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ISOLATION BASICS AND HAND HYGIENE
Q: What personal protective equipment (PPE) do visitors need to wear when visiting patients on isolation?
A: For patients on Contact Precautions, visitors do not need to wear any PPE. For patients on Droplet or Airborne Precautions, visitors should wear a regular surgical mask while in the patient’s room. They do not need to wear an N-95 respirator for patients on Airborne Precautions. For all patients, visitors should wash their hands or use the alcohol hand gel before and after visiting any of our patients.
Q: Why aren’t visitors required to wear a gown and gloves when visiting a patient on Contact Precautions?
A: Visitors are not a major source of infection or spread of infection from patient-to-patient because they do not have contact with multiple patients. Therefore, we do not require visitors to wear gowns or gloves for Contact Precautions patients like we do for our healthcare workers. We do ask that they wash their hands or use the alcohol hand gel upon room entry and when leaving the patient room.
Q: Why do I have to “gown up, etc” when I enter an isolation room if I’m just observing and do not intend to touch the patient?
A: Studies have shown that over 90% of the time a healthcare worker enters the room, they touch either the patient or objects in the patient’s environment. This may be due to unexpected issues that arise once the healthcare worker enters the room (such as an alarming ventilator or IV device). Thus, VUMC policy is to wear the required PPE regardless of how much contact with either the patient or the patient’s environment is anticipated.
Q: How do I get more supplies when the cart is empty?
A: Contact your unit’s service center for more supplies. In addition, many units have their own stock of PPE that may be used to replenish the carts.
Q: Where do I get N-95 masks?
A: When a patient is placed on Airborne Precautions, the isolation cart will be delivered to the patient’s room. The carts no longer contain the N-95 respirators. These must be obtained from the clean supply room of each unit. This allows for more rapid retrieval of respirators to provide protection to our employees in the event there is a delay in delivery of the isolation cart and for better control and oversight of our respirator stock.
Q: How do I know what precautions are needed?
A: There are several ways to know what type of precautions are needed for isolation patients: 1) Look at the sign on the door to the patient’s room – it will indicate exactly what type of isolation precautions and personal protective equipment you must wear before entering the room, 2) refer to the Department of Infection Control & Prevention’s website, or 3) call the Department of Infection Control & Prevention at 936-0725 or 24/7 on call pager 835-1205.
Q: Does a patient with HIV need isolation precautions?
A: Patients with HIV in general do not need to be placed on isolation precautions, however, if the HIV+ patient has respiratory symptoms (i.e., cough, shortness of breath, coughing up blood, chest pain, etc.) they need to be placed on Airborne Precautions until an alternative diagnosis can be confirmed. HIV patients do not manifest typical symptoms of pulmonary tuberculosis, so the suspicion index should be high. Infection Control and Prevention should be consulted for any questions on patient placement through the on-call beeper- # 835-1205.
Q: Do I need to wash my hands if I wear gloves when performing patient care?
A: YES! Because bacteria can pass through tiny invisible holes in gloves and because your hands can become contaminated when gloves are being removed, you still must remove your gloves and wash your hands or use alcohol hand gel after patient contact. Also DO NOT REUSE gloves between patients, as this can be a method to spread germs from one patient to another.
Q: How do I refill the alcohol hand gel dispenser? What if the dispenser is empty or broken?
A: Fortunately, each unit has an ample supply of dispensers, so you should still be able to perform hand hygiene with another dispenser nearby. But, we also want to make sure that the dispensers stay filled. As a part of routine room cleaning, Environmental Services will check the status of gel for each room and replace those that are empty. But we must all be responsible for making sure an empty dispenser is addressed. Each unit has supplies to refill the gel dispensers. If you find a dispenser that is empty, please notify the patient’s nurse or the unit charge nurse, who should restock the dispenser. If you find a broken dispenser, please notify the unit charge nurse. The charge nurse should record the details of the broken dispenser into the unit’s maintenance log. Plant services will replace the broken dispenser promptly.
Q: What is the policy regarding isolations patients leaving the room to smoke?
A: Although smoking is not considered a medical necessity for leaving the floor while on Contact Precautions, some patients may demand to leave. For infection prevention purposes, request the patient perform hand hygiene up to the elbows before leaving, put on a clean hospital cover gown and request patient only go to the designated smoking area.
