UPMC POLICY AND PROCEDURE MANUAL POLICY: HS-IC0609 * …€¦ · a face shield that fully covers...

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UPMC

POLICY AND PROCEDURE MANUAL

POLICY: HS-IC0609 *

INDEX TITLE: Infection Prevention

and Control

SUBJECT: Isolation/Standard Precautions Policy

DATE: November 8, 2013

TABLE OF CONTENTS I. POLICY STATEMENT……………………………………………………………………………….3

II. STANDARD PRECAUTIONS………………………………………………………………………..3

1. Scope………………………………………………………………………………….……….3

2. Procedure…………………………………………………………………………….………..4

Hand Hygiene…………………………………………………………………………….4

Personal Protection Equipment PPE

o Gloves………………………………………………………….……………….4

o Eye/Face Protection………………………………….…………………………4

o Gowns…………………………………………………….…………………….5

Patient Care Equipment…………………………………………………………………..5

Environmental control……………………………………………………………………5

Textiles and Laundry …………………………………………………………………….5

Eating Utensils……………………………………………………………………………6

Needles and other sharps …………………………………………………………………6

Patient Resuscitation……………………………………………………………………...6

Respiratory hygiene/cough etiquette……………………………………………………..6

Protective Environment…………………………………………………………………..7

III. TRANSMISSION BASED PRECAUTIONS………………………………………………………...7

1. Scope…………………………………………………………………………………………...7

2. Definition………………………………………………………………………………………7

3. Procedure………………………………………..……………………………………………..7

4. Types of Precautions……………………………………………………………………..…….8

A. Airborne Precautions…………………………………………………………………8

B. Droplet Precautions…………………………………………………………………..9

C. Contact Precautions…………………………………………………………………..9

D. Airborne/Contact Precautions……………………………………………………….11

E. Droplet/Contact Precautions………………………………………………………...11

5. Education for HCW”S patients and families ………………………………………………………11

IV. POLICIES REFERENCED WITHIN THIS POLICY…………………………………………….11

Attachment I – Procedure for Donning and Removing Personal Protective

Equipment……………………………………………………………………………………………………….13

Attachment II – Miscellaneous………………..……………………………………………………………….14

Disinfecting Equipment…………………………………………………..………………….14

Water Pitchers……………………………………………………………..…………………14

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Dietary Trays………………………………………………………………..……………….14

Admitting/Consent Forms……………………………………..…………………………….14

Reusable Items…………………………………………………………..…………………..14

Attachment III – Adaptations to Transmission Based

Precautions for Behavioral Health………………………………………………………………………………15

Attachment IV- Adaptations for Rehabilitation Units…………………………………………………………18

Attachment V - Procedures to Follow for Patients with Newly Emerging Organisms that Require Additional

Preventive Measures such as VISA/VERSA……………………………………………………………………20

Observer/Personnel Log ………………………………………………………………………………………..25

Attachment VI – Disease Specific Reference List

Type and duration of precautions needed for selected infections and

conditions……………………………………………………………………………….……………………….26

Attachment VII – Respiratory hygiene/cough etiquette……………………………………………………….51

Attachment VIII - Components of a Protective Environment…………………………………………………52

Attachment IX - Isolation Signs………………………………………………………………………………..53

Attachment X - Guidelines for Transporting Patients in

Isolation…………………………………………………………………………………………………………61

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UPMC

POLICY AND PROCEDURE MANUAL

POLICY: HS-IC0609 *

INDEX TITLE: Infection Prevention

and Control

SUBJECT: Isolation/Standard Precautions Policy

DATE: November 8, 2013

I. POLICY STATEMENT

It is the policy of UPMC to reduce the risk of transmission of pathogens by implementing

Standard Precautions and Transmission Based Precautions. To achieve this goal, two

tiers of precautions will be utilized. The first and most important tier is those precautions

designed for the care of all patients in the hospital regardless of their diagnosis or

presumed infection status. Implementation of these “Standard Precautions” is the primary

strategy for successful healthcare-associated infection control as well as employee safety.

The second tier, “Transmission-based Precautions” reflects infection control measures, in

addition to standard precautions that are needed to prevent transmission with patients

known or suspected to be infected or colonized with pathogens that can be transmitted by

a well defined route.

Links are provided to policies referenced within this policy and a list can also be found in

Section IV.

II. STANDARD PRECAUTIONS

1. SCOPE

Standard Precautions apply to all United States based UPMC patients receiving

care regardless of their diagnosis or presumed infection status.

Standard Precautions apply to:

Blood

All body fluids, secretions and excretions except sweat, regardless of

whether they contain visible blood

Non-intact skin

Mucous membranes

Standard Precautions are designed to reduce the risk of transmission of all

microorganisms from both recognized and unrecognized sources of infections in

hospitals.

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Standard Precautions merges the major feature of Universal Precautions (designed

to reduce the risk of transmission of Bloodborne Pathogens (BBP) and Body

Substance Isolation (BSI - designed to reduce the risk of transmission of all

pathogens from moist body substances).

2. PROCEDURE

Hand hygiene

Decontaminate hands using soap and water or an alcohol based hand rub utilizing

the World Health Organization (WHO) 5 Moments of Hand Hygiene as defined

by the System Hand Hygiene Policy HS-IC0615.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Gloves

Wear gloves (clean nonsterile, non-vinyl gloves are adequate) when touching

blood, body fluids, secretions, excretions, contaminated items, mucous

membranes and nonintact skin or potentially colonized intact skin (e.g. patient

with diarrhea).

Do not use torn or discolored gloves.

Change gloves between tasks and procedures on the same patient after contact

with material that may contain a high concentration of microorganisms.

In patient care areas, gloves should not be used for non-patient care activities

such as answering the telephone, using a computer, or pushing elevator

buttons.

Do not wear the same pair of gloves for care of more than one patient.

Remove gloves after contact with blood/body fluids, secretions/excretions

Remove gloves after contact with contaminated items and environmental

surfaces

Do not wash gloves

Decontaminate hands immediately after glove removal to avoid transfer of

microorganisms to other patients or environments

Mask/Eye Protection/Face Shield

Use personal protective equipment (PPE) to protect the mucous membranes of

the eyes, nose and mouth during procedures and patient-care activities that are

likely to generate splashes or sprays of blood, body fluids, secretions and

excretions. Masks, goggles, face shields, and combinations of each should be

selected according to the task performed.

During procedures that generate sprays of respiratory secretions

(e.g./bronchoscopy, suctioning and intubations) wear gloves, gown, and either

a face shield that fully covers the front and sides of the face, or a mask and

goggles. Use a NIOSH approved N95 respirator or Powered Air Purifying

http://infonet2.upmc.com/Policies/systemwide/Documents/HSIC0615.pdf

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Respirator (PAPR) instead of a surgical mask if the patient has a suspected or

proven infection that is likely to be transmitted by the airborne route.

Gowns

Wear a fluid resistant/impervious nonsterile gown to protect skin and prevent

soiling of clothing during procedures and patient care activities that are likely

to generate splashes or sprays of blood, body fluids, secretions or excretions

or cause soiling of clothing.

Select a gown that is appropriate for activity and amount of fluid likely to be

encountered.

Promptly remove a soiled gown and decontaminate hands to avoid transfer of

microorganisms to other patients or environment. PPE grossly contaminated

with blood or body fluids is discarded in the biohazard waste receptacle.

