Elsevier

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May.27.2020

Elsevier Clinical Skills

Isolation Precautions: Droplet (Ambulatory) - CE

ALERT

Avoid physical contact with the patient before donning appropriate personal protective equipment (PPE).1

Perform hand hygiene with soap and water or use an alcohol-based hand rub (ABHR) immediately after removing all PPE.

Don appropriate PPE based on the patient’s signs and symptoms and indications for isolation precautions.

OVERVIEW

Infection prevention and control measures help to ensure the protection of patients, in a range of settings, who may be vulnerable to acquiring an infection both in the general community and when receiving care because of health problems.

Infection-control practices that reduce and eliminate sources of infection transmission help to protect patients and health care personnel from disease. The health care team member is responsible for educating the patient about infection control. Knowledge of the infectious process, disease transmission, and critical-thinking skills associated with use of aseptic techniques and barrier protection is essential for both health care team members and patients.

Droplet transmission is a form of contact transmission when some form of infectious agent is transmitted by droplet route (direct or indirect contact). However, in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the infectious person’s respiratory tract (e.g., coughing, sneezing, talking) to the recipient’s susceptible mucosal surfaces, generally over short distances.3

Health care team members working with patients who have an illness that can be transmitted via droplet route (e.g., influenza) should don a mask when within 1.8 to 3 m (6 to 10 ft) of the patient or upon entry into the patient’s room.3 The difference between droplet precautions and airborne precautions is related to the size of the particle. With droplet-transmitted pathogens, the particle is greater than 5 micrometers3 and does not hang suspended in air. Airborne-transmitted pathogens are less than 5 micrometers3 and are able to hang suspended in the air for long periods of time. Airborne precautions require special air handling and ventilation.3

Standard (tier 1) precautions, assume that every patient is potentially infected or colonized with an organism that could be transmitted in the health care setting. The health care team member should apply standard precautions when caring for patients (Box 1)Box 1.3 Standard precautions are the primary strategies 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. The strategy for respiratory hygiene and cough etiquette applies to any person with signs of respiratory infection (e.g., cough, congestion, rhinorrhea, increased production of respiratory secretions) when entering a health care facility.

Tier 2 precautions include measures designed for the care of a patient who is known to be or suspected of being infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission (Table 1)Table 1.3 Organisms may be transmitted by the contact, droplet, or airborne route or by contact with contaminated surfaces. The three types of transmission-based precautions—airborne, droplet, and contact—may be combined for diseases that have multiple routes of transmission (e.g., chickenpox) (Table 1)Table 1.3 Tier 2 precautions should be used with standard precautions. Additional more stringent precautions may be applied to specific outbreaks of a virus or bacteria.

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 patient’s room, health care team members must keep PPE in place and continue to wear it correctly. A breach may include skin exposure, a needlestick, or a tear in the PPE. 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

  • Explain the purpose of the isolation to the patient.
  • Teach the patient appropriate use of barrier techniques for home care, as applicable.
  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Review the patient’s medical history (if available) for possible indications and risk factors for illnesses associated with droplet isolation precautions (e.g., influenza, adenovirus, rhinovirus).
  4. Review the precautions for the specific isolation criteria, including appropriate PPE to apply (Box 1)Box 1 (Table 1)Table 1.
  5. Review the patient’s laboratory test results, if applicable.
  6. Determine whether the patient has a known latex allergy.
  7. Provide proper PPE access and signage as needed.
  8. Prevent extra trips in and out of the room; gather all needed equipment and supplies before entering the room.
  9. Dedicate medical equipment (i.e., stethoscope, blood pressure cuff, and thermometer) to be used only with the patient.3
  10. Choose a barrier protection that is appropriate for the type of isolation used and the organization’s practice (Box 1)Box 1 (Table 1)Table 1.
    1. Contact precautions: Standard precautions plus gloves and gown
    2. Droplet precautions: Standard precautions plus a mask
    3. Airborne precautions: Standard precautions plus an N95 respirator or powered air-purifying respirator (PAPR)
  11. Perform hand hygiene.
  12. 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.
  13. Don a procedure mask or face shield around the mouth and nose.
    1. Secure the ties at the middle of the head and neck.
    2. Fit the flexible band to the nose bridge.
    3. Ensure that the mask fits snugly on the face and below the chin.
  14. Don eye protection (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.
  15. Don gloves, bringing the glove cuffs over the edge of the gown sleeves.
  16. Enter the patient’s room and arrange the supplies.
  17. Introduce yourself to the patient.
  18. Verify the correct patient using two identifiers.
  19. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  20. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
  21. Provide designated 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 clean gloves.
    4. If supplies are needed, enlist another health care team member to hand in new supplies without entering the room.
  22. Administer medications as ordered while maintaining precautions.
    1. Provide oral medication in a wrapper or cup and then discard the wrapper or cup in the proper trash receptacle within the patient’s room.
    2. Wear gloves when administering injections.
      Rationale: Gloves act as a barrier to reduce the risk of exposure to blood.
    3. Discard disposable syringes and uncapped or sheathed needles in the proper sharps receptacle in the patient’s room.
    4. Place the reusable plastic syringe holder in a clean glove or, if used, on a paper towel for eventual removal and disinfection after leaving the patient’s room.
  23. Collect any ordered specimens.
    1. In the presence of the patient, label the specimen per the organization’s practice.2
    2. Prepare the specimen for transport and transport it to the laboratory immediately per the organization’s practice.
  24. Inform the patient when you plan to return to the room. Ask whether the patient requires any personal care items or has any questions.
  25. Discard supplies.

