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Infection Control and Isolation Precautions as Part of Preparedness Against Use of Biological Weapon


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Title: Infection Control and Isolation Precautions as Part of Preparedness Against Use of Biological Weapon

Infection Control and Isolation Precautions as
Part of Preparedness Against Use of Biological
Weapons A Module for Nursing Professionals
  • Felissa R. Lashley, RN, PhD, FAAN, FACMG
  • Professor, College of Nursing, and
  • Interim Director, Nursing Center for Bioterrorism
    and Infectious Disease Preparedness, College of
  • Rutgers, The State University of New Jersey

  • In this module, general information is given on
    infection control and isolation procedures in
    hospitals as they pertain to nurses.
  • Standard and specific transmission-based
    precautions are discussed.
  • Following this are additional specific
    information related to each procedure (e.g.,
    handwashing, patient transport) or equipment
    (e.g., gloves, gowns).
  • Teaching cough etiquette to patients with
    respiratory infections is covered.
  • Finally, some considerations for planning
    infection control in an outbreak situation are
  • This module was supported in part by USDHHS, HRSA
    Grant No. T01HP01407.
  • Comprehensive details are found in the revised
    document guidelines for isolation precautions
    preventing transmission of infectious agents in
    healthcare settings 2007. http//

  • At the completion of this module, participants
  • be able to
  • 1. Describe the types of isolation precautions.
  • 2. Describe the three elements for infection
  • 3. Identify components of effective handwashing.
  • 4. Describe conditions under which to use
    standard precautions.
  • 5. Describe conditions under which to use contact
  • 6. Describe conditions under which to use droplet
  • 7. Describe conditions under which to use
    airborne precautions.

Infection Control
Infection Control-2
  • Sources of microorganisms can include
  • Patients
  • Health care workers
  • Visitors
  • These sources can include
  • Persons with acute illness or infection
  • Those who are carriers, and
  • Those who are colonized with microorganisms
    (harbor the organism without showing any apparent
  • Inanimate objects such as furniture and medical
    equipment can also be sources of microorganisms.

Patient Isolation Precautions for Hospitals
  • Are designed to prevent transmission of
    infections in the hospital setting
  • Require cooperation and responsibility from
    various units including administration,
    education, other clinical services, and
  • Infection transmission in the hospital requires
  • Source or reservoir of microorganisms
  • Susceptible host with a portal of entry
    receptive to the microorganism
  • Means of transmission

Patient Isolation Precautions for Hospitals-2
  • The term host refers to the person or animal who
    becomes infected.
  • Hosts differ in susceptibility due to
    characteristics, some innate, such as
  • Age (the elderly and infants are more susceptible
    to infection),
  • Immune status,
  • Genetic susceptibility factors,
  • Malnutrition, and
  • Factors, such as underlying illness (e.g.,
    diabetes mellitus and HIV infection), medical
    treatments (e.g., immunosuppressive drugs or
    radiation), surgical procedures, and placement of
    invasive devices (e.g., IVs, chest tubes, and
    urinary catheters).
  • Infectious agents vary in regard to various
    factors such as virulence, antigenicity, and
  • There are various outcomes that may occur after
    exposure to a microorganism including
    colonization, symptomatic disease, and more. The
    outcome depends on complex interactions among
    agent, host and environment.

Patient Isolation Precautions for Hospitals-3
  • There are several main routes of transmission of
    microorganisms. A microorganism may be spread by
    a single or multiple routes. These are
  • Contact, direct or indirect
  • Droplet
  • Airborne
  • Vectorborne (usually arthropod) and
  • Common environmental sources or vehicles -
    includes foodborne and waterborne as well as
    medications such as contaminated IV fluids

Patient Isolation Precautions for Hospitals-4
  • Patient care units are usually mainly concerned
    with direct and indirect contact, droplet and
    airborne transmission. In most hospitals in the
    US vector-borne transmission is not relevant.
  • Environmental and engineering aspects (including
    waste disposal, disposal of sharps, and laundry)
    are not covered in this module

Patient Isolation Precautions for Hospitals-5
  • Standard precautions are used for all patient
  • Additional isolation precautions are based on
    patients known or suspected infection, what is
    known about the microorganism causing it, and its
    route of transmission.
  • Highly contagious or diseases with high mortality
    such as Ebola hemorrhagic fever may require more
    stringent infection control, such as double
    gowning and double gloving.
  • Institutions may modify the CDC-recommended
    precautions to be more stringent.

