MAHMUD, JINAAN S.

BSN-3C

The manual introduced the category system of isolation precautions. It recommended that
hospitals use one of seven isolation categories (Strict Isolation, Respiratory Isolation, Protective
Isolation, Enteric Precautions, Wound and Skin Precautions, Discharge Precautions, and Blood
Precautions).
In hospitals and other medical facilities, an isolation ward is a separate ward used
to isolate patients suffering from infectious diseases. Several wards for individual patients are
usually placed together in an isolation unit.

7 CATEGORIES OF ISOLATION
 
Isolation is the separation of a patient from contact with others in order to control the spread of
an infectious or communicable disease. Patients are isolated according to the mode of
transmission of the disease.
 
a. Strict Isolation. Strict isolation is used to prevent the transmission of all highly
communicable diseases that are spread by both, contact or airborne routes of transmission.
Examples of such diseases are chickenpox and rabies.
 
b. Respiratory Isolation. Respiratory isolation is used to prevent transmission of organisms by
means of droplets that are sneezed or breathed into the environment. Examples of such
diseases are influenza and tuberculosis.
 
c. Protective Isolation. Protective isolation is used to prevent contact between potentially
pathogenic microorganisms and uninfected persons who have seriously impaired resistance.
Patients with certain diseases, such as leukemia, who are on certain therapeutic regimens are
significantly more susceptible to infections.
 
d. Enteric Precautions. Enteric precautions are used to control diseases that can be
transmitted through direct or indirect oral contact with infected feces or contaminated articles.
Transmission of infection depends on ingestion of the pathogen. Examples of diseases requiring
enteric precautions are dysentery and hepatitis.
 
e. Wound and Skin Precautions. Wound and skin precautions are used to prevent the spread
of microorganisms found in infected wounds (including burns and open sores) and contact with
wounds and heavily contaminated articles. Conditions requiring these precautions include
infected burns, infected wounds, and infections with large amounts of purulent discharge.
Diseases that may require wound and skin precautions include herpes, impetigo, and ringworm.
 
f. Blood Precautions. Blood precautions are used to prevent acquisition of infection by patients
and personnel from contact with blood or items contaminated with blood. Examples of diseases
that require blood precautions (refer to Lesson 1) are HBV and HIV/AIDS.

 
g. Discharge Precautions.

(1) Secretion precautions-lesions. These precautions are used to prevent acquisition of infection

by personnel and patients from direct contact with wounds and secretion-contaminated articles.
Some examples of diseases requiring these precautions are conjunctivitis, gonorrhea, and
syphilis.
 
(2) Secretion precautions-oral. These precautions are used to prevent acquisition of infection by
personnel from direct contact with oral secretions. Some examples of diseases requiring these
precautions are herpes areolas and scarlet fever.
 
(3) Excretion precautions. These precautions are used to prevent acquisition of infection by
personnel and patients from direct contact with fecal excretions. Some examples of diseases
requiring these precautions are poliomyelitis and staphylococcal food poisoning

UNIVERSAL PRECAUTIONS VS. STANDARD PRECAUTIONS

"Universal precautions are mandated for home health agencies but the type of pathogens that
exist today require standard precautions that protect staff and patients against more threats of
infection than universal precautions," says Barbara B.
Universal Precautions
In 1983, Centers for Disease Control (CDC) published the Guideline for Isolation Precautions in
Hospitals. One section, “Blood and Body Fluid Precautions,” encouraged in-hospital healthcare
workers to adhere to these precautions when a patient was known or suspected to be infected
with a bloodborne pathogen like HIV or Hepatitis B.

The CDC followed up with “Recommendations for Prevention of HIV Transmission in Health-
Care Settings” in August 1987.  These 1987 recommendations encouraged the use of blood
and body fluid precautions for all patients regardless of their infection status.

The extension of precautions to all patients was referred to as “Universal Precautions.” Under
these guidelines, blood and body fluids of all patients were considered potentially infectious.
Universal Precautions specified the use of gloves and face shields and avoiding exposure with
needles and other instruments after use when the potential for contact with blood and bodily
fluids was anticipated. The importance of frequent handwashing was at the core of these
recommendations.