    Option 1: Removal of PPE, if Using a Nondisposable or Disposable Gown

    1. Remove gloves.
      If hands become contaminated during glove removal, immediately perform hand hygiene with soap and water or use an ABHR.
      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 receptacle.
    3. 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.
    4. Place the gown directly into a designated gown receptacle.
    5. Remove the eye protection and mask or face shield. Untie the bottom of the mask or face shield first, untie the top of the mask or face shield next, then pull the mask or face shield away from the face.
      Do not touch the outer surface of the mask or face shield.
      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.
    6. Discard the eye protection and mask or face shield in the proper receptacle or place it in an appropriate container for disinfection.
    7. Perform hand hygiene.
    8. Option 2: Removal of PPE, if Using a Disposable Gown

      1. Remove gown and gloves.
        If hands become contaminated during glove removal, immediately perform hand hygiene with soap and water or use an ABHR.
        1. Grasp the gown in the front and pull it away from the body so that the ties break. Touch only the outside of the gown 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. Touch 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 receptacle.
      3. Remove eye protection and mask or face shield. Untie the bottom of the mask or face shield first, untie the top of the mask or face shield next, then pull the mask or face shield away from the face.
        Do not touch the outer surface of the mask or face shield.
        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.
      4. Discard the eye protection and mask and or face shield in the proper receptacle or place it in an appropriate container for disinfection.
      5. Perform hand hygiene.
  • Transport the specimen to the laboratory per the organization’s practice.
  • Perform hand hygiene.
  • Document the procedure in the patient’s record.
  • EXPECTED OUTCOMES

    • Patient can explain purpose of isolation and cooperates with precautions.
    • No evidence of suspected breach of isolation precautions exists.
    • Health care team members are free from infection.
    • Health care team members perform donning and doffing correctly.

    UNEXPECTED OUTCOMES

    • Patient does not cooperate with precautions.
    • Evidence of suspected breach of isolation precautions exists.
    • Health care team member contracts an infection.
    • Health care team members do not perform donning and doffing correctly.

    DOCUMENTATION

    • Patient education
    • Procedures performed
    • Evidence or suspected breach of isolation precautions
    • Unexpected outcomes and related interventions
    • Evaluation findings communicated to the clinical team leader per the organization’s practice

    PEDIATRIC CONSIDERATIONS

    • Isolation creates a sense of separation from family and the loss of control. A strange environment may add to any confusion the child feels during isolation. A preschool-age child is unable to understand the cause-and-effect relationship for isolation. Older children may be able to understand cause, but they still may be frightened.
    • A child requires simple explanations; for example, “This is a special room that will help you get better.” All barrier precautions should be shown to the child. The family should be actively involved in any explanations.
    • For preschool-age and school-age children, making a game out of wearing the mask (e.g., superheroes) can lessen the child’s anxiety regarding PPE.

    OLDER ADULT CONSIDERATIONS

    • Older adults may become confused when they are confronted with a health care team member using barrier precautions or when left in a room with the door closed. The need for closing the door (negative-pressure airborne isolation infection room [AIIR]), along with the patient’s safety and additional safety measures, should be evaluated.

    REFERENCES

    1. Centers for Disease Control and Prevention (CDC). (2015). Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Retrieved March 12, 2020, from https://www.cdc.gov/hai/pdfs/guidelines/ambulatory-carechecklist_508_11_2015.pdf (Level VII)
    2. Joint Commission, The. (2020). National patient safety goals: Ambulatory health care accreditation program. Retrieved March 12, 2020, from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_AHC_Jan2019.pdf (Level VII)
    3. Siegel, J.D. and others. (2007, updated 2019). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved March 12, 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