Day 1 Expanded Precautions

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EXPANDED PRECAUTIONS

Day 1Basic Infection Prevention and Control

Course for NursesFAAltura, RN 2008

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Expanded Precautions

• A term that has replaced “Transmission Based Precautions” to reflect infection control measures.

• In addition to STANDARD PRECAUTIONS, they are needed to prevent transmission of highly transmittable or epidemiologically important infectious agents

• Expanded Precautions are for patients who are known or suspected to be infected with epidemiologically important pathogens that require additional control measures to prevent transmission

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• Categories of precautions included in Expanded Precautions:– Contact Precautions– Droplet Precautions

– Airborne Infection Isolation (AII)

– Protective Environment (PE) for allogeneic HSCT Patients

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• More than one category may be used for diseases that have multiple routes of transmission (i.e., SARS)

• When used either singularly or in combination, they are always used in addition to STANDARD PRECAUTIONS

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CONTACT PRECAUTIONS

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Contact Precautions• Clostridium Difficile• Rotavirus• Congenital Rubella• Decubitus Ulcer• Hepatitis A, diapered or incontinent patients• Herpes Simplex, mucocutaneous, disseminated or primary, severe (until

lesions dried or crusted)• Impetigo• Lice (Head, Body, Pubic)• Poliomyelitis• Scabies• Typhoid Fever• Multidrug Resistant Organisms

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Contact Precautions

• Use CONTACT PRECAUTIONS for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission, including colonization or infection with Multi drug Resistant Organisms (MDROs)

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Contact Precautions: PATIENT PLACEMENT

• Acute Long Care Setting: Single Patient Room• Long Term Setting: Make decisions regarding

patient placement on a case-to-case basis, balancing infection risks to other patients in the room and the potential adverse psychosocial impact on the infected or colonized patient

• Ambulatory Setting: Place patients who require CONTACT PRECAUTIONS in an examination room or cubicle as soon as possible

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• Hierarchy of alternatives when single-patient rooms are in short supply (Category II)– Prioritize patients with conditions that may facilitate

transmissions (e.g., uncontained drainage, stool incontinence) for single-patient placement

– Place together (cohort) in the same room patients who are infected or colonized with the same pathogen and are suitable roommates (e.g. at low risk for acquiring an infection or for an adverse outcome should transmission occur)

• Ensure that patients are physically separated (i.e. >3 feet) from each other. Draw privacy curtain between beds to minimize opportunity for direct contact

• Change protective attire and perform hand hygiene in between patients

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– Avoid placing patients in 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)

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Contact Precautions:HAND HYGIENE, GOWNS, GLOVES

• Observe hand hygiene practices and wear gloves according to Standard Precautions and whenever touching the patient’s intact skin (Category IB) or surfaces and articles in close proximity to the patient (e.g. medical equipment or bed rails)

• Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or items in the patient’s room. Remove the gown and observe hand hygiene before leaving the patient’s environment

• After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces to avoid transfer or microorganisms to other patients or environmental surfaces.

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Contact Precautions:PATIENT TRANSPORT

• Limit transport and movement of patients outside of the room to medically necessary purposes. When transport is required, ensure that infected or colonized areas of the patient are contained and covered.

• Remove contaminated PPE and perform hand hygiene prior to transporting patient on Contact Precautions

• Don Clean PPE to handle the patient when the transport destination has been reached.

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Contact Precautions:PATIENT CARE EQUIPMENTS

• Manage patient care equipments according to Standard Precautions

• Use disposable patient care items whenever possible or implement patient-dedicated use of non critical equipment to avoid sharing between patients.

• If use of common equipment or items is unavoidable, clean and disinfect them before using to another patient (70% Alcohol)

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Contact Precautions

• Discontinue Contact Precautions after signs and symptoms have resolved or according to pathogen specific recommendations.

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GlovesGloves


Contact Precaution

Private room or Private room or

Cohort with Cohort with same infectionsame infection

GownsGowns

Limit TransportLimit Transport

Dedicate use of Dedicate use of equipmentequipment

HandwashingHandwashing

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DROPLET PRECAUTIONS

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Infections Requiring Droplet Precaution• Diphtheria, Pharyngeal• Haemophilus influenzae type b in children• Influenza 5 days except immunocompromised person• Mumps 9 days• Rubella 7 days after onset of rash• Neisseria meningitidis (meningitis, pneumonia, Meningococcemia) 24 hours

• Pertussis 5 days• Pneumonic Plague 72 hours • Adenovirus, parvovirus B19• Group A Streptococcal infection in children 24hrs• scarlet fever