Patient Care Equipment

Handle used patient care equipment soiled with blood, body fluids, secretions and

excretions in a manner that prevents skin and mucous membrane exposures,

contamination of clothing and transfer of microorganisms to other patients and

environments. Reusable equipment should not be used for the care of another

patient until it has been appropriately cleaned, disinfected and/or reprocessed.

Single-use items are discarded in the appropriate container.

Environment Control

Hospital approved procedures for the routine care, cleaning and disinfection of

environmental surfaces, beds, bedrails, bedside equipment and other frequently

touched surfaces will be followed.

All spills of blood or body fluids are to be disinfected with a 10% solution (9 parts

water: 1 part bleach) of 5.25% sodium hypochlorite (bleach) or other approved

disinfectant wearing gloves and gowns and protective face wear as needed. All

patient specimens may be contaminated on the outside of the container and must

be handled with gloves. All patient specimens are to be transported in leak-proof

containers and bags that are labeled with the biohazardous symbol.

All trash that is contaminated with blood and body fluids must be treated as

infectious and disposed of in biohazardous bags.

Textiles and Laundry

Laundry visibly soiled with blood or body fluids must be handled with gloves.

All laundry must be placed in a fluid resistant bag. If linen hamper is used inside

the patient room, it should be as close to the door as possible. Do not place

laundry in a biohazardous bag. If the outside of the bag is visibly soiled with

POLICY HS-IC0609

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blood or body fluids, the bag must be placed inside another bag. All used laundry

must be considered contaminated. If personal clothing becomes contaminated

with blood or other potentially infectious material, it cannot be taken home until it

is laundered or disinfected.

Handle used laundry with minimum shaking to avoid contamination of air,

surfaces, and persons.

When handling used linen, always hold it away from your body.

If laundry chutes are used, ensure that they are properly designed, maintained,

and used in a manner to minimize dispersion of aerosols from contaminated

laundry.

Eating Utensils

No special precautions are needed for dishes, glasses, cups or eating utensils. The

combination of hot water and detergents used in hospital dishwashers is sufficient

to decontaminate dishware and eating utensils.

The hospital dietary tray should not be used as a means to dispose of any medical

devices or contaminated objects.

Dishes and/or food trays from any patient’s rooms, which are visibly

contaminated by blood or body fluids, should be cleaned by nursing personnel

prior to being returned to the food cart.

Needles and other sharps

Do not recap, bend, break, or hand—manipulate used needles; if recapping is

required, use a one-handed scoop technique only; use safety features when

available; place used sharps in puncture-resistant container. For additional

information refer to UPMC Policy HS-IC0616, Guidelines for Handling Sharps.

For additional information refer to UPMC Policy HS-IC0604, OSHA Bloodborne

Pathogen Standard Exposure Control Plan.

Patient Resuscitation – Use Mouthpiece, resuscitation bag, other ventilation

devices to prevent contact with mouth and oral secretions.

Respiratory hygiene/cough etiquette – instruct symptomatic persons to cover

mouth/nose when sneezing, coughing; use tissues and dispose in no-touch

receptacle and perform hand hygiene after soiling of hands with respiratory

secretions; wear surgical mask if tolerated or maintain spatial separation, > 3 feet

if possible. (See Respiratory Hygiene/Cough Etiquette guidelines,

Attachment VII).




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Protective Environment – refer to Attachment VIII “Components of a Protective

Environment” for specified patient populations.

III. TRANSMISSION BASED PRECAUTIONS

1. SCOPE

Transmission-based Precautions are used for patients known or suspected to be

infected or colonized with epidemiologically important pathogens spread by

airborne or droplet transmission, or by direct contact with patients or surfaces

potentially contaminated by the patient. Transmission-based Precautions are to be

strictly adhered to within the hospital. Modifications of Transmission-based

Precautions cannot be made without the consent of the Medical Director of

Infection Control and/or Hospital Infection Committee Chairperson of that

facility.

2. DEFINITION

Transmission-based Precautions are designed for patients documented or

suspected to be infected with highly transmissible or epidemiologically important

pathogens for which additional precautions beyond Standard Precautions are

needed to interrupt transmission in Health Care Facilities.

Transmission-based Precautions include:

1. Airborne Precautions

2. Droplet Precautions

3. Contact Precautions

Or a combination of the above may be used:

Airborne/Contact Precautions

Droplet/Contact Precautions

3. PROCEDURE

It is the responsibility of the healthcare provider to implement isolation for

patients under his or her care. When a physician or nurse is in doubt regarding the

need and type of isolation or precaution, they should consult the Infection

Prevention Policies on line. An Infection Prevention Practitioner should be

consulted for specific questions or recommendations not found in the manual.

The Medical Director of Infection Prevention, Infection Committee Chairperson,

or designee may initiate isolation or special precautions as deemed necessary.

Refer to Attachment IX - System Isolation Signage

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4. TYPES OF PRECAUTIONS

A. AIRBORNE PRECAUTIONS

In addition to Standard Precautions, Airborne Precautions are used for patients

known or suspected to be infected with microorganisms transmitted by airborne

droplet nuclei (small-residue [5 microns or smaller in size] (e.g. Tuberculosis

(TB) or Measles (Rubeola).

Non-immune HCWs should not care for patients with vaccine preventable

airborne diseases (if immune caregivers are available.) All HCW’s entering room

should wear a NIOSH approved N95 respirator or Powered Air Purifying

Respirator (PAPR).

Patient Placement

Place the patient in a private room that has:

Monitored negative air pressure in relation to the surrounding areas.

Six to twelve air changes per hour.

Appropriate discharge of air outdoors or monitored high-efficiency filtration

of room air before the air is circulated to other areas in the hospital.

Keep doors closed and the patient in the room.

When a private room is not available the patient will be placed in a room with

a patient(s) who has been infected with the same microorganism, but with no

other communicable infection (cohorting) Cohorting patients in a negative

pressure room is permitted if necessary(private room is not available and the

patient is infected with same microorganism)

Respiratory Protection

Wear approved respiratory protection a NIOSH approved N95 respirator or

Powered Air Purifying Respirator (PAPR) when entering the room.

Patient Transport (See Attachment X)

Limit the movement and transport of the patient from the room for essential

purposes only. If transport or movement is necessary place a mask

(regular/procedure/surgical) on the patient (do not use the N95 respirator for the

patient). For patients with skin lesions associated with varicella (chickenpox)

smallpox or draining skin lesions caused by M. tuberculosis, cover the patient to

prevent aerosolization or contact with the infectious agent present in skin lesions.

The receiving areas must be informed about the patient’s isolation status. No PPE

is worn by the HCW during transportation unless special

circumstances/conditions warrant additional procedures.

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For additional precautions for preventing transmission of tuberculosis, refer to the

UPMC Policy HS-IC0611, TB Exposure Control Plan.

B. DROPLET PRECAUTIONS

In addition to Standard Precautions, Droplet Precautions are used for patients

known or suspected to be infected with microorganisms transmitted by droplets

[particles larger than 5 microns in size] that can be generated by the patient during

coughing, sneezing, talking or the performance of cough inducing procedures

(e.g. Neisseria meningitis, and influenza).

Patient Placement

Place the patient in a private room. If a private room is not available, place the

patient in a room with a patient(s) who has active infection with the same

microorganism, but with no other communicable infection (cohorting).