Patient Isolation Precautions for Hospitals-6
  • Multidrug-resistant organisms (MDROs)may require
    more stringent protection, such as methicillin
    resistant Staphylococcus aureus (MRSA).
  • Isolation precautions may be combined for
    diseases that have more than one route of
    transmission. For example, protection from
    varicella requires contact and airborne
  • See CDC guidelines at http//

Patient Isolation Precautions for Hospitals-7
  • Standard Precautions (Basic level)
  • Are used for care of ALL patients in a hospital
    all of the time regardless of diagnosis or
    infection status
  • Combine the major features of universal, and body
    substance precautions, terms formerly used
  • Applied to blood, body fluids, excretions and
    secretions regardless of whether they contain
    visible blood, mucous membranes and non-intact
  • All other transmission-based precautions include
    (are in addition to) Standard Precautions
  • Level of use depends on anticipated contact with

Patient Isolation Precautions for Hospitals-8
  • Other Transmission-Based Precautions Commonly
    Used in Hospitals Consist of
  • Direct and Indirect Contact Precautions
  • Airborne Precautions
  • Droplet Precautions
  • These may be used in combinations depending on
    whether the microorganisms and infection in
    question have multiple routes of transmission
    with barrier nursing.
  • Special adaptations may be needed for multidrug
    resistant organisms and Category A agents of
  • For all, appropriate signage meeting unit
    criteria should be at entrance to patient room.
  • Unit staff should be educated and updated
    frequently as to appropriate infection control
    for patients on their unit.
  • Unit staff with certain transmissible diseases,
    such as infective conjunctivitis, should be
    relieved from direct patient contact until no
    longer infectious.
  • If possible, dedicate same patient care staff to
    care of infected patient(s) during their stay.

Infection Control and Barrier Nursing
  • Barrier nursing is a term sometimes used to
    describe the use of barriers to carry out the
    appropriate infection control protocol for the
    particular infection
  • Nurses and other health care professionals use
    appropriate infection control precautions to
    prevent transmission of a microorganism from
  • Infected patient to other patients and vice-versa
  • Infected patient to visitors and vice-versa
  • Infected patient to general hospital environment
    and vice-versa
  • Infected patient to health care worker and

Infection Control and Barrier Nursing-2
  • The general hospital environment and "permanent"
    equipment need to be protected
  • Appropriate sharp/needle precautions should be
    followed as should proper disposal of clinical
    waste and laundry

Patient Isolation PrecautionsStandard Precautions
  • Hand hygiene after patient contact
  • Wear clean, non-sterile protective gloves when
    touching blood, body fluids, secretions,
    excretions and contaminated items
  • Wear mask, eye protection or facial shield and
    gown during procedures likely to generate
    splashes or spray of blood, body fluids,
    secretions or excretions. Use depends on
    anticipated exposure and safe injection practices
    as well

Patient Isolation PrecautionsStandard
  • Handle contaminated patient-care equipment and
    linen in a manner that prevents the transfer of
    microorganisms to people or equipment
  • Use care when handling sharps and follow proper
    disposal of needles and other sharp instruments
  • Use a mouthpiece or other ventilation device as
    an alternative to mouth-to-mouth resuscitation
    when practical
  • Place the patient in a private room when feasible
    if they may contaminate the environment
  • Three new elements have been added to standard
    precautions. These are
  • Respiratory hygiene/cough etiquette
  • Safe injection practices
  • Use of masks for insertion of catheters or
    injection into spinal or epidural areas

Contact PrecautionsConsists of standard
precautions (see previous frames) plus
precautions for direct and indirect contact
  • Intended to prevent spread of microorganisms from
    an infected patient through direct means
    (touching the patient) and indirect means
    (touching surfaces or objects that have been in
    contact with the patient). These objects include
    chairs, bedrails, telephones, IV pumps, light
    switches and so on. Used in such illnesses as
    impetigo, herpes simplex, and hepatitis A.
  • Placing the patient in a private room is
    preferred or when not available, it is
    recommended that a set of principles be followed
    such as cohorting with someone with the same

Contact Precautions-2
  • Use gloves when entering the room. Change gloves
    after contact with infective material. Remove
    gloves before leaving the room. Wash hands or use
    appropriate gel after glove removal. Do not touch
    infective material or surfaces with hands. Clean,
    non-sterile gloves are usually adequate.
  • Use protective gown when entering the room if
    direct contact with patient or potentially
    contaminated surfaces or equipment near patient
    is anticipated or if the patient has diarrhea or
    colostomy or wound drainage that is not covered
    by a dressing. Remove gown and observe hand
    hygiene prior to leaving room, and do not come in
    contact with potentially contaminated
    environmental surfaces