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Droplet Precautions

• Use Droplet Precautions for patients known or suspected to be infected with microorganisms transmitted by respiratory droplets (large particle droplets {>5 µ in size}) that can be generated by the patient during sneezing, talking or the performance of cough-inducing procedures

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Droplet Precautions:PATIENT PLACEMENT

• Acute Care Setting: Single Patient Room• Residence Care Setting: Place Patient who may

require Droplet Precautions in an examination room or cubicle as soon as possible – Instruct patients and accompanying individuals to

follow recommendations for Respiratory Hygiene/Cough Etiquette

• Ambulatory Setting: Same

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Droplet Precautions:MASK AND EYE PROTECTION FOR

HEALTH CARE PERSONNEL

• Wear a Surgical Mask for close patient contact (e.g., within 3 feet) Category IB

• No recommendation for wearing eye protection In addition to a surgical mask for close contact with patients who require droplet precautions for conditions other than SARS or Avian Influenzae and as recommended for Standard Precautions.

• For Patients with SARS or Avian Influenza, wear both EYE protection and Respiratory Protection

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Droplet Precautions:PATIENT TRANSPORT

• Limit movement and transport of the patient outside of the room to medically necessary purposes. Category II

• Instruct patient to wear a surgical mask and follow Respiratory Hygiene/Cough Etiquette during transport. Category II

• No Mask is required for handling transport

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Droplet Precautions

• Discontinue Contact Precautions after signs and symptoms have resolved or according to pathogen specific recommendations.

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Expanded Precaution

Droplet Precaution

Face MaskFace Mask Cohort Patient with Cohort Patient with same infectionsame infection



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Airborne Infection Isolation (AII) Precautions

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• Measles (Rubeola)

• Varicella Zoster

• Pulmonary or Laryngeal Tuberculosis, Confirmed or Suspected

• SARS

• Smallpox

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• Use AII for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route e.g., tuberculosis, measles, chickenpox, smallpox, SARS and AVIAN INFLUENZA

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• Acute Care Hospitals: Place patient in an AII that should be a single patient room equipped with the following:

1. Continuous, monitored negative pressure placed in the room with the door closed

2. At least 6 (existing facility) or 12 (new construction) air exchanges per hour

3. Direct exhaust of air to the outside. If it is not possible to exhaust the air from an AII room directly to the outside, the air may be returned through HEPA filters to the air-handling system serving exclusively the Isolation Room

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4. Keep the room door closed when not required for entry and exit

5. When a private room is not available or in the event of an outbreak or exposure where large number of patients require AII precautions, consult Infectious Disease Consultants before patient placement to determine the safety of alternative rooms that do not meet engineering requirements for AII and/or cohorting patients together based on clinical diagnosis in areas with the lowest risk of airborne transmission

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Airborne Infection Isolation (AII) Precautions• Ambulatory Setting:

1. Develop systems (e.g., triage, signs) to identify and segregate patients with known or suspected infections that require AII precautions as soon as possible after entry into a healthcare setting, including emergency department.

2. Place a surgical mask on the patient immediately and maintain until the patient has been placed in an AII room.

3. Place patients in appropriately ventilated AII rooms when available.If such rooms are not available, place these patients in an examination room at the farthest distance from other patient rooms. Once the patient leaves, the room should remain vacant for the appropriate time, usually one hour, to allow full exchange of air.

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• 4. When hospital admission is indicated, place patients with confirmed or suspected airborne transmitted infections in AII rooms.

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Airborne Infection Isolation (AII) PrecautionsPERSONAL PROTECTIVE EQUIPMENT

• Restrict SUSCEPTIBLE healthcare personnel from entering the rooms of patients known or suspected to have measles, chickenpox, smallpox if other immune healthcare personnel are available.

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• Wear fit tested NIOSH approved respiratory protection (N95 respirator or higher) when entering the room of a patient when the following diseases are suspected or confirmed:– Infectious Pulmonary or Laryngeal Tuberculosis or draining

skin lesions – Smallpox (Vaccinated and Unvaccinated), SARS

• Respiratory Protection is recommended even for health care personnel, even with a documented “take” after smallpox vaccination due to the risk of a genetically engineered virus against which the vaccine may not provide protection, or of exposure to a very large load (e.g., from high-risk aerosol-generating procedures, immunocompromised patients, hemorrhagic or flat smallpox)

