Isolation is a significant aspect of a nursing center’s infection prevention program. Its purpose is to avoid the spread of nosocomial or in-house developed infection. The Centers for Disease and Prevention (CDC) guidance recommends using standard precautions for the care of all, regardless of the presence of illness or infection status. Standard precautions extend beyond protecting health care workers from exposure to blood borne pathogens and include body substances that may contain potentially infectious microorganisms. This applies to blood, all body fluids, secretions and excretions except sweat, regardless of whether or not they contain visible blood, non-intact skin and mucous membranes.
In addition to standard precautions, it is prudent for centers to implement transmission-based precautions. The CDC guides us that transmission-based precautions are in addition to standard-based precautions. They should be used as proactive or preventative measures that need to be implemented when there is suspicion of colonization and or infection due to a highly infectious or epidemiologically significant organism in order to interrupt transmission to others. There are three types of transmission-based precautions:
- Droplet, and
- Airborne isolation.
Contact isolation includes the use of gowns and gloves when in the immediate patient care environment. Droplet precautions require the use of a mask when within three-to-six feet of the patient. Airborne isolation requires the use of an N95 mask in addition to the patient being placed in a negative pressure room. At times, more than one type of isolation may be necessary in order to interrupt transmission of infection. For example, some respiratory illnesses, such as those due to multi-drug resistant organism or adenovirus, require both contact and droplet precautions. Disseminated shingles or someone who is immunocompromised is another example that requires two types of isolation, airborne and contact.
Isolation precautions can be challenging in the long term care environment, especially when it comes to determining when isolation precautions can be discontinued. The Healthcare Infection Control Practices Advisory Committee (HICPAC) 2007
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings is the go-to resource for recommendations on the type and duration of isolation required for infections; however, there are times when the guidelines do call for evaluation of the patient and environment in order to make a decision on discontinuing isolation. This scenario is often encountered when a resident has an infection due to a multi-drug resistant organism (MDRO) such as MRSA, ESBL or MDR-Pseudomonas. To determine when to discontinue isolation precautions, consider:
- Is the resident symptomatic?
- Has the resident been treated for their infection?
- Does the resident have any draining wounds or uncontained body fluids?
- Are there currently other residents with this type of infection, making it more challenging to prevent transmission to others?
- Does the resident have the ability to maintain good hand hygiene or can staff ensure the resident performs hand hygiene prior to leaving their room?
An important note: residents who are colonized or have an infection due to an MDRO must be asymptomatic, have all body fluids contained and have hand hygiene performed in order to discontinue isolation.
We encourage you to use the best support and science available to not only protect your residents/patients, staff and visitors, but to also reduce your organizational risk. Promising care practices include inclusion of CDC and/or APIC guidelines for evidence-based guidance.