Contact Precautions-3
  • Limit the movement or transport of the patient
    from the room. Be sure any infected or colonized
    areas are contained or covered and PPE is
    discarded. Perform hand hygiene.
  • Ensure that patient care items, bedside
    equipment, and frequently touched surfaces
    receive daily cleaning.
  • Dedicate use of non-critical patient care
    equipment to a single patient, or cohort of
    patients with the same pathogen. If not feasible,
    adequate disinfection between patients is
  • Note some authorities recommend use of shoe
  • During transport, be sure clean PPE is used

Contact Precautions-4
  • Leak resistant bag for linens should be at
  • Dedicated thermometer, B/P apparatus and
    stethoscopes are preferred unless unavoidable and
    then must be cleaned and completely disinfected
    before using with other patient.
  • Indirect contact transmission can occur when a
    susceptible patient is in contact with an
    intermediate inanimate object in the patients

Airborne PrecautionsConsists of standard
precautions plus specifics for airborne
  • Used to prevent or reduce the transmission of
    microorganisms that are airborne in small droplet
    nucleii (5 m or smaller in size) or dust
    particles containing the infectious agent.
  • These can remain suspended in the air or be
    dispersed widely by air currents even through
    ventilation systems.
  • They can be inhaled by or deposited on a host in
    the same room or further away.
  • Includes such diseases as pulmonary tuberculosis,
    rubeola (measles), and varicella.

Airborne Precautions-2
  • Place the patient in an AIIR private room with
    anteroom if possible, that has negative air
    pressure, with 6-12 air changes/per hour.
  • Appropriate monitored, high-efficacy filtration
    of air before it is discharged from the room.
    Pressure should be monitored with visible
  • Use of respiratory protection (e.g., fit tested
    N95 respirator) or powered air-purifying
    respirator (PAPR) when entering the room
  • Limit movement and transport of the patient. Use
    a mask on the patient if they need to be moved
  • Keep patient room door closed.

Airborne Precautions-3
  • If private room absolutely not available, consult
    infectious disease consultants before cohorting
  • Limit patient movement or transport only if
  • Use surgical or N95 mask on patient if transport
    is needed (see frame on patient transport for
  • Known susceptible health care workers should not
    enter room of patients with varicella or rubeola
    if other workers are available
  • If AIIR not available, transfer to a facility
    that has one

Droplet PrecautionsConsists of standard
precautions plus specifics for droplet precautions
  • Used to reduce the risk of transmission of
    microorganisms transmitted by large particle
    droplets (larger than 5 m in size).
  • This type of transmission usually requires close
    contact between the source person and the
    recipient because droplets do not remain
    suspended in the air. They usually travel 3 feet
    or less within the air and thus special air
    handling is not required, however newer
    recommendations suggest a distance of 6 feet be
    used for safety.

Droplet Precautions-2
  • Droplet transmission involves contact of the
    conjunctiva of the eyes or the mucous membranes
    of the nose or mouth of a person with the
    microorganism generated from the infected source
    person during coughing, sneezing or talking, or
    during the performance of procedures such as
    suctioning and bronchoscopy.
  • Includes such diseases as influenza, rubella,
    parvovirus B19, and mumps.

Droplet Precautions-3
  • Place the patient in a private room
  • If not available, cohort with patient with active
    infection with same microorganism
  • Use of respiratory protection such as a mask when
    entering the room recommended and definitely if
    within 3 feet of patient
  • Limit movement and transport of the patient. Use
    a mask on the patient if they need to be moved
    and follow repiratory hygiene/cough etiquette
  • Keep patient at least 3 feet apart between
    infected patient and visitors
  • Room door may remain open
  • Specific regulations are available for SARS and
    influenza, http//, and
  • http//

Handwashing and Hand Hygiene
  • One of the most important ways to protect against
    transmission of microbes and disease is hand

Handwashing and Hand Hygiene-2
  • Should be done
  • Before gloving,
  • After removing gloves
  • After touching blood, body fluids, tissues,
    secretions, excretions or any contaminated items.
    If not visibly soiled can use alcohol- based but
    if visibly soiled or contaminated with
    proteinacious material use soap and wash hands.
  • Between patients
  • After procedures on some patients to prevent
    cross-contamination of different body sites
  • After contact with patients intact skin or
    inanimate objects near the patient

Handwashing and Hand Hygiene-3
  • Wash with soap and water at least 15 seconds when
    hands are visibly soiled and follow institutional
  • Use friction
  • Can use alcohol-based rubs to decontaminate hand,
    if soiled
  • Fingernails should be short, clean and free from
  • Artificial nails should be avoided