NIOSH – National Institute for Occupational Safety and Health

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• Wear nose/mouth protection upon entering the room or home of a patient known or suspected of having measles (rubeola), varicella, or disseminated zoster (immune and susceptible) for consistency and because of the difficulties in establishing definite immunity in all health-care personnel. Category II

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Airborne Infection Isolation (AII) PrecautionsPATIENT TRANSPORT

• Limit movement and transport of patients who require AII precautions to medically purposes. Category II

• If transport or movement outside an AII room is necessary, place a surgical mask on the patient. For patients with skin lesion associated with varicella or smallpox or draining skin lesions caused by Mycobacterium Tuberculosis, cover the patient to prevent aerosolization or contact with the infectious agent present in the skin lesion. Category II

• Wear respiratory precautions when transporting patients who require AII precautions.

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• Discontinue AII Precautions after signs and symptoms have resolved or according to pathogen-specific recommendations.

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Airborne Precaution

Negative PressureNegative Pressure

Face MaskFace MaskPrivate Room/Door closedPrivate Room/Door closed



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AVIAN INFLUENZA

• Influenza A– Periodic Gene Segment re-assortments between human

and animal viruses produce important antigenic changes, referred to as “shifts”

– These can lead to deadly pandemics as what occurred in:

• 1886

• 1918

• 1957

• 1968

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•Highly pathogenic avian influenza, or, as it was termed originally, 'fowl plague’.

•Initially recognised as an infectious disease of birds in chickens in Italy, 1878 (Perroncito 1878).

•Due to a former hot spot in the Italian upper Po valley it was also referred to as 'Lombardian disease'.

• Although Centanni and Savonuzzi, in 1901, identified a filtrable agent responsible for causing the disease, it was not before 1955 that Schäfer characterised these agents as influenza A viruses (Schäfer 1955).

•In the natural reservoir hosts of avian influenza viruses, wild water birds, the infection generally runs an entirely asymptomatic course as influenza A virus biotypes of low pathogenicity co-exist in almost perfect balance with these hosts (Webster 1992, Alexander 2000).

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What is AVIAN FLU?

• Avian Influenza is an infectious viral disease of birds caused by type ‘A’ strains of the influenza

virus. The flu virus appears naturally among birds. Wild migratory birds such as ducks,

geese, gulls and shorebirds are natural carriers of the virus, but are resistant to severe infection from the virus. However, the virus is contagious among domesticated poultry birds and can cause

very severe consequences.

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How can it be Tested?

• AI is diagnosed in humans by isolating the virus from nasal secretions by rapid testing methods.

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How is AI Treated?• Symptomatically including administration of

plenty of fluids.• Newer antiviral medications such as

Ostelmavir (Tamiflu) and Zanamavir (Relenza) are used, which however may only be partially effective.

• People at risk should receive the current season’s INFLUENZA VACCINE only to reduce the possibility of infection with both avian and human influenza.

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How is it Transmitted?

• To poultry- Exposure of poultry to infected water fowl

• Within a flock- Bird to bird by direct contact

• Farm to farm- Movement of infected poultry, equipment and people

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What is High and Low Pathogenicity

• Different serotypes of the Avian Influenza virus depending on the hemagglutinin [HA] and neuraminidase [NA] surface proteins.– 15 different types of HA– 9 different NA.

• Based on the combination of these proteins, certain AI are more pathogenic than the rest.

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HIGH PATHOGENICITY

• Highly Pathogenic Avian Influenza (HPAI) infections are characterized by a severe and highly contagious illness, affecting most vital organs with mortality rates in domestic flocks approaching 100%.

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LOW PATHOGENICITY

• Low Pathogenicity Avian Influenza (LPAI) on the other hand is the form which is commonly found in the wild bird population. Illness with LPAI is characterized by mild respiratory symptoms and has a low mortality rate in domesticated flocks.

• LPAI like all other influenza viruses has the ability to mutate and become Highly Pathogenic Avian Influenza.

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INCUBATION PERIOD

• Most cases of AI develop within 3-7 days of exposure to infected birds or contaminated surfaces.

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SIGNS AND SYMPTOMS

• People infected with AI manifest with typical flu like symptoms such as fever, cough, sore throat and muscle aches, to eye infections, acute respiratory distress, and pneumonia amongst others.

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PROTECTIVE ENVIRONMENT

• Differ from other categories in that the goal of placing a high risk patient in a PE is to prevent the patient from acquiring fungal infections from the environment whereas the goals of the other categories are to protect HCWs, visitors and other patients from acquiring infectious agents from infected patients

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PROTECTIVE ENVIRONMENT

• Place Allogeneic Hematopoeitic stem cell transplact (HSCT) patients in a PE to reduce exposure to environmental fungi (e.g., Aspergillus sp.)