By 1987, a set of rules known as Body Substance Isolation (BSI) was added. It expanded the
concept of personal protective equipment to include plastic aprons and covers for hair and
shoes to keep all moist body substances off hair, skin, clothes, and mucous membranes. BSI
went beyond simply discarding needles in puncture-resistant containers to placing them in
puncture-proof containers. Hands were to be thoroughly washed before as well as after patient
care and wearing gloves. Body Substance Isolation utilized hospital gowns, medical gloves,
shoe covers, safety goggles, and surgical masks or N95 respirators. However, there was not a
consistent interpretation or use in either BSI or universal precautions.

Standard Precautions
Times have changed since Universal Precautions were first set in place. The 21st century has
seen devastating illness from Ebola virus, avian flu, West Nile virus, SARS, Zika virus and
biological warfare as well as the pandemic flu from previous generations. Gloves alone do not
completely protect a health professional or patient. Even diseases usually transmitted by
contact can be aerosolized by saliva and respiratory secretions. Irrigating a wound can risk a
splash back of fluid. Respirator masks can be contaminated. Today, public health officials must
prepare against contact and airborne transmission as well as bloodborne risks.

In 1996, the Centers for Disease Control and Prevention established the term “Standard
Precautions.” This broadened the focus on prevention, applying the principles to all patients
regardless of diagnosis or presumed infection status.  These guidelines consider the risk of
transmission of illness from both recognized and unrecognized sources.
In the very simplest terms, Standard Precautions involve washing hands before and after patient
contact, whether or not gloves are worn. They involve wearing clean gloves when touching
blood, body fluids, and contaminated items, as well as a clean, non-sterile gown and a mask,
eye protection or face shield in the likely event of splashes or sprays. Soiled equipment and
linen are carefully handled to prevent injuries from used equipment.

These measures are the minimum infection prevention practice applying to all patient care,
regardless of the healthcare setting or whether a patient is known or suspected to carry disease.
The presence or absence of a “safety culture” (also known as a safety climate) promoting
standard precautions in the medical setting is a key component in any medical malpractice
case. ALN Consulting’s team of nurse consultants can help you pinpoint whether a
provider has been in compliance with them…and be your best foot forward in pursuing
or defending a medical malpractice suit.

Universal vs. standard precautions: Which to use?

Protect staff, patients from airborne, contact contagions. All home health agencies have
policies to prevent the spread of infection, but with recent focus on the threat of a pandemic,
home health managers need to look more closely at how prepared their agency will be for a
situation that requires a higher level of protection than universal precautions, experts say.

"Universal precautions are mandated for home health agencies but the type of pathogens that
exist today require standard precautions that protect staff and patients against more threats of
infection than universal precautions," says Barbara B. Citarella, RN, BSN, MS, CHCE,
president and CEO of RBC Limited, a home care consulting firm located in Staatsburg, NY. It is
also important to note that the Centers for Disease Control and Prevention (CDC) guidelines for
pandemic flu require standard precautions as opposed to universal precautions, she adds

The first step in evaluating your infection control program's readiness for pandemic flu is to
understand the difference between universal and standard precautions, says Citarella.

"Universal precautions were developed in 1991 to address the risk of bloodborne pathogens
because at that time the majority of high-risk infectious disease was transmitted through blood,"
explains Citarella. "Now, with the threat of avian flu, West Nile virus, biological weapons, and
pandemic flu, we face the risk of contact and airborne transmission as well as bloodborne
transmission," she says.

Standard precautions were developed by the CDC to synthesize the major features of
universal precautions, which were designed to reduce the risk of transmission of bloodborne
pathogens, and body substance isolation, which was designed to reduce the risk of
transmission of pathogens from moist body substances.

"It is important to recognize that even if a pathogen is usually transmitted by contact, the
pathogen can be aerosolized by saliva," points out Citarella. For this reason, gloves alone won't
protect the employee, she adds.

"We use standard precautions, so all of our clinicians have gloves, masks, goggles, aprons, and
gowns in their bags," says Frances Traver, RN, BSN, quality improvement manager for St.
Francis Home Health Care in Poughkeepsie, NY. "Aprons, gowns, and goggles are important in
wound care if there is a risk of splash back when irrigating the wound," she says.

My 5 Moments for Hand Hygiene

 before touching a patient,
 before clean/aseptic procedures,
 after body fluid exposure/risk,
 after touching a patient, and.
 after touching patient surroundings.