When a private room is not available and cohorting is not easily achievable,

consult with Infection Prevention professionals before patient placement.

Respiratory Protection

A mask (regular/procedure/surgical) should be worn when within three feet of the

isolated patient


Limit the movement and transport of the patient from the room for essential

purposes only. If transport or movement is necessary, minimize patient dispersal

of droplets by placing a mask (regular/procedure/surgical) on the patient. The

receiving areas must be informed about the patient’s isolation status. No PPE is

worn by the HCW during transportation unless special circumstances/conditions

warrant additional procedures.

C. CONTACT PRECAUTIONS

In addition to Standard Precautions, use Contact Precautions for specified patients

known or suspected to be infected or colonized with epidemiologically important

microorganisms including Multidrug-resistant organisms (MDROs) that can be

transmitted by direct contact with the patient (hand or skin-to-skin), or indirect

contact (touching) with environmental surfaces or patient-care items in the

patient’s environment.

*Enhanced signage is utilized for patients on Contact Precautions which require soap

and water for hand hygiene after contact with the patient and/or environment; such as

C.difficile or Norovirus. Refer to facility specific guidelines.


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Patient Placement

Place the patient in a private room. When a private room is not available, the

patient can be placed in a room with a patient(s) who has been identified with the

same microorganism, but with no other communicable infection (cohorting).

When a private room is not available and cohorting is not easily achievable,

consult with Infection Prevention professionals before patient placement.

Gloves and Hand Hygiene

In addition to Standard Precautions, wear clean, non-sterile non-vinyl procedure

gloves for contact with the patient and or environment. During the course of

providing care for a patient, change gloves after contact with infective material.

Remove gloves and immediately decontaminate hands with an antimicrobial

agent or an alcohol based hand rub.

Gowns

In addition to Standard Precautions, wear a clean non-sterile gown for contact

with the patient and or the environment. Remove gown before you leave the

patients environment and decontaminate hands with an antimicrobial agent or an

alcohol based hand rub. See Attachment I for the procedure for donning and

removing isolation garb.


Limit the movement and transport of the patient from the room to essential

purposes only. Generally, patients in Contact Precautions should not go to

common areas on the nursing unit or within the facility. If the patient is

transported out of the room, ensure that precautions are maintained to minimize

the risk of transmission of microorganisms to other patients and contamination of

environmental surfaces or equipment. The receiving areas must be informed

about the patient’s isolation status. No PPE is worn by the HCW during

transportation unless special circumstances/ conditions warrant additional

procedures.

Patient Care Equipment

When possible, dedicate the use of noncritical patient-care equipment to a single

patient (or cohort of patients infected or colonized with the pathogen requiring

precautions). If use of common equipment or items is unavoidable, then

adequately clean and disinfect them before use for another patient.

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D. AIRBORNE/CONTACT PRECAUTIONS

Patients requiring both Airborne Precautions and Contact Precautions should be

placed into this category (e.g. chickenpox, disseminated herpes zoster, or

smallpox).

Non-immune HCW’s should not care for patients with vaccine preventable

airborne diseases (e.g. chickenpox, smallpox) if immune caregivers are available.

All HCW’s entering room should wear a NIOSH approved N95 respirator or

Powered Air Purifying Respirator (PAPR) .

Emerging Infectious Diseases may require eye protection in addition to Airborne

Precautions (e.g. SARS, Avian Influenza).

E. DROPLET/CONTACT PRECAUTIONS

Patients requiring both Droplet Precautions and Contact Precautions such as

Vancomycin Resistant Staph Aureus (VRSA) should be placed into this category.

All precautions listed for each category must be maintained.

Emerging Infectious Diseases may require eye protection in addition to Droplet

Precautions (e.g. SARS, Avian Influenza).

5. EDUCATION OF HCW’S, PATIENTS AND FAMILIES

Healthcare workers will receive training on Standard and Transmission based

Precautions during orientation and annually thereafter.

It is the responsibility of Healthcare providers to educate patients and visitors

about the use of precautions and their responsibility for adherence to them.

Adherence to precautions may be monitored and findings used to direct

improvements. Document all education in the patient record.

IV. POLICIES REFERENCED WITHIN THIS POLICY

HS-IC0615 Hand Hygiene

HS-IC0604 OSHA Bloodborne Pathogen Exposure Control Plan

HS-IC0611 TB Exposure Control Plan

HS-IC0605 CJD/Prion Transmission Prevention

HS-IC0612 Respiratory Pathogens-Emerging Viruses (RPEV)

HS-IC0608 Infection Control Bioterrorism Readiness Guidelines







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SIGNED: Tami Minnier

Chief Quality Officer

ORIGINAL: August 8, 2003

APPROVALS:

Policy Review Subcommittee: October 10, 2013

Executive Staff: November 8, 2013

PRECEDE: July 8, 2013

SPONSOR: System Infection Prevention and Control Committee

Attachments

* With respect to UPMC business units described in the Scope section, this policy is intended to replace

individual business unit policies covering the same subject matter. In-Scope business unit policies covering

the same subject matter should be pulled from all manuals.

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Attachment I

Procedure for Donning and Removing Personal Protective Equipment

Donning Personal Protective Equipment:

Obtain gown, gloves and/or mask as required.

Put on the gown with the opening in the back and tie at the neck and waist.

Don mask per specific isolation requirement.

Place mask over nose and mouth and adjust for close fit.

Change mask when it becomes moist.

Never wear the mask lowered or hung around the neck.

Mask with eye shield is used when splashing is possible.

N95 respirator may be reused.

If PAPR is used, follow specific hospital procedure.

Practice hand hygiene with soap and water or hand sanitizer

Put on non-sterile non-vinyl procedure gloves. Examine gloves for possible tears, cracks, or

tiny holes. Replace damaged gloves as soon as possible.

Removing Personal Protective Equipment

Untie gown at waist.

Remove gloves by:

Grasp glove near the cuff and pull glove down with the inside out.

Cup the glove in the palm of the gloved hand.

Insert two fingers of the bare hand inside the cuff of the gloved hand.

Pull down on this glove so that it comes off with the inside out and with the first glove

tucked into the center.

Decontaminate hands.

Remove mask.

*Note that for Airborne Precautions, N95 Respirator or PAPR should remain on until exiting the

room.

Remove gown:

Untie gown at the neck.

Roll the gown over the forearms and hands so that the gown is also inside out. Do not touch

the outside surface of the gown.

Roll the gown into a compact bundle for disposal.

Gowns, gloves and masks must be removed before exiting the room and placed in the

appropriate waste container.

Decontaminate hands.

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Attachment II: Miscellaneous

Disinfecting Equipment Used for Isolation

Dedicated equipment is used for isolation patients (e.g. thermometers, stethoscopes,

tourniquets.)

If reusable equipment must be used, it must be disinfected between patients (e.g. pulse ox,

glucometers, bed scales) with a hospital approved disinfectant.

Isolation Related Issues

Water pitchers

Water pitchers cannot leave the isolated patient’s room to be refilled.

Dietary trays

Dietary trays for patients must be delivered by personnel wearing appropriate garb if contact

with the environment is anticipated.

After patient or environmental contact the tray must be placed directly in the dietary cart or

designated area.

Trays removed from patient rooms should not be placed on counter tops outside of patient

rooms.

