Three types, always added to standard precautions
The CDC uses three types of transmission-based precautions: contact, droplet and airborne. You use them when standard precautions alone do not fully stop an infection from spreading.
Key points:
- They are always added to standard precautions. They never replace them.
- Some diseases spread more than one way, so a client may need more than one type.
- Start them when the client shows signs of a transmissible infection. Do not wait for lab results, because these can take two days or more.
Isolation can make clients anxious or depressed and reduce their contact with staff. Work to reduce these effects.
Contact precautions
What it is for: germs spread by touching the client or things in the client’s environment.
Examples: VRE, C. difficile, norovirus and RSV. Multidrug-resistant organisms (MDROs) are also managed this way. Use contact precautions too when there is a lot of wound drainage, fecal incontinence or other body discharge that can contaminate the room.
Room: a single-patient room is preferred. If none is free, ask infection control. Clients with the same germ may share a room (cohorting). In a shared room, keep beds more than 3 feet apart and draw the curtain. Avoid a roommate who is immunocompromised or has an open wound.
PPE: wear a gown and gloves for any contact with the client or nearby surfaces. Put them on when you enter. Take them off and clean your hands before you leave the room.
Hand hygiene: wash with soap and water whenever your hands are visibly dirty. For C. difficile, the sources differ:
- CDC prefers alcohol-based hand rub for most care, even for C. difficile, unless hands are visibly dirty. Its priority is gloves and a gown, removed carefully. During an outbreak of C. difficile or norovirus, CDC encourages soap and water.
- The Open RN Fundamentals textbook says to use only soap and water for clients with C. difficile, because hand rub does not work against its spores.
Both sources accept soap and water, so on a test question it is the safest choice after caring for a client with C. difficile.
Equipment: use disposable or client-only items, such as a blood pressure cuff. If an item must be shared, clean and disinfect it before using it on another client.
Transport: only when medically necessary. Cover the infected area of the client’s body. Remove your used PPE and clean your hands before transport, and put on clean PPE at the destination.
Droplet precautions
What it is for: germs spread by close contact with respiratory secretions, for example when the client coughs, sneezes or talks. These germs do not stay infectious over long distances, so special air handling is not needed.
Examples: pertussis, influenza, adenovirus, rhinovirus, N. meningitidis, and group A streptococcus (during the first 24 hours on antibiotics).
Room: a single-patient room is preferred. If not possible, keep beds more than 3 feet apart and draw the curtain. The client can be cohorted with clients who have the same infection. Avoid a roommate who is immunocompromised.
PPE: wear a mask when you enter the room. A respirator is not needed.
Transport: the client wears a mask if tolerated and follows cough etiquette.
Airborne precautions
What it is for: germs that stay infectious over long distances while floating in the air.
Examples: tuberculosis (TB), measles, chickenpox (varicella) and disseminated herpes zoster (shingles that has spread widely).
Room: an airborne infection isolation room (AIIR). This is a single-patient room with:
- negative pressure compared with the area around it, checked every day while in use
- at least 6 air changes per hour (existing buildings) or 12 (new or renovated buildings)
- air sent directly outside, or filtered through HEPA (high-efficiency particulate air) filters before it returns
- the door kept closed except to go in and out
If there is no AIIR, the client should be transferred to a facility that has one. In a clinic without an AIIR, put a mask on the client and use a private room with the door closed.
PPE: an N95 or higher-level respirator (NIOSH-approved and fit-tested), put on before you enter.
Staff: staff who are not immune should not enter the room of a client with measles, chickenpox or disseminated zoster when immune staff are available.
Transport: the client wears a surgical mask. If the client is masked and any infectious skin lesions are covered, the transport staff do not need a mask or respirator.
Putting on and taking off PPE
Putting on (CDC sequence):
- Gown
- Mask or respirator
- Goggles or face shield
- Gloves (pulled over the gown cuffs)
Taking off (CDC Example 1):
- Gloves
- Goggles or face shield
- Gown
- Mask or respirator
- Hand hygiene right away
Take off all PPE before you leave the room, except a respirator. Remove the respirator after you leave and close the door. CDC also shows a second safe method, in which the gown and gloves come off together first.
The outside and front of used PPE are contaminated. Do not touch the front of the mask or respirator. Clean your hands right away if they become contaminated at any step, and always after removing all PPE.