient care areas. If not, they may be printed from "Printable Isolation Signs" under "Isolation Guidelines."  Detailed instructions for carrying out isolation are available throughout this document, but particularly at "Detailed Instructions for Setting Up and Carrying Out Isolation."  

    This section contains general information necessary for the proper use of isolation techniques. Many of these techniques are applicable not only to care of patients in isolation, but also to routine patient care.

    Hand hygiene

    Hand hygiene is the single most important means for preventing spread of infections in hospitals, whether or not a patient is in isolation. Micro-organisms causing health-care associated infections may be transmitted person to person on the hands of care providers. Hand hygiene effectively interrupts that transmission. Hand hygiene should be performed at a minimum before and after contact with a patient, and after using the bathroom. (see "Hand Hygiene" for more detailed information).

    Hand hygiene may be accomplished by either hand washing or use of alcohol-based hand disinfectants. Hand washing should be performed prior to the first patient contact of the day and any other time hands are visibly soiled. For 15 seconds, one should rub together thoroughly lathered hands, then thoroughly rinse under a stream of water. Turn off the spigot with a clean paper towel, then dry hands with another fresh paper towel. Frequent use of soap and water may cause cracking and drying of the hands. To preserve the integrity of the skin, UMMC provides a hand lotion in wall-mounted dispensers which is compatible with our disinfectant soaps. Any breaks in the skin should be covered when handling blood, body fluids or any contaminated objects.

    If hands are not visibly soiled, the alcohol-based hand wash may be used. Dispense a quarter-sized amount on to the palm and then rub this over all surfaces of the hands and allow to air dry. These rubs are more effective disinfectants than soap and water and are less drying and irritating to the skin.

    Health care providers must always cleanse their hands after every patient contact. Hands should be cleansed even if gloves were worn since all gloves may leak. Hands should be washed after contact with soiled linens or soiled equipment, prior to performing invasive procedures, before touching wounds, after using the bathroom, or when hands are visibly soiled from any source.

    Masks

    Masks are used to prevent transmission of infectious agents through the air. Transmission can occur from large particle aerosols (droplets). These travel only a short distance (usually three feet or less) prior to falling to the ground. Transmission may also occur via small particle aerosols (droplet nuclei). These particles may remain in the air, sometimes for prolonged periods in areas with limited airflows, and may travel larger distances than droplets. Masks also prevent transmission of infectious agents that are spread by direct contact with mucous membranes. Two types of masks are available for use with isolation patients - regular isolation masks, which are the same as surgical masks, and N95 particulate respirator masks.

    Regular isolation masks are used for patients in Droplet Precautions and situations where disease is spread by contact with mucous membranes. These masks should be used only once and discarded in regular trash. Masks should cover both mouth and nose.

    N95 particulate respirator masks are intended for use in patient under Airborne Infection Isolation, that is patients who may harbor disease spread by small particle aerosols. Most commonly this will be tuberculosis or chicken pox; however there are other, rarer infections requiring Airborne Infection Isolation. (See Alphabetical Listing of Organisms and Diseases

    N95 masks may be used for multiple patient visits and for more than one patient until the fit is no longer snug. After donning the mask, mold the metal nosepiece so that the mask conforms snugly to your face. Blow out sharply with hands cupped around your face. If you feel air coming out around the edges of the mask, you don't have a snug fit. If this is the case, you should try a different mask size.

    Any employee who may enter the room of a patient under Airborne Infection Isolation must undergo N95 mask fit testing performed by the Student-Employee Health Service. At that time, it will be decided what size mask best fits an individual's face. Some individuals cannot be successfully fitted due to the shape of the face or presence of facial hair. These individuals may not enter the room of a patient under Airborne Infection Isolation.

    Gowns

    Gowns and protective apparel are worn to provide barrier protection and to reduce the potential for transmission of infectious agents in hospitals. Gowns are worn to prevent contamination of clothing and to protect health-care workers from blood and body fluid exposures. Impermeable gowns, leg coverings and shoe covers provide greater protection when exposure to large volumes of blood or body fluids is anticipated. The OSHA Bloodborne Pathogens Standard mandates the use of impermeable gowns and other protective apparel under specific circumstances to reduce the risk of exposure to bloodborne pathogens.

    Gowns are also worn during the care of patients infected or colonized with certain micro-organisms to reduce the opportunity for transmission from patients or their environment to other patients, their families or health-care providers. In this situation, gowns should be removed prior to leaving the patient's room, and hands must be washed.

    Sterile gowns may be required rarely in care of patients suffering from extensive burns or extensive wounds during dressing changes.

    Gloves

    In hospitals, gloves are worn for several reasons.