There are three categories of Transmission-Based Precautions :

Contact Precautions, Droplet Precautions, and Airborne Precautions. Transmission-Based
Precautions are used when the route(s) of transmission is (are) not completely interrupted using
Standard Precautions alone. For some diseases that have multiple routes of transmission (e.g.,
SARS), more than one Transmission-Based Precautions category may be used. When used
either singly or in combination, they are always used in addition to Standard Precautions. When
Transmission-Based Precautions are indicated, efforts must be made to counteract possible
adverse effects on patients (i.e., anxiety, depression and other mood disturbances, perceptions
of stigma, reduced contact with clinical staff, and increases in preventable adverse events in
order to improve acceptance by the patients and adherence by HCWs.

1. Contact precautions

Contact Precautions are intended to prevent transmission of infectious agents, including

epidemiologically important microorganisms, which are spread by direct or indirect contact with
the patient or the patient’s environment 

Contact Precautions also apply where the presence of excessive wound drainage, fecal
incontinence, or other discharges from the body suggest an increased potential for extensive
environmental contamination and risk of transmission. A single-patient room is preferred for
patients who require Contact Precautions. When a single-patient room is not available,
consultation with infection control personnel is recommended to assess the various risks
associated with other patient placement options (e.g., cohorting, keeping the patient with an
existing roommate). In multi-patient rooms, ≥3 feet spatial separation between beds is advised
to reduce the opportunities for inadvertent sharing of items between the infected/colonized
patient and other patients. Healthcare personnel caring for patients on Contact Precautions
wear a gown and gloves for all interactions that may involve contact with the patient or
potentially contaminated areas in the patient’s environment. Donning PPE upon room entry and
discarding before exiting the patient room is done to contain pathogens, especially those that
have been implicated in transmission through environmental contamination

2. Droplet precautions.
Droplet Precautions are intended to prevent transmission of pathogens spread through close
respiratory or mucous membrane contact with respiratory secretions Because these pathogens
do not remain infectious over long distances in a healthcare facility, special air handling and
ventilation are not required to prevent droplet transmission. Infectious agents for which Droplet
Precautions are indicated are found in Appendix A and include B. pertussis, influenza virus,
adenovirus, rhinovirus, N. meningitides, and group A streptococcus (for the first 24 hours of
antimicrobial therapy). A single patient room is preferred for patients who require Droplet
Precautions. When a single-patient room is not available, consultation with infection control
personnel is recommended to assess the various risks associated with other patient placement
options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of ≥3
feet and drawing the curtain between patient beds is especially important for patients in multi-
bed rooms with infections transmitted by the droplet route. Healthcare personnel wear a mask
(a respirator is not necessary) for close contact with infectious patient; the mask is generally
donned upon room entry. Patients on Droplet Precautions who must be transported outside of
the room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.

3. Airborne Precautions

Airborne Precautions prevent transmission of infectious agents that remain infectious over long
distances when suspended in the air (e.g., rubeola virus [measles], varicella virus
[chickenpox], M. tuberculosis, and possibly SARS-CoV)
The preferred placement for patients who require Airborne Precautions is in an airborne
infection isolation room (AIIR). An AIIR is a single-patient room that is equipped with special air
handling and ventilation capacity that meet the American Institute of Architects/Facility
Guidelines Institute (AIA/FGI) standards for AIIRs (i.e., monitored negative pressure relative to
the surrounding area, 12 air exchanges per hour for new construction and renovation and 6 air
exchanges per hour for existing facilities, air exhausted directly to the outside or recirculated
through HEPA filtration before return). Some states require the availability of such rooms in
hospitals, emergency departments, and nursing homes that care for patients with M.
tuberculosis. A respiratory protection program that includes education about use of respirators,
fit-testing, and user seal checks is required in any facility with AIIRs. In settings where Airborne
Precautions cannot be implemented due to limited engineering resources (e.g., physician
offices), masking the patient, placing the patient in a private room (e.g., office examination
room) with the door closed, and providing N95 or higher level respirators or masks if respirators
are not available for healthcare personnel will reduce the likelihood of airborne transmission
until the patient is either transferred to a facility with an AIIR or returned to the home
environment, as deemed medically appropriate. Healthcare personnel caring for patients on
Airborne Precautions wear a mask or respirator, depending on the disease-specific
recommendations that is donned prior to room entry. Whenever possible, non-immune HCWs
should not care for patients with vaccine-preventable airborne diseases (e.g., measles,
chickenpox, and smallpox).