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Apr.3.2020

Elsevier Clinical Skills

Isolation Precautions: Contact (Pediatric) - CE

ALERT

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

Perform hand hygiene with soap and water or use an alcohol-based hand sanitizer immediately after removing all PPE.4

Avoid physical contact with the patient before donning appropriate PPE.1

OVERVIEW

Transmission of pathogens via the contact route can be divided into subgroups: direct contact and indirect contact. Direct contact is when direct transmission occurs because microorganisms are transferred from one infected person to another (e.g., cuts or abrasions in skin where blood or bodily fluids come into contact with mucous membranes).3 Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person (e.g., contact with contaminated equipment, surfaces, or supplies).3

Contact isolation is used for any person with signs of an illness easily transmitted by direct patient contact or by indirect contact with items in the patient’s environment. Illnesses requiring contact precautions may include those presenting with fecal incontinence (e.g., norovirus, rotavirus, or Clostridium difficile), draining wounds, uncontrolled secretions, pressure injuries, or a generalized rash.

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, and mucous membranes, as well as 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.

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 worn correctly. A breach may include skin exposure, a needlestick, or a tear in the PPE. Removing or adjusting PPE while in the procedure room increases the risk of contamination. The doffing process is a time of high risk, and a systematic procedure must be followed.1

SUPPLIES

Click here for a list of supplies.

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 spread by contact route.
  • 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 prior to admission.
  • 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, if available, for possible indications and risk factors for illnesses associated with contact isolation precautions (e.g., presence of stool incontinence [e.g., norovirus, rotavirus, Clostridium difficile], draining wounds, uncontrolled secretions, pressure injuries, or the presence of a generalized rash).
  3. Review the precautions for contact isolation criteria, including the appropriate PPE to don (Box 1)Box 1 (Table 1)Table 1.
  4. Consider the types of care to be performed while in the patient’s room (e.g., medication administration, dressing change).
  5. Determine whether the patient has a known latex allergy.

Preparation

  1. Provide proper PPE for contact isolation precautions (i.e., gloves and gown) and signage as needed.
  2. Prevent extra trips in and out of the room; gather all needed equipment and supplies before entering the room.
  3. Provide dedicated equipment (e.g., stethoscope, blood pressure cuff, thermometer) in the room.4

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)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 a mask over the mouth and nose.
    1. Secure the ties or elastic bands 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. Don eye protection (i.e., goggles or face shield), if needed, 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.
  6. Enter the isolation 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.
    4. If supplies are needed, enlist another health care team member to hand in new supplies without entering the room.
  11. Collect any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.3
    2. Place the labeled specimen in a biohazard bag.
  12. At the door, have another health care team member hold a biohazard bag into which the specimen is placed.
    Rationale: This prevents contamination of the outside of the biohazard bag.
  13. Discard supplies.
    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. 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 with 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.
    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 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.
    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 only the inside of the gown.
    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 into 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 bottom elastics and then the top ties or elastics and pull the mask away from the face. Discard the mask in the proper receptacle.
    2. For reuse, leave the patient care area and carefully fold the face mask, keeping the outer surface held inward and against itself to reduce contact with the outer surface during storage. Store the mask between uses in a clean, sealable paper bag or breathable container.2
      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 over the health care team member’s uniform.
  7. Perform hand hygiene.
  8. Leave the room and close the door.
  9. Ensure that specimens have been transported to the laboratory per the organization’s practice.
  10. Document the procedure in the patient’s record.

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

  1. Remove gown and gloves.
    If hands become contaminated during glove removal, or any other step in 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, touching 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 container.
  3. Remove eye protection from the back by lifting the headband or earpieces. Discard eye protection in the proper container.
  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. Discard the mask in the proper receptacle.
    2. For reuse, leave the patient care area and carefully fold the face mask, keeping the outer surface held inward and against itself to reduce contact with the outer surface during storage. Store the mask between uses in a clean, sealable paper bag or breathable container.2
      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 over the health care team member’s uniform.
  5. Perform hand hygiene.
  6. Leave the room and close the door.
  7. Ensure that specimens have been transported to the laboratory per the organization’s practice.
  8. 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 exists.
  • 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 or suspected breach of isolation precautions
  • Unexpected outcomes and related interventions

REFERENCES

  1. Centers for Disease Control and Prevention (CDC). (2015). Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Retrieved April 1, 2020, from https://www.cdc.gov/hai/pdfs/guidelines/ambulatory-carechecklist_508_11_2015.pdf (Level VII)
  2. Centers for Disease Control and Prevention (CDC). (2020). Coronavirus disease 2019 (COVID-19): Strategies for optimizing the supply of facemasks. Retrieved April 1, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html (Level VII)
  3. Joint Commission, The. (2020). National patient safety goals. Hospital accreditation program. Retrieved April 1, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf (Level VII)
  4. Siegel, J.D. and others. (2007, updated 2019). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved April 1, 2020, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level VII)

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