    First, gloves are worn as a protective barrier and to prevent contamination of the hands when touching blood, body fluids, mucous membranes or non-intact skin. The OSHA Bloodborne Pathogens Standard requires wearing of gloves in specific circumstances to reduce the risk of exposure to bloodborne pathogens.

    Second, gloves are worn to reduce the risk of transmission of infectious organisms from the hands of health-care providers to patients during invasive procedures or procedures that involve contact with mucous membranes or non-intact skin.

    Lastly, gloves or worn to reduce the likelihood that hands of personnel contaminated with microorganisms from a patient or a fomite can transmit these microorganisms to another patient. Gloves must be changed between patient contacts and hands must be cleansed after gloves are removed.

    Wearing gloves does not replace the need for hand hygiene. All gloves have small leaks that may allow for contamination of hands, or hands may become contaminated as gloves are removed. Failure to change gloves between patient contacts poses a serious infectious risk to patients.

    Gloves should be worn for any contact with blood or body fluids, mucous membranes or non-intact skin. Gloves should be worn when handling specimens of blood or body fluids, performing venipuncture, starting intravenous catheters or changing wound dressings.

    All gloves are disposable and single use. After removing gloves hands must be cleansed prior to touching any clean items.

    Patient placement

    Whenever possible patients with epidemiologically important or highly transmissible infections should be placed in a private room. Private rooms reduce the possibility of direct or indirect contact transmission. Private rooms separate infected or colonized patients from susceptible patients and lessen the risk of transmission by any route.

    Patients requiring Airborne Infection Isolation, Protective Environment, Contact Isolation or Droplet Precautions (or any combination of these) should be placed in private rooms. Private rooms are also desirable when patients have poor hygienic habits, contaminate the environment or cannot assist in maintaining infection control precautions.

    The area considered under isolation precautions includes the patient, the patient's room or physical surroundings, plus all the patient's equipment and furniture.

    When a private room is unavailable, patients infected or colonized with the same micro-organism can usually be placed in the same room if it may be reasonably presumed that they do not carry other transmissible micro-organisms and that the risk of re-infection or recolonization is minimal. Such cohorting of patients may be especially useful in outbreak situations or when there is a shortage of private rooms. Patient cohorting must be approved by the Infection Control practitioner.

    An exception exists for patients with cystic fibrosis, who should never be placed in rooms with other patients with cystic fibrosis.

    Negative pressure rooms

    For a few infections, private rooms with special ventilation are required. These are for patients requiring Airborne Infection Isolation. In many areas of the hospital, patient rooms are under "positive pressure" to the hallways, meaning that the air circulates from the patient's room into the hall. Also, it is possible in these rooms for the air to mix in the ventilating system and enter other rooms. This obviously is not desirable when housing patients infected with micro-organisms that may be transmitted by airborne small particle aerosols (droplet nuclei), such as tuberculosis or chicken pox.

    Negative pressure rooms are engineered such that the airflow goes from the hallway into the room, then is vented directly to the outside without recirculation of the air. The large volume of air flowing through these rooms dilutes the air sufficiently to prevent the exhausted air from causing infections. (Location of patient rooms under negative pressure).

    When an order is written for Airborne Infection Isolation, the patient should be moved to a negative pressure room. If a negative pressure room is unavailable, an order should be written for a portable high efficiency particulate air (HEPA) filter to be placed in the patient's room. These units circulate the air in the patient's room through a filter that essentially "scrubs" the air and removes infecting micro-organisms and prevents their escape from the room. These units work well, but are not as efficient as true negative pressure rooms.

    Patients at high risk for transmitting disease, such as a patient with cavitary tuberculosis, must be given priority in occupying negative pressure rooms. Per hospital protocol, Infection Control practitioners have the authority to transfer patients into or out of negative pressure rooms based on an assessment on the relative risk of a patient transmitting an infection via airborne droplet nuclei. Contact the Infection Control Department at (601) 984-2188 if you feel a patient requires a negative pressure room and one is not available. Click on the following for more information regarding Airborne Infection Isolation, tuberculosis and chicken pox.

    Cough-inducing procedures, such as broncoscopy, sputum induction or aerosol administration of ribavarin or pentamidine, should be done with negative pressure ventilation or in proximity to a HEPA filter.

    Once a patient under Airborne Infection Isolation is transferred to another area or discharged, the room should remain vacant for one hour while negative pressure or the HEPA filter processes the air. During this time, anyone entering the room should wear an N95 particulate respirator. At the end of one hour, the room is safe for occupancy by another patient.

    Additional considerations for isolation precautions

    • Detailed instructions

      Click here for detailed information regarding use of correct isolation techniques, such as handling linen, drawing blood specimens, obtaining isolation equipment, etc.