Admitting/Consent Forms

If a patient known to be colonized with resistant organisms is being admitted, forms should

be placed on a clipboard and held away from the patient or environment as the patient signs

the form to help avoid contamination.

Forms can then be placed in the chart as usual.

Reusable items

Community non health care related items (i.e. magazines, books, etc.) should be discarded

when patient is discharged.

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Attachment III

Adaptations to Transmission-based Precautions for

Behavioral Health Facilities

Modifications/adaptations of Transmission-based Precautions may be made on a case-by-case

basis for the care and special needs of special population (e.g. behavioral health) with the

approval of the Director of Infection Prevention and Control or his/her designee. Modifications

cannot be made for conditions requiring Airborne Precautions (i.e. Tuberculosis), or

Airborne/Contact precautions. Modifications/adaptations may include but are not limited to:

CONTACT PRECAUTIONS

Private Room - A private room is indicated, however patients infected with the same

organism may share a room if necessary.

The patient may come out of their room to attend group activities in the therapeutic

milieu. If the patient is incontinent, they must wear an adult incontinence brief, wear

double barriers (e.g. in street clothes, or gown with robe) and only sit on community

furniture covered with a plastic pad. Continent patient must wear double barriers

(e.g. street clothes or gown with robe.)

In addition, patient must clean hands under staff observation before coming into the

milieu.

Gloves - Wear non-sterile, non-vinyl procedure gloves for contact with the patient and/or

environment. Change gloves after contact with infective material. Remove gloves

immediately.

Gowns – Wear gowns if you anticipate that your clothes will have contact with the patient,

environmental surfaces, or items in the patient’s room. Remove gown before you leave the

patients environment.

Hand Hygiene- Decontaminate hands using soap and water or an alcohol based hand rub.

Transport – Limit the movement transport of patients to essential purposes only. During

transport, ensure that all precautions are maintained at all times.

Equipment – Delegate the use of patient care equipment to a single patient. If common

equipment is used, disinfect between patients with a hospital approved disinfectant.

EXAMPLES (FOR CONTACT PRECAUTIONS):

Acute diarrhea with a likely infectious cause in an incontinent or diapered patient

Drainage, uncontrolled (cannot be contained in a dressing)

Gastroenteritis, if caused by E. coli 0157:H7, Shigella, or

Hepatitis A (in a patient incontinent of stool)

Multiple-resistant bacteria, infection or colonization (any site) with any of the following:

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1. Gram negative bacilli resistant to all aminoglycosides or to multiple advanced generation

beta-lactams.

2. Enterococcus – Resistant to vancomycin

3. Other resistant bacteria may be included in this isolation category if they are judged by

the Infection Control team to be of special clinical and epidemiological significance

Clostridium difficile

Pediculosis (lice)

Scabies

Staphylococcal disease, in a major wound or burn

Herpes simplex, disseminated mucocutaneous or severe primary

DROPLET PRECAUTIONS

Private Room – A private room is indicated, however patients with the same organism may

share a room.

The door to the patient’s room may be left ajar.

Gloves and gowns should be worn as per standard precautions.

A mask should be worn when entering the room or when within three feet of the isolated

patient.

If necessary, patient may enter the therapeutic milieu if wearing a mask at all times. The

patient cannot come to milieu without a mask until they are completely asymptomatic.

Transport – Limit the movement/transport of patients to essential purposes only. During

transport, place mask on patient.

EXAMPLES (FOR DROPLET PRECAUTIONS):

Diphtheria, pharyngeal

Meningitis (known or suspected Meningococcal, or H. Influenza)

Meningococcal pneumonia

Streptococcal (Group A)-Pneumonia or Pharyngitis

Parvovirus – B-19

Meningococcemia (meningococcal sepsis)

Influenza

Mumps (infectious parotitis)

Pertussis (whooping cough)

Plague, pneumonic

Rubella (German Measles)

Pneumonia-known or suspected mycoplasma

DROPLET/CONTACT PRECAUTIONS:

All precautions used for Droplet and Contact Precautions must be observed as above.

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EXAMPLES FOR CONTACT/DROPLET PRECAUTIONS:

Adenovirus

Norovirus

Diphtheria, cutaneous

Streptococcal disease (group A), pneumonia or in major wound or burn

Multiply-resistant bacteria, infection or colonization (any site) with any of the following:

1. Pneumococcus resistant to penicillin.

2. Haemophilus influenzae resistant to ampicillin (beta-lactamase positive) and

chloramphenicol.

Other resistant bacteria may be included in this isolation category if they are judged by the

Infection Prevention and Control Department to be of special clinical and epidemiologic

significance.

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Attachment IV

Adaptations to Transmission-based Precautions for Rehabilitation Units

Modifications/adaptations of Transmission-based Precautions may be made on a case-by-case

basis for the care and special needs of special population (e.g. Rehabilitation Units) with the

approval of the Director of Infection Prevention and Control or his/her designee. Modifications

cannot be made for conditions requiring Airborne Precautions (i.e. Tuberculosis), or

Airborne/Contact precautions. Modifications/adaptations may include but are not limited to:

CONTACT PRECAUTIONS

Modification in multi-patient therapeutic treatment area:

1. Therapeutic staff having direct contact with the patient will complete hand hygiene and

don gloves during therapy.

2. Upon completion of therapy staff will remove gloves and complete hand hygiene.

3. If patient cannot wear isolation gown the therapist treating must wear both gown and

gloves.

Community Outings:

1. Patients in contact isolation that require community interactions for rehabilitation

purposes should be evaluated and assessed by the Rehabilitation Nursing Staff for the

appropriateness of the outing with input from the Infection Prevention and Control

department as needed.

2. Criteria considered during the evaluation process:

a. From what body site(s) has organism been cultured?

b. Is the drainage or body substance containable?

c. What invasive devices, if any, are present?

d. What is the mental competence and personal hygiene of the individual and how

do these factors relate to the patient’s potential to transmit resistant organisms?

e. What kind of direct patient care is being provided to the patient?

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Common Areas:

1. Patients in contact isolation are permitted to eat in the dining area, sit in common

hallways, and practice mobility within the unit/department.

2. Patients should wear an isolation gown and complete hand hygiene before exiting the

room.

3. Patients are permitted to participate in therapies off of the unit in designated therapy

areas with supervision.

4. Areas of restriction include the gift shop, cafeteria and lobby area.

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Attachment V

Procedures to Follow for Patients with Newly Emerging Organisms that Require

Additional Preventive Measures

Additional measures may be required for patients that are identified with newly emerging

organisms in order to prevent healthcare-associated transmission. These organisms are often

times untreatable or difficult-to-treat multidrug-resistant organisms that are emerging in the

United States or other parts of the world.

VISA & VRSA:

Vancomycin -intermediate Staphylococcus aureus (VISA) and Vancomycin-resistant

Staphylococcus aureus (VRSA) are specific types of antimicrobial-resistant bacteria. Persons

who develop this type of staph infection may have underlying health conditions (such as diabetes

and kidney disease), tubes going into their bodies (such as catheters), previous infections with

methicillin-resistant Staphylococcus aureus (MRSA), and recent exposure to vancomycin and

other antimicrobial agents.

Staphylococcus aureus in general is an important cause of healthcare and community associated

infections. The diseases associated with this organism range from mild skin and soft-tissue

infections to potentially fatal systemic illnesses such as endocarditis and toxic-shock syndrome.

