Transmission Based Precautions

Recommendations

General principles

In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission (Strong Recommendation, High Grade Evidence)

Extend duration of Transmission-Based Precautions, (e.g., Droplet, Contact) for immunosuppressed patients with viral infections due to prolonged shedding of viral agents that may be transmitted to others (Strong Recommendation, High Grade Evidence)

Consistent with the persons care needs, minimize the number of healthcare workers and the time healthcare workers are exposed to an infectious patient. (Good Practice Statement)

Contact Precautions

Contact precautions, in addition to standard precautions, are implemented in the presence of known or suspected infectious agents that are spread by direct or indirect contact with the patient or the patient's environment. (Strong Recommendation, High Grade Evidence)

 Patient placement

Place patients who require Contact Precautions in a single-patient room when available (Strong Recommendation, Moderate Grade Evidence)

When single-patient rooms are in short supply, apply the following principles for making decisions on patient placement:

·       Prioritize patients with conditions that may facilitate transmission (e.g., uncontained drainage, stool incontinence) for single-patient room placement. (Good Practice Statement)

·       Place together in the same room (cohort) patients who are infected with or colonized with the same pathogen and are suitable roommates. (Strong Recommendation, Moderate Grade Evidence)

If it becomes necessary to place a patient who requires Contact Precautions in a room with a patient who is not infected or colonized with the same infectious agent:

·       Avoid placing patients on Contact Precautions in the same room with patients who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission (e.g., those who are immunocompromised, have open wounds, or have anticipated prolonged lengths of stay). (Good Practice Statement)

·       Ensure that patients are physically separated (i.e., >3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for direct contact. (Good Practice Statement)

·       Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one or both patients are on Contact Precautions. (Strong Recommendation, Moderate Grade Evidence)

Use of personal protective equipment

·       Gloves

Wear gloves whenever touching the patient’s intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don/ put on gloves upon entry into the room or cubicle. (Strong Recommendation, Moderate Grade Evidence)

·       Gowns

Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don/ put on gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment (Strong Recommendation, Moderate Grade Evidence)

After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces (Good Practice Statement)

Patient transport

·       Limit transport and movement of patients outside of the room to medically-necessary purposes. (Good Practice Statement)

·       When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient’s body are contained and covered. (Good Practice Statement)

·       Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions. (Good Practice Statement)

·       Don/ put on clean PPE to handle the patient at the transport destination. (Good Practice Statement)

Patient-care equipment and instruments/devices

·       Handle patient-care equipment and instruments/devices according to Standard Precautions (Strong Recommendation, Moderate Grade Evidence)

·       Use disposable noncritical patient-care equipment (e.g., blood pressure cuffs) or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient (Strong Recommendation, Moderate Grade Evidence)

Environmental measures

•  Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and disinfection (e.g., at least daily) with a focus on frequently-touched surfaces (e.g., bed rails, overbed table, bedside commode, lavatory surfaces in patient bathrooms, doorknobs) and equipment in the immediate vicinity of the patient. (Strong Recommendation, Moderate Grade Evidence)

•  Discontinue Contact Precautions after signs and symptoms of the infection have resolved or according to pathogen-specific Recommendation (Strong Recommendation, Moderate Grade Evidence)

Droplet Precaution

Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets (i.e., large-particle droplets >5µ in size) that are generated by a patient who is coughing, sneezing or talking (Strong Recommendation, Moderate Grade Evidence)

·       Patient placement

Place patients who require Droplet Precautions in a single-patient room when available (Good Practice Statement)

When single-patient rooms are in short supply, apply the following principles for making decisions on patient placement:

·       Prioritize patients who have excessive cough and sputum production for single-patient room placement (Good Practice Statement)

·       Place together in the same room (cohort) patients who are infected with the same pathogen and are suitable roommates (Strong Recommendation, Moderate Grade Evidence)

If it becomes necessary to place patients who require Droplet Precautions in a room with a patient who does not have the same infection:

·       Avoid placing patients on Droplet Precautions in the same room with patients who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission (e.g., those who are immunocompromised, have or have anticipated prolonged lengths of stay). (Good Practice Statement)

·       Ensure that patients are physically separated (i.e., >3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for close contact (Strong Recommendation, Moderate Grade Evidence)

·       Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one patient or both patients are on Droplet Precautions (Strong Recommendation, Moderate Grade Evidence)

Use of personal protective equipment

•  Don/ put on a mask upon entry into the patient room or cubicle (Strong Recommendation, Moderate Grade Evidence)

Patient transport

·        Limit transport and movement of patients outside of the room to medically-necessary purposes. (Good Practice Statement)

·        If transport or movement in any healthcare setting is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette. (Strong Recommendation, Moderate Grade Evidence)

·        Discontinue Droplet Precautions after signs and symptoms have resolved or according to pathogen-specific recommendation. (Strong Recommendation, Moderate Grade Evidence)

Airborne Precautions

Use Airborne Precautions for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (Strong Recommendation, High Grade Evidence)

Patient placement

Place patients who require Airborne Precautions in an air borne infection isolation room (AIIR)

·        Provide at least six (existing facility) or 12 (new construction/renovation) air changes per hour. (Strong Recommendation, High Grade Evidence)

·        Direct exhaust of air to the outside. If it is not possible to exhaust air from an AIIR directly to the outside, the air may be returned to the air-handling system or adjacent spaces if all air is directed through HEPA filters. (Strong Recommendation, High Grade Evidence)

·        Whenever an AIIR is in use for a patient on Airborne Precautions, monitor air pressure daily with visual indicators (e.g., smoke tubes, flutter strips), regardless of the presence of differential pressure sensing devices (e.g., manometers). (Strong Recommendation, High Grade Evidence)

·        Keep the AIIR door closed when not required for entry and exit. (Strong Recommendation, High Grade Evidence)

Develop systems (e.g., triage, signage) to identify patients with known or suspected infections that require Airborne Precautions upon entry into health care setting (Strong Recommendation, High Grade Evidence)

Place the patient in an AIIR as soon as possible. If an AIIR is not available, place a surgical mask on the patient and place him/her in an examination room. Once the patient leaves, the room should remain vacant for the appropriate time, generally one hour, to allow for a full exchange of air (Strong Recommendation, Moderate Grade Evidence)

Instruct patients with a known or suspected airborne infection to wear a surgical mask and observe Respiratory Hygiene/Cough Etiquette. Once in an AIIR, the mask may be removed; the mask should remain on if the patient is not in an AIIR (Strong Recommendation, Moderate Grade Evidence)

Personnel restrictions.

Restrict susceptible healthcare personnel from entering the rooms of patients known or suspected to have measles (rubeola), varicella (chickenpox), disseminated zoster, or smallpox if other immune healthcare personnel are available (Strong Recommendation, Moderate Grade Evidence)

Use of PPE

Wear a fit-tested NIOSH-approved N95 , FFP2 respirator or higher level respirator for respiratory protection when entering the room or home of a patient when the following diseases are suspected or confirmed:

·        Infectious pulmonary or laryngeal tuberculosis or when infectious tuberculosis skin lesions are present and procedures that would aerosolize viable organisms (e.g., irrigation, incision and drainage, whirlpool treatments) are performed (Strong Recommendation, Moderate Grade Evidence)

Patient transport

Limit transport and movement of patients outside of the room to medically-necessary purposes. (Good Practice Statement)

If transport or movement outside an AIIR is necessary, instruct patients to wear a surgical mask, and observe Respiratory Hygiene/Cough Etiquette (Good Practice Statement)

For patients with skin lesions associated with varicella or smallpox or draining skin lesions caused by M. tuberculosis, cover the affected areas to prevent aerosolization or contact with the infectious agent in skin lesions (Strong Recommendation, Moderate Grade Evidence)

Discontinue Airborne Precautions according to pathogen-specific  Recommendation. (Strong Recommendation, Moderate Grade Evidence)