PLACEMENT INTO AND REMOVAL FROM ISOLATION PRECAUTIONS
Q: How do I remove a patient with MRSA from Contact Precautions?
A: Patients must be off MRSA-specific antibiotics for 72 hours and have no evidence of continued colonization with MRSA, as evidenced by negative nasal (anterior nares) cultures at day 0 and day 7. In addition, a culture from all draining wounds must be negative for MRSA x 1. Finally, cultures from the original site of isolation of MRSA, if obtainable without increased risk for substantial patient morbidity (e.g., tracheal aspirate culture in patient with tracheostomy is easily obtained; however, collection of pleural fluid for sole intent of removal off isolation precautions would not be required), should be negative x 1.
Q: How do I remove a patient with VRE from Contact Precautions?
A: Patients must be off VRE-specific antibiotics for 72 hours and have no evidence of continued colonization with VRE, as evidenced by negative rectal or stool cultures at day 0, day 7 and day 14. In addition, cultures from the original site of isolation of VRE, if obtainable without increased risk for substantial patient morbidity (see above), should be negative x 1.
Q: How do I remove a patient with C. difficile infection from Contact Precautions? (UPDATED NOV 2011) A: 1) Patients for whom a C. difficile test is ordered are placed on empiric Contact Precautions. If the test is negative and an alternative diagnosis for the diarrheal symptoms is documented by the patient’s provider, Contact Precautionscan be discontinued.
2) A negative test is NOT required for removal from isolation.
3) Patients placed on Contact Precautions for confirmed C. difficile infection stay on isolation until the following has occurred:
A. Resolution of symptoms for 48 hours AND
B. Discharge or transfer from room so that all surfaces in room may be cleaned thoroughly (NOTE: patient must be bathed, placed in a clean gown, and placed in a clean bed if transferred to new room) AND
C. Approval by the Department of Infection Control and Prevention
Q: How do I remove a patient with a multidrug-resistant (MDR) Gram-negative organism (such as MDR Acinetobacter baumannii, CRE, and ESBL+ organisms) from Contact Precautions?
A: Patients with multidrug-resistant Acinetobacter must stay on Contact Precautions until discharge from VUMC due to the high concern for nosocomial transmission of these agents and the limited number of antibiotics available to treat such pathogens.
Q: How do I remove a patient from Airborne Precautions/TB isolation?
A: Removal from Airborne Precautions must be made in consultation with the Department of Infection Control & Prevention. Specific information regarding the patient’s clinical symptoms, history, and lab data will be used to determine appropriateness for removal. Please click here for details on the Department of Infection Control & Prevention’s process for removal from Airborne Precautions.
Q: Should patients who have a history of infection of colonization with a resistant organism during a prior hospitalization be placed on isolation upon readmission to VUMC?
A: If the patient is readmitted within 90 days from the prior hospitalization, the patient should be placed on empiric isolation. For those presenting greater than 90 days since the prior hospitalization, isolation status will be determined by the Department of Infection Control & Prevention.
OPERATING ROOM ISOLATION PRECAUTIONS
Q: Who has to wear personal protective equipment (PPE) into an isolation OR room?
A: Everyone who enters the isolation OR room MUST wear the appropriate PPE upon room entry. For Airborne Precautions, this means wearing the N-95 respirator until the patient is intubated and then after the patient is extubated. For Droplet Precautions, wear a surgical mask until patient is intubated and then after the patient is extubated. For Contact Precautions, wear gown and gloves upon room entry for the entire duration of the case.
Q: Which isolation cases must be boarded in the OR for the end of the day?
A: Any patient on Airborne Precautions (for example, those with known or suspected tuberculosis, varicella [chickenpox], measles, smallpox, or SARS).
Q: What about breaks or relief staffing?
A: As staff from the isolation OR room need to leave for breaks, they must remove PPE and perform hand hygiene upon leaving the room. Relief staff must don appropriate PPE and perform hand hygiene before entering the room. No exceptions.
Q: Why do we have to reduce traffic in the ORs?
A: It is recommended to reduce traffic in all operating rooms to reduce the incidence of surgical site infections. Isolation OR rooms have the added burden of contamination that must not be transported by personnel from room to room.
Q: Do we have to wear PPE once a patient on Contact Precautions in the OR is draped?
A: Yes. Every person entering the room must wear the appropriate PPE. They must remove the PPE if they exit the room. Should they need to re-enter the room, PPE must be donned again.