Handwashing and Hand Hygiene-4
  • Rings should not be worn
  • Watches and bracelets should be removed
  • For alcohol-based rubs, apply to palm of one hand
    and rub hand together covering all surfaces of
    hand and fingers until hands are dry
  • Paper towels should be used to dry hands. Do not
    touch faucet handles with hands after washing
  • Wash hands with soap and water before eating and
    after using the restroom and if exposure to B.
    anthracis is suspected since some antiseptic
    agents have poor activity against spores.
  • Detailed information on hand washing may be found
    at CDC. (2002). Guidelines for hand hygiene in
    healthcare settings. MMWR, 51 (RR-16), 1-44

Personal Protective Equipment (PPE)
  • May consist of
  • Gloves
  • Gowns, usually impermeable
  • Aprons, usually impermeable
  • Face shields
  • Eye wear, such as goggles to protect eyes
  • Masks, such as N-95, which should be
    appropriately fitted
  • Boots or shoe coverings
  • Leggings
  • Head covering

Personal Protective Equipment (PPE)-2
  • The appropriate combination depends on the nature
    of the microorganism, certain characteristics of
    the host (i.e. ability to cooperate), and
    microbial route of transmission
  • Only work if used appropriately and correctly

  • Long sleeves
  • Need to be large enough to completely cover
  • Undisrupted front
  • Impermeable (water repellent)

  • Back closure
  • Add apron if extensive contact with fluid or
    splashing is anticipated
  • Inner layer of clothes under gown should be scrub
    suit or clothes can be disposed of, if
    contaminated in certain situations
  • When re-gowning avoid touching outside, unfasten
    neck ties, loosen gown by grasping edge near neck
    tie, grasp inside sleeve cuff and remove sleeve
    over hand, grasp opposite cuff and pull off, roll
    inside out in bundle and drop in appropriate

  • Wear gloves when anticipated contact with
    patients blood, body fluids and tissue
  • Are not substitute for appropriate hygiene
  • Do not need to be sterile unless procedure
    requires it
  • Be appropriate for hand size
  • Materials may be latex, vinyl or surgical but
  • Must be long enough to reach above the wrist (4-6
    inches from wrist along arm) and overlap cuff of

  • Change gloves between procedures, same patient
    after contact with material, or tissue that may
    contain a high number of microbes
  • Remove gloves immediately after use and before
    caring for another patient

  • Decontaminate hands before and after gloves are
  • In highly infectious situations, such as care of
    patients with viral hemorrhagic fever, may double
  • Use care in removing gloves if soiled, so as not
    to contaminate hands or environment
  • Single use gloves should not be washed or reused
  • Glove selection is task-appropriate

Eye/Facial Protective Devices
  • Usually goggles or face shields should be used to
    protects eyes and face from microorganism
    contamination, splattering or spraying of
    patients body fluid, saliva, or blood secretions
  • May have side panels or be complete face shield
  • Should not impair vision
  • Eyewear that forms a seal around eyes gives
    highest degrees of protection
  • Fit over mask or respirator

Eye Protective Devices-2
  • To remove handle by "clean" ear or head
  • Also piece to protect against large droplets such
    as in RSV infection is needed
  • Eyeglasses such as prescription eye glasses are
    not a substitute for proper shield
  • For further details see CDC. Eye protection for
    infection control. May 13,2008

Boots/Overshoes/Foot Coverings
  • Used if floor is only contaminated or wet
  • Protects wearer from the microorganisms
  • Prevents transport of microbes from health care
    worker's shoes in infectious patient's rooms of
    non-infected patients

  • Should be appropriately fitted
  • A N-95 mask such as the 3M is preferred to filter
    out small airborne particles
  • Discard after use or change if becomes moist

  • Worn by healthcare providers and visitors to
    protect against microbes transmitted by airborne
    or droplet means
  • May also be worn by patient with airborne or
    droplet transmissible diseases, especially under
    certain circumstances such as during direct care
    or transport
  • The appropriate mask and circumstance depends on
    microorganism and setting.

Work "Clean" to "Dirty"
  • Disinfect gloves if any possible contact with
    secretion/excretion of patient to reduce
    transmission into environment
  • To leave room,
  • Disinfect gloves
  • Remove gloves with right glove hand
  • Take off right glove turning it inside out with
    left glove

Work "Clean" to "Dirty"-2
  • Dispose of gloves
  • Disinfect hands
  • Go into anteroom
  • Remove goggles avoiding contact with front and
    your eyes
  • Disinfect goggles
  • Disinfect hands
  • Take off mask, avoiding touching front
  • Discard mask

Infected Patient Transport Within Institution
  • If patient has airborne or droplet transmitted
    infection should only leave room, if essential
  • Patient should wear mask during transport
  • Transport personnel should wear appropriate PPE
  • Transport route should avoid populated areas
  • Receiving personnel should be aware of what PPE
    and infection control procedures are needed and
    when patient is coming
  • Protect stretchers or wheelchairs appropriately
  • Appropriate hand hygiene should be used

Infected Patient Transport Within Institution-2
  • Disinfect all transport equipment and linens
  • Patient should be in clean gown
  • Patient should wear or use appropriate barriers
    such as impermeable dressings for wounds
  • Let patients know how they can assist

Respiratory Hygiene/Cough Etiquette/Patient
  • Initiate at first point of contact with even a
    potentially infected person with respiratory
  • Includes education which may be visual and/or
    verbal at an appropriate educational level with
    cultural considerations of patients and the
    people who accompany themas well as health care
  • These are now incorporated into standard

Respiratory Hygiene/Cough Etiquette/Patient
  • Elements and Instruction should include
  • Informing personnel if they have any symptoms of
    respiratory infection,
  • Having tissues provided to patients and visitors,
  • Covering mouth/nose with tissue
  • Throwing tissues away properly when coughing or
  • Using surgical masks on coughing person when
  • Providing alcohol-based hand-rubbing dispensers
    and supplies for handhygiene, and educating
    patients and staff in their use,
  • Encouraging handhygiene after coughing or

Patient Teaching/Cough Etiquette-3
  • Instruction should include cont.
  • Offering masks to persons who are coughing,
  • Separating coughing persons at least 3 feet away
    from others in a waiting room or have separate
  • Instructing patients and providers not to touch
    eyes, nose, or mouth.
  • Having health care personnel observe droplet
    precautions in addition to standard precautions.
  • Health care workers should use standard
    precautions with all patients.

Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents
  • Special situations require the activation of each
    institutions preparedness plan which should
  • Processes for triage and care for large numbers
    of affected individuals,
  • Chain of command information
  • Personnel policies for staff,
  • Obtaining necessary and sufficient equipment and
    supplies, including pharmaceuticals,
  • Handling of those with anxiety and panic,
  • Plan to control traffic,
  • Communication plan,
  • Plan to provide care without running water or
    usual power sources,
  • Procedure for distribution of chemoprophylaxis or
    medications, and
  • Others

Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-2
  • There will need to be a plan for rapid receiving
    and triage as well as for allocation and
    reallocation of sparse resources.
  • For example, it must be considered how limited
    numbers of ventilators would be distributed and
    used in the case of an outbreak of botulism which
    respiratory failure would be sudden and ongoing.
  • Further discussion is beyond the scope of this

Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-3
  • Usually each health care institution will
    designate a specific area or area that will
  • Receive and identify patients,
  • Triage them,
  • Treat immediately or admit, or
  • Transport or house patients with the specific
    infection, in a designated wing or building, or
    in some cases, a site separated from the
    hospital, such as a nearby school or outside
    tented area.

Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-4
  • This plan will usually clear all non-emergency
    patients and visitors who are not exposed to the
    agent in question.
  • The infected patients should be segregated from
  • Parts of the plan depend on what agent was used
    and whether it is transmissible naturally, or has
    been altered to be transmissible, from person to

Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-5
  • Health care workers may receive chemoprophylaxis
    or immunization depending on the organism
  • Patients may need to remove contaminated clothing
    and store them in labelled plastic bags for chain
    of evidence.
  • Patients may need to shower with soap and water
    and shampoo hair depending on the available
    facilities and need to do so.

Special Situations Relating to Bioterrorism
Linked Outbreaks of Biological Agents-6
  • Medical equipment may need to be shared among
    patients with the same infection.
  • In the event of a large-scale outbreak or
    epidemic, optimal infection control, such as
    private rooms for infected patients probably will
    not be possible.
  • Each nurse should be familiar with the
    preparedness plan at their own institutions and
    in their community.
  • Planning must include how infection control
    principles can be applied under potential
    emergency conditions with sparse supplies and
    lack of running water.

Further Reading OSHA. OSHA Best Practices for
Hospital- based First Receivers of victims,
Center for Health Policy, Columbia University
School of Nursing Adapting Standards of Care
Under Extreme Conditions. American Nurses
Association, March, 2008.