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COMPONENTS of PROTECTIVE ENVIRONMENT

I. Patients: Allogeneic Hematopoietic Stem Cell Transplant (HSCT) only

• Maintain in PE room except for required diagnostic or therapeutic procedures that cannot be performed in the room (e.g., radiology, operating room)

• Respiratory Protection e.g., N95 respirator, for the patient when leaving PE during periods of construction

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COMPONENTS of PROTECTIVE ENVIRONMENT

II. Standard and Expanded Precautions:

• Observe Hand hygiene before and after patient contact

• Gown, gloves, mask NOT required fro HCWs or visitors for routine entry to the room unless indicated for suspected or proven infections

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COMPONENTS of PROTECTIVE ENVIRONMENTIII. Surface:• Daily wet dusting of horizontal surfaces using

cloths moistened with disinfectant/detergent• Avoid dusting methods that disperse dust• No carpeting in patient rooms and hallways• No upholstered furniture and furnishingIV. Others• No flowers (fresh or dried) or potted plants in PE

rooms or areas

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Protective Environment

Positive PressurePositive PressureFace Mask & GownFace Mask & Gown


Single RoomSingle Room

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Combination

• Adenovirus in Children – D, C• Aerosolizable Anthrax – AII, C• AVIAN INFLUENZA – AII, D, C (14 days after onset of symptoms)• Disseminated Herpes Zoster – AII, C• Monkey Pox – AII, C (Until lesions crusted)• SARS – AII, D, C (Plus 10 days after resolution of feve, provided

respiratory symptoms are absent or improving)• Smallpox – AII, C• Tuberculosis, Extrapulmonary, draining lesions – AII,C• Varicella – AII, C (Until lesions dried and crusted)• Viral Hemorrhagic Fever due to Ebola, Lass, Marburg, Crimean –

Congo Fever viruses – AII, C

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Transmission-Based Precautions for Hospitalized Patients

Category Single Room

Mask Gown Gloves

AIRBORNE Yes, neg. air P vent

Yes No No

DROPLET Yes* Yes, for close contact

No No

CONTACT Yes* No Yes Yes

*Cohorting acceptable

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A 6-yr old boy developed low grade fever and vesicular rash on the face, chest and

extremities. Onset of illness was 2 days after admission to the wards. The patient was

diagnosed to have Varicella.

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Isolation of Hospitalized Patients with Varicella

STANDARD PRECAUTION PLUS CONTACT PRECAUTION

Private room with neg air pressure

Masks

Gowns

Gloves

Handwashing

YES

YES for all susceptible persons entering room

YES if clothing will come into contact w/ patient; remove before leaving room

YES, remove before leaving room

YES

PLUS AIRBORNE PRECAUTION

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A 20-yr old employee was admitted for blood-streaked sputum and weight loss. Chest-xray showed Cavitary Pulmonary Tuberculosis.

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Isolation of Hospitalized Patients with Tuberculosis

STANDARD PRECAUTION PLUS AIRBORNE PRECAUTION

Private room with neg air pressure

Masks

Gowns

Gloves

Handwashing

YES

YES, N95 masks preferable

NO, unless dictated by Standard precaution


YES

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A 15-yr old student was admitted for fever, loss of appetite, nausea and generalized body

weakness. On physical examination, she had icteric sclerae and enlarged tender liver. She was diagnosed to have Hepatitis A infection.

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Isolation of Hospitalized Patients with Hepatitis A Infection

STANDARD PRECAUTION PLUS CONTACT PRECAUTION

Private room

Masks

Gowns

Gloves

Handwashing

YES, if incontinent


YES

YES

YES

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A neonate delivered to a known HIV-positive mother by caesarean section. The baby was fullterm, adequate for gestational age with no

perinatal complications. The baby has Perinatal Exposure to HIV (possible HIV

infection).

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Isolation of Hospitalized Patients with HIV Infection

STANDARD PRECAUTIONPrivate room

Masks

Gowns

Gloves

Handwashing

NO, unless w/ severe immunosuppression

NO unless procedure likely to generate splashes, sprays of blood, body fluids, secretions, etc

NO unless procedures likely to generate splashes, sprays of blood, body fluids, secretions, etc

NO, unless touching blood or body fluids contaminated w/ blood,mucus membranes, nonintact skinYES

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Day 1 Expanded Precautions