    • Admission

      At the time of admission, special consideration should be given to patients recently exposed to a communicable disease. If the admission is elective, it should be postponed until it is determined that the patient has not contracted the illness or the illness has resolved. For non-elective admissions, the patient should be placed under appropriate isolation guidelines at the time of admission (this will most often be pertinent to Batson Children's Hospital).

    • Prophylaxis and immunization

      Prophylacticantibiotics or passive or active immunization may prevent or lessen the severity of certain infections when used appropriately in exposed patients and employees. Their inappropriate use may lead to adverse drug reactions, antimicrobial resistance and increased expense. These agents can be adjuncts to isolation precautions in preventing the spread of infections.

    • Staffing

      When at all possible, susceptible personnel should not be assigned to care for a patient with a communicable disease (for example, an individual seronegative for varicella (chicken pox) who has not been vaccinated should not care for a patient with chicken pox.) Conversely, special staffing is not required for care of immunocompromised patients; that is no nurse should be solely assigned to care for only certain patients on a ward to the exclusion of others simply because the patients have undergone transplantation or are immunosuppressed.

      As long as a care provider follows appropriate infection control guidelines, he/she should not be excluded from care of anyone. Exceptions to this rule may occur in outbreak situations where it be necessary to cohort patients with a certain infection on a ward. It may then be necessary to have an individual responsible for caring only for those individuals.

      Employees and care providers with communicable illnesses, including colds, pink eye (conjunctivitis), bronchitis and influenza-like illnesses, should stay away from the hospital until their illness resolves. What may seem a trivial illness to a healthy individual may be transmitted to an immunocompromised patient in whom it may be serious or fatal.

    • Isolation and the pregnant health care worker

      In most situations, no special precautions need be taken by pregnant care providers when caring for patients in isolation. Some exceptions exist, especially for chicken pox or disseminated varicella. Pregnant care providers may care for patients infected with cytomegalovirus (CMV).

    • Patient care equipment

      Whenever possible, disposable patient care equipment should be used. Reusable articles are considered contaminated and must be properly decontaminated after use in a Contact or Contact-Droplet Isolation room. Patient-care equipment (tourniquets, sphygmomanometer, stethoscope, etc.) should be assigned to that patient's room and not removed for the duration of hospitalization.

    • Patient supplies

      For patients on Contact or Contact-Droplet Isolation, only 24 hours of worth of supplies essential for the patient's care should be kept in the patient's room. If a patient is transferred, supplies in the room should be sent with the patient. Upon discharge, unused supplies must be discarded. An exception to this is made for the contents of unopened boxes of supplies. Although the outside of the box is considered contaminated, the contents are considered safe.

    • Handling of linen

      All linen removed from an isolated patient's room is considered contaminated. All such linen should be placed in bags while still in the patient's room, and double-bagged if necessary. Linen may then be reprocessed as usual.

    • Documentation of isolation

      Isolation is documented by a sign on the patient's door, a sticker placed on the front of the patient's chart, cardex, patient education form, and on the Patient Factor page of the Envision system on the main frame computer. The diagnosis requiring isolation should never be written on the patient's isolation sign.

    • Discontinuation of isolation

      Isolation guidelines continue until the patient is discharged or no longer a risk for transmitting infection. In some conditions, patients may never be able to be taken out of isolation and indeed should be placed on isolation at time of re-admission to the hospital. See Alphabetical Listing of Organisms and Diseases for specific conditions. Per hospital protocol, infection control practitioners are authorized to remove patients from isolation or resume isolation precautions after discontinuation by a physician.

    Responsibilities

    • UMMC staff

      • Must follow standard precautions and the requirements of each category of isolation precautions and ensure patient confidentiality.
    • Authorized prescriber/registered nurse

      • Shall write an order in the medical record to initiate isolation precautions based on known or suspected diseases. 
      • Shall notify MSDH as indicated for known or  suspected organisms listed in the Reportable Diseases list. 
      • Shall educate the patient/designated representative regarding isolation/precaution specifics. 
      • After consultation with MSDH or the appropriate criteria are met, a written order shall be placed in the patient's medical record to remove/discontinue isolation.
    • Registered nurse

      • Shall report isolation-based information at change of shift or transfer report to receiving nurse.
    • Supervisor/manager - all departments

      • Will consult with nursing, medical and other staff to initiate isolation/precautions and assist with measures to discontinue isolation. 
      • Shall discontinue isolation status as deemed appropriate.
    • Biomedical

      • Maintain portable HEPA filters and assist with questions concerning their use, operation and repair.
    • Patient equipment

      • Distribute portable HEPA filters and maintain adequate supplies.