S. aureus is a common pathogen that affects individuals across the age spectrum.

CRE-NDM:

Enterobacteriaceae is a large family of Gram-negative bacteria that includes both normal and

pathogenic enteric bacteria such as Escherichia coli, Klebsiella, Proteus, Enterobacter, Serratia,

Salmonella and Shigella. CRE are those Enterobacteriacea that have developed high levels of

resistance to antibiotics, including last-resort antibiotics called carbapenems. CRE infections

most commonly occur among patients who are receiving antibiotics and significant medical

treatment for other conditions.

Carbapenem-resistant Enterobacteriaceae (CRE) New Delhi metallo-β-lactamase (NDM) is a

specific type of antimicrobial-resistant bacteria associated with a high mortality rate and the

potential to spread widely. This organism is more common in other areas of the world and in the

United States has generally been found among patients who received medical care in countries

where these organisms are known to be present.

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A. IDENTIFICATION AND NOTIFICATION

Once the microbiology laboratory suspects the presence of VISA, VRSA, CRE-NDM or any

newly identified organism of epidemiologic concern the laboratory should immediately notify

Infection Prevention and Control personnel, the clinical unit and the attending physician.

Infection Prevention and Control will notify the Medical Director of Infection Prevention and

Control and/or Chairperson of the Infection Prevention and Control Committee, the State and/or

Local Health Department, Administration and the Centers for Disease Control and Prevention

(CDC). The Medical Director of Infection Prevention and Control and/or Chairperson of the

Infection Prevention and Control Committee will be responsible for informing medical

leadership.

B. ISOLATION

The patient will be placed in Contact precautions (gown and gloves required when

entering room). Mask and/or face shield should be worn to protect the mucous

membranes of the eyes, nose and mouth during procedures and patient-care activities

that are likely to generate splashes or sprays of blood, body fluids, secretions and

excretions.

Performing hand hygiene according to policy HS-IC0615 Hand Hygiene is

imperative.

The patient’s current room will be closed to admissions until terminally cleaned. The

patient will be moved as soon as possible to a private room preferably one that has an

anteroom. This room should have dialysis capability if the patient requires it, as the

patient will not be able to leave the room unless absolutely necessary. If this room is

not immediately available, transfers must be made expeditiously to make one

available. If the anteroom serves two rooms, the other room must be blocked or used

as cohort room for another isolation patient with the same organism.

HCW having contact with the patient will be limited. (One nurse should care for the

patient per shift if possible).

Isolation precautions will be utilized through the patient’s entire hospitalization.

A long-term isolation code will be applied in the electronic health record indicating

the patient will be isolated upon readmission until the code is removed according to

current CDC recommendations and/or per the recommendation of Infection

Prevention and Control Department.

If a newly identified organism, isolation type may be changed per Infection

Prevention and Control recommendations.

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C. OBSERVER/CONTROLLER

The function of this person will be to restrict access to the room, maintain personnel

log, and enforce HH and PPE precautions. Traffic into the room will be controlled

twenty-four hours per day. These individuals will be oriented by Infection Prevention

and Control and given a copy of the policy and procedure.

A log of all personnel will be completed by the observer for HH and PPE compliance

and maintained by Infection Prevention and Control as a reference for potential

outbreak surveillance.

The information will be documented on the Personnel Log (See Attachment A).

D. TRANSPORT

Any non-critical diagnostic or therapeutic procedure should be postponed. Others

will be done portable in the isolation room, such as dialysis.

If the patient must be transported, the observer/controller will accompany the patient,

providing information and direction as needed, and be responsible for transporting the

patients chart. The chart should not be placed on top of the patient bed/stretcher or

wheelchair.

Those having contact with the patient must wear gowns and gloves. Persons having

direct contact with the patient during transport or during a medical procedure must be

added to the personnel log as described above.

The patient will:

1. be given a fresh grown to decrease the bioburden.

2. be placed on a stretcher and/or wheelchair layered with clean sheets.

3. be covered as much as possible so that very little skin is exposed and an isolation

gown should be placed atop the sheets as a visual cue for those in contact with the

patient during transfer.

Linen should be carefully placed in a linen bag and laundered as usual.

Any item or equipment (including stretcher or wheelchair) coming in direct contact

with the patient must be cleaned thoroughly with a hospital approved disinfectant

before being used on the next patient.

E. SIGNAGE/COMMUNICATION

Contact signage will be displayed according to hospital policy.

Isolation will be prominently marked on registration forms and in the medical record.

The banner bar in the electronic health record will display the appropriate isolation

code.

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Staff should hand off the appropriate information during shift change and when the

patient is being transported or transferred to a different department or being

discharged to an outside facility.

Consultation with an Infectious Disease physician is strongly recommended.

F. EQUIPMENT AND SUPPLIES

There will be dedicated equipment. When possible, use disposable patient care items.

Sharing of general supplies (tape, 4 x 4s, betadine) and equipment (I.V. poles, BP

cuff, stethoscope, and thermometer) is not permitted.

Any equipment that cannot be dedicated to the patient, which enters the room, must

be thoroughly cleaned with hospital approved disinfectant before leaving.

All supplies other than reusable equipment are discarded after discharge.

G. ENVIRONMENTAL SERVICES

The room will be cleaned daily by Environmental Services using sodium hypochlorite

(bleach) and/or a hospital-approved disinfectant. Close attention is necessary in

cleaning high-touch surfaces.

The mop head must not be used in other rooms.

A laundry hamper for linen will be kept in the isolation room.

Once the linen is bagged, it can be handled per routine.

Terminal isolation cleaning procedures should be used for all areas (patient room,

procedure areas etc.) and include changing of cubicle curtains.

H. SPECIMENS

Specimens are collected in the room and placed in a leak-proof container affixed with

a patient label/identifier.

The container is wiped with an alcohol wipe before being placed in a sealable

specimen bag.

The specimen is placed in a bag (being held opened by an assistant) avoiding

contamination of the outside of the bag.

I. DIETARY

Trays/dishes must be removed from patient room following procedure for patients in

isolation.

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J. EDUCATION

Infection Prevention and Control will provide in-service education for the staff as

needed.

Infection Preventionist and/or nursing staff will provide education and counseling for

the patient and family.

Discharge instructions will be in conjunction with the CDC recommendations.

K. VISITORS/FAMILY MEMBERS

Visitors and/or family members will be encouraged to maintain limited visitation.

Visitors in appropriate barrier attire will be permitted as per guidelines.

L. OUTBREAK SURVEILLANCE

If a contact investigation is warranted, the Infection Prevention and Control

department will follow guidelines to determine whether transmission has occurred.

This may include the collection of baseline cultures from the anterior nares and hands

of all healthcare workers, roommates and others with direct patient contact.

Contacts (healthcare workers, visitors, volunteers, etc.) who are potentially exposed

will be categorized based on their level of interaction (i.e., extensive, moderate, or

minimal) with the colonized or infected patient during an outbreak investigation.

CDC guidelines will be reviewed but ultimate decisions regarding interaction

category will be made by Infection Prevention and Control.

If there was a roommate involved in a potential exposure, he/she should be placed in

a private room in contact precautions and the attending physician must be notified.

If there are additional cases, the unit may be closed to new admissions per review by

Infection Prevention and Control and hospital Administration.

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Attachment A

PERSONNEL LOG

Please print

(Include observer/control name per shift)

Dates/Shift

Name

Job Title

Department

Phone #

Comments

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Attachment VI:

DISEASE-SPECIFIC REFERENCE LIST

The Disease-Specific Reference List lists most of the common infectious agents and diseases

that are likely to be found in U.S. hospitals and the specific isolation precautions indicated for

each. Diseases are listed alphabetically in several ways: by anatomical site of syndrome

(abscess, burn wound, cellulitis, etc.), by etiologic agent (Chlamydia trachomatis, Clostridium

perfringens, Escherichia coli, etc.) and sometimes by a combination of a syndrome and etiologic

agent (endometritis, group A Streptococcus; pneumonia, Staphylococcus aureus, etc.). In an

attempt to make the table useful to all hospital personnel, including those from nonclinical areas

(admitting, dietary, housekeeping, laundry, etc.), common terminology and jargon (such as

gangrene and “TORCH” syndrome) are also used in the alphabetical listing of diseases.

For some diseases or conditions listed, we recommend more stringent isolation precautions for

infants and young children than for adults since the risk of spread and the consequences of

infection are greater in infants and young children. We use the term “young children” rather

than an age breakpoint because children mature at such different rates. Thus, the interpretation

of the term “young children” will differ in various pediatric settings according to the patient

population.

The Disease-Specific Reference List specifies the Type of Isolation, Duration of Precautions

and Comments. Symbols used in the Disease Specific Reference list include the following:

Type of Isolation A Airborne

C Contact

D Droplet

S Standard

*When A, C, and D are specified, also use S

In general, patients infected with the same organism may share a room. For some diseases or

conditions a private room is indicated if patient hygiene is poor. A patient with poor hygiene

does not wash hands after touching infective material (feces, purulent drainage, or secretions),

contaminates the environment with infective material, or shares contaminated articles with other

patients. Likewise, for some diseases a mask is indicated only for those who get close (about 3

feet) to the patient. Hand Hygiene is not listed in the table because it is important for all patient

care, whether or not the patient is infected, and is always necessary to prevent transmission of

infection.

Duration of Isolation

CN Until off antimicrobial treatment and culture negative.

DI Duration of illness (with wounds, DI means until wounds stop draining)

DE Until environment completely decontaminated

U Until time specified in hours (hrs.) after initiation of effective therapy

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In addition to including the specific precautions indicated for each disease, the Disease-Specific

Reference List identifies which secretions, excretions, discharges, body fluids, and tissues are

infective or might be infective. Again, common terms such as feces and pus are used to describe

infective material. In the table the term “pus” refers to grossly purulent as well as serous

drainage that is likely to be infective. In the table, we also tell how long to apply the precautions

and other considerations that personnel should be aware of when taking care of an infected or

colonized patient for whom isolation precautions are indicated.

It is imperative that all employees utilize STANDARD PRECAUTIONS when in contact with

all blood and body fluids.

These Precautions are based upon published literature and CDC guidelines. Individual

facilities may have additional precautions applied based upon their facility specific standard.

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28

ATTACHMENT VI

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS

Infection/Condition Precautions

Type * Duration † Comments

Abscess

Draining, major C DI No dressing or containment of drainage; until drainage stops or can be contained by dressing

Draining, minor or limited S Dressing covers and contains drainage

Acquired human immunodeficiency syndrome (H IV) S Post-exposure chemoprophylaxis for some blood exposures 866.

Actinomycosis S Not transmitted from person to person

Adenovirus infection ( see agent-specific guidance under gastroenteritis, conjuctivitis, pneumonia)

Amebiasis S

Person to person transmission is rare. Transmission in settings for the mentally challenged and in a family group has been reported 1045. Use care when handling diapered infants and mentally challenged persons 1046.

Anthrax S Infected patients do not generally pose a transmission risk.

Cutaneous S

Transmission through non-intact skin contact with draining lesions possible, therefore use Contact Precautions if large amount of uncontained drainage. Handwashing with soap and water preferable to use of waterless alcohol based antiseptics since alcohol does not

1 Type of Precautions: A, Airborne Precautions; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S.

† Duration of precautions: CN, until off antimicrobial treatment and culture-negative; DI, duration of illness (with wound lesions, DI means until wounds stop draining); DE, until environment completely decontaminated; U, until time specified in hours (hrs) after initiation of effective therapy; Unknown: criteria for establishing eradication of pathogen has not been determined

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ATTACHMENT VI




have sporicidal activity 983.

Pulmonary S Not transmitted from person to person

Environmental: aerosolizable spore-containing powder or other substance

DE

Until decontamination of environment complete 203 . Wear respirator (N95 mask or PAPRs), protective clothing; decontaminate persons with powder on them (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a3.htm) Hand hygiene: Handwashing for 30-60 seconds with soap and water or 2% chlorhexidene gluconate after spore contact (alcohol handrubs inactive against spores 983. Post-exposure prophylaxis following environmental exposure: 60 days of antimicrobials (either doxycycline, ciprofloxacin, or levofloxacin) and post-exposure vaccine under IND

Antibiotic-associated colitis (see Clostridium difficile)

Arthropod-borne viral encephalitides (eastern, western, Venezuelan equine encephalomyelitis; St Louis, California encephalitis; West Nile Virus) and viral fevers (dengue, yellow fever, Colorado tick fever)

S

Not transmitted from person to person except rarely by transfusion, and for West Nile virus by organ transplant, breastmilk or transplacentally 530, 1047 . Install screens in windows and doors in endemic areas Use DEET-containing mosquito repellants and clothing to cover extremities

Ascariasis S Not transmitted from person to person

Aspergillosis S Contact Precautions and Airborne Precautions if massive soft tissue infection with copious drainage and

repeated irrigations required 154.

Avian influenza (see influenza, avian below)

Babesiosis S Not transmitted from person to person except rarely by transfusion,

Blastomycosis, North American, cutaneous or pulmonary S Not transmitted from person to person

Botulism S Not transmitted from person to person

Bronchiolitis (see respiratory infections in infants and young children) C DI Use mask according to Standard Precautions.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a3.htm

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ATTACHMENT VI




Brucellosis (undulant, Malta, Mediterranean fever) S

Not transmitted from person to person except rarely via banked spermatozoa and sexual contact 1048, 1049 . Provide antimicrobial prophylaxis following laboratory exposure 1050.

Campylobacter gastroenteritis (see gastroenteritis)

Candidiasis, all forms including mucocutaneous S

Cat-scratch fever (benign inoculation lymphoreticulosis) S Not transmitted from person to person

Cellulitis S

Chancroid (soft chancre) (H. ducreyi) S Transmitted sexually from person to person

Chickenpox (see varicella)

Chlamydia trachomatis

Conjunctivitis S

Genital (lymphogranuloma venereum) S

Pneumonia (infants < 3 mos. of age)) S

Chlamydia pneumoniae S Outbreaks in institutionalized populations reported, rarely 1051, 1052

Cholera (see gastroenteritis)

Closed-cavity infection

Open drain in place; limited or minor drainage S Contact Precautions if there is copious uncontained drainage

No drain or closed drainage system in place S

Clostridium

C. botulinum S Not transmitted from person to person

C. difficile (see Gastroenteritis, C. difficile) C Length of

Stay

C. perfringens

Food poisoning S Not transmitted from person to person

Gas gangrene S Transmission from person to person rare; one outbreak in a surgical setting reported

1053. Use Contact

Precautions if wound drainage is extensive.

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ATTACHMENT VI




Coccidioidomycosis (valley fever)

Draining lesions S

Not transmitted from person to person except under extraordinary circumstances because the infectious arthroconidial form of Coccidioides immitis is not produced in humans 1054 .

Pneumonia S

Not transmitted from person to person except under extraordinary circumstances, (e.g., inhalation of aerosolized tissue phase endospores during necropsy, transplantation of infected lung) because the infectious arthroconidial form of Coccidioides immitis is not produced in humans 1054, 1055.

Colorado tick fever S Not transmitted from person to person

Congenital rubella C

Until 1 yr of age

Standard Precautions if nasopharyngeal and urine cultures repeatedly neg. after 3 mos. of age

Conjunctivitis

Acute bacterial S

Chlamydia S

Gonococcal S

Acute viral (acute hemorrhagic) C DI

Adenovirus most common; enterovirus 70 1056,

Coxsackie virus A24 1057) also associated with community outbreaks. Highly contagious; outbreaks in eye clinics, pediatric and neonatal settings, institutional settings reported. Eye clinics should follow Standard Precautions when handling patients with conjunctivitis. Routine use of infection control measures in the handling of instruments and equipment will prevent the occurrence of outbreaks in this and other settings. 460, 814,

1058, 1059 461, 1060 .

Corona virus associated with SARS (SARS-CoV) (see severe acute respiratory syndrome)

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ATTACHMENT VI




Coxsackie virus disease (see enteroviral infection)

CRE (Carbapenem-resistant Enterobacteriaceae) C

CRE-NDM (New Delhi metallo-β-lactamase) C See Attachment (V ) for Additional measure that must be followed.

Creutzfeldt-Jakob disease CJD, vCJD

S

Use disposable instruments or special sterilization/disinfection for surfaces, objects contaminated with neural tissue if CJD or vCJD suspected and has not been R/O; No special burial procedures 1061

Croup (see respiratory infections in infants and young children)

Crimean-Congo Fever (see Viral Hemorrhagic Fever) S

Cryptococcosis S Not transmitted from person to person, except rarely via tissue and

corneal transplant 1062, 1063

Cryptosporidiosis (see gastroenteritis)

Cysticercosis S Not transmitted from person to person

Cytomegalovirus infection, including in neonates and immunosuppressed patients

S No additional precautions for pregnant HCWs

Decubitus ulcer (see Pressure ulcer)

Dengue fever S Not transmitted from person to person

Diarrhea, acute-infective etiology suspected (see gastroenteritis)

Diphtheria

Cutaneous C CN Until 2 cultures taken 24 hrs. apart negative

Pharyngeal D CN Until 2 cultures taken 24 hrs. apart negative Ebola virus (see viral hemorrhagic fevers) Echinococcosis (hydatidosis) S Not transmitted from person to person Echovirus (see enteroviral infection) Encephalitis or encephalomyelitis (see specific etiologic agents) Endometritis (endomyometritis) S Enterobiasis (pinworm disease, oxyuriasis) S Enterococcus species (see multidrug-resistant organisms if

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ATTACHMENT VI




epidemiologically significant or vancomycin resistant)

Enterocolitis, C. difficile (see C. difficile, gastroenteritis)

Enteroviral infections (i.e., Group A and B Coxsackie viruses and Echo viruses) (excludes polio virus) S

Use Contact Precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks

Epiglottitis, due to Haemophilus influenzae type b D U 24 hrs See specific disease agents for epiglottitis due to other etiologies)

Epstein-Barr virus infection, including infectious mononucleosis S

Erythema infectiosum (also see Parvovirus B19)

ESBL (extended spectrum beta lactamase organism) C

Escherichia coli gastroenteritis (see gastroenteritis)

Food poisoning

Botulism S Not transmitted from person to person

C. perfringens or welchii S Not transmitted from person to person

Staphylococcal S Not transmitted from person to person

Furunculosis, staphylococcal S Contact if drainage not controlled. Follow institutional policies if MRSA

Infants and young children C DI

Gangrene (gas gangrene) S Not transmitted from person to person

Gastroenteritis S

Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks for gastroenteritis caused by all of the agents below

Adenovirus

S Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control

institutional outbreaks

Campylobacter species S

Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control institutional outbreaks

Cholera (Vibrio cholerae) S


C. difficile C Length of

Stay Discontinue antibiotics if appropriate. Do not share electronic thermometers 853, 854; ensure consistent environmental cleaning and

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ATTACHMENT VI




disinfection. Hypochlorite solutions may be required for cleaning if transmission continues

847.

Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in waterless antiseptic handrubs 983.

Cryptosporidium species S


E. coli

o Enteropathogenic O157:H7 and other shiga toxin-producing Strains

S Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control


o Other species S Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control


Giardia lamblia S Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control


Noroviruses D/C

Ensure consistent environmental cleaning and disinfection with focus on restrooms even when apparently unsoiled 273, 1064 ). Hypochlorite solutions may be required when there is continued transmission 290-292. Hand Hygiene should be performed using soap and water. Cohorting of affected patients to separate airspaces and toilet facilities may help interrupt transmission during outbreaks.

Rotavirus C DI Ensure consistent environmental cleaning and disinfection and frequent removal of soiled diapers. Prolonged shedding may occur in both immunocompetent and immunocompromised children and the elderly 932, 933.

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ATTACHMENT VI




Salmonella species (including S. typhi) S


Shigella species (Bacillary dysentery) S


Vibrio parahaemolyticus S


Viral (if not covered elsewhere) S


Yersinia enterocolitica S Use Contact Precautions for diapered or incontinent persons for the duration of illness or to control


German measles (see rubella; see congenital rubella)

Giardiasis (see gastroenteritis)

Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia, acute conjunctivitis of newborn)

S

Gonorrhea S

Granuloma inguinale (Donovanosis, granuloma venereum) S

Guillain-Barré’ syndrome S Not an infectious condition

Haemophilus influenzae (see disease-specific recommendations)

Hand, foot, and mouth disease (see enteroviral infection)

Hansen’s Disease (see Leprosy)

Hantavirus pulmonary syndrome S Not transmitted from person to person

Helicobacter pylori S

Hepatitis, viral

Type A S Provide hepatitis A vaccine post-exposure as recommended 1065

Diapered or incontinent patients

C Maintain Contact Precautions in infants and children <3 years of age

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ATTACHMENT VI




for duration of hospitalization; for children 3-14 yrs. of age for 2 weeks after onset of symptoms; >14 yrs. of age for 1 week after onset of symptoms 833, 1066, 1067.

Type B-HBsAg positive; acute or chronic S

See specific recommendations for care of patients in hemodialysis centers 778

Type C and other unspecified non-A, non-B S

See specific recommendations for care of patients in hemodialysis centers 778

Type D (seen only with hepatitis B) S

Type E S

Use Contact Precautions for diapered or incontinent individuals for the duration of illness 1068

Type G S

Herpangina (see enteroviral infection)

Hookworm S

Herpes simplex (Herpesvirus hominis)

Encephalitis S

Mucocutaneous, disseminated or primary, severe C Until lesions

dry and crusted

Mucocutaneous, recurrent (skin, oral, genital) S

Neonatal C Until lesions

dry and crusted

Also, for asymptomatic, exposed infants delivered vaginally or by Csection and if mother has active infection and membranes have been ruptured for more than 4 to 6 hrs until infant surface cultures obtained at 24-36 hrs. of age negative after 48 hrs incubation 1069, 1070

Herpes zoster (varicella-zoster) (shingles)

Disseminated disease in any patient

Localized disease in immunocompromised patient until disseminated infection ruled out

A,C DI Susceptible HCWs should not enter room if immune caregivers are available.

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ATTACHMENT VI




Localized in patient with intact immune system with lesions that can be contained/covered

S DI

Susceptible HCWs should not provide direct patient care when other immune caregivers are available.

Histoplasmosis S Not transmitted from person to person

Human immunodeficiency virus (H IV) S Post-exposure chemoprophylaxis for some blood exposures 866.

Human metapneumovirus C DI HAI reported

1071, but route of transmission not established 823 . Assumed to be Contact transmission

as for RSV since the viruses are closely related and have similar clinical manifestations and epidemiology. Wear masks according to Standard Precautions..

Impetigo C U 24 hrs

Infectious mononucleosis S

Influenza

Human (seasonal influenza) D

5 days except DI in

immuno compromised

persons

Single patient room when available or cohort; avoid placement with high-risk patients; mask patient when transported out of room; chemoprophylaxis/vaccine to control/prevent outbreaks 611 . Use gown and gloves according to Standard Precautions may be especially important in pediatric settings. Duration of precautions for immunocompromised patients cannot be defined; prolonged duration of viral shedding (i.e. for several weeks) has been observed; implications for transmission are unknown 930.

Avian (e.g., H5N1, H7, H9 strains)) See www.cdc.gov/flu/avian/professional/infect-control.htm for current

avian influenza guidance.

Pandemic influenza (also a human influenza virus)

D 5 days from

onset of sympto

ms

See http://www.pandemicflu.gov for current pandemic influenza guidance.

Kawasaki syndrome S Not an infectious condition

Lassa fever (see viral hemorrhagic fevers)

http://www.cdc.gov/flu/avian/professional/infect-control.htm

http://www.pandemicflu.gov/

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ATTACHMENT VI




Legionnaires’ disease S Not transmitted from person to person

Leprosy S

Leptospirosis S Not transmitted from person to person

Lice http://www.cdc.gov/ncidod/dpd/parasites/lice/default.htm

Head (pediculosis) C U 24 hrs

Body S

Transmitted person to person through infested clothing. Wear gown and gloves when removing clothing; bag and wash clothes according to CDC guidance above

Pubic S Transmitted person to person through sexual contact

Listeriosis (listeria monocytogenes) S

Person-to-person transmission rare; cross-transmission in neonatal settings reported 1072, 1073 1074, 1075

Lyme disease S Not transmitted from person to person

Lymphocytic choriomeningitis S Not transmitted from person to person

Lymphogranuloma venereum S

Malaria S

Not transmitted from person to person except through transfusion rarely and through a failure to follow Standard Precautions during patient care 1076-1079 . Install screens in windows and doors in endemic areas. Use DEET-containing mosquito repellants and clothing to cover extremities

Marburg virus disease (see viral hemorrhagic fevers)

Measles (rubeola) A 4 days after

onset of rash; DI in immune

compromised

Susceptible HCWs should not enter room if immune care providers are available; no recommendation for face protection for immune HCW; no recommendation for type of face protection for susceptible HCWs, i.e., mask or respirator 1027, 1028 . For exposed susceptibles, post- exposure vaccine within 72 hrs. or immune globulin within 6 days when available 17, 1032, 1034 . Place exposed susceptible patients on Airborne Precautions and exclude susceptible healthcare personnel

http://www.cdc.gov/ncidod/dpd/parasites/lice/default.htm

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ATTACHMENT VI




from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine 17.

Melioidosis, all forms S Not transmitted from person to person

Meningitis

Aseptic (nonbacterial or viral; also see enteroviral infections) S Contact for infants and young children

Bacterial, gram-negative enteric, in neonates S

Fungal S

Haemophilus influenzae, type b known or suspected D U 24 hrs

Listeria monocytogenes (See Listeriosis) S

Neisseria meningitidis (meningococcal) known or suspected D U 24 hrs See meningococcal disease below

Streptococcus pneumoniae S

M. tuberculosis S

Concurrent, active pulmonary disease or draining cutaneous lesions may necessitate addition of Contact and/or Airborne Precautions; For children, airborne precautions until active tuberculosis ruled out in visiting family members (see tuberculosis below)

42

Other diagnosed bacterial S

Meningococcal disease: sepsis, pneumonia, meningitis D U 24 hrs Postexposure chemoprophylaxis for household contacts, HCWs exposed to respiratory secretions; postexposure vaccine only to control outbreaks 15, 17.

Molluscum contagiosum S

Monkeypox A,C

A-Until monkeypox confirmed

and smallpox excluded C-Until lesions crusted

Use See www.cdc.gov/ncidod/monkeypox for most current recommendations. Transmission in hospital settings unlikely

269. Pre- and post-exposure smallpox vaccine recommended for exposed

HCWs

http://www.cdc.gov/ncidod/monkeypox

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ATTACHMENT VI



Type *

Duration †

Comments

MRSA C

Cohorting of infected and colonized patients may be indicated if private rooms are not available.

Mucormycosis S

Multidrug-resistant organisms (MDROs), infection or colonization (e.g., MRSA, VRE, VISA/VRSA, ESBLs, resistant S. pneumoniae)

S/C See specific organism listing in this document.

Mumps (infectious parotitis) D

U 9 days

After onset of swelling; susceptible HCWs should not provide care if immune caregivers are available. Note: (Recent assessment of outbreaks in healthy '8-24 year olds has indicated that salivary viral shedding occurred early in the course of illness and that 5 days of isolation after onset of parotitis may be appropriate in community settings; however the implications for healthcare personnel and high-risk patient populations remain to be clarified.)

Mycobacteria, nontuberculosis (atypical) Not transmitted person-to-person

Pulmonary S

Wound S

Mycoplasma pneumonia D DI

Necrotizing enterocolitis S Contact Precautions when cases clustered temporally '°8°-'°83 .

Nocardiosis, draining lesions, or other presentations S Not transmitted person-to-person

Norovirus (see gastroenteritis)

Norwalk agent gastroenteritis (see gastroenteritis)

Orf S

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Parainfluenza virus infection, respiratory in infants and young children C DI Viral shedding may be prolonged in immunosuppressed patients 1009, 1010 Reliability of antigen testing to

determine when to remove patients with prolonged hospitalizations from Contact Precautions uncertain.

Parvovirus B19 (Erythema infectiosum) D Maintain precautions for duration of hospitalization when chronic disease occurs in an immunocompromised patient. For patients with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days. Duration of precautions for immunosuppressed patients with persistently positive PCR not defined, but transmission has occurred 929.

Pediculosis (lice) C

U 24 hrs after

treatment

Pertussis (whooping cough) D U 5 days Single patient room preferred. Cohorting an option. Post-exposure chemoprophylaxis for household contacts and HCWs with prolonged exposure to respiratory secretions 863 . Recommendations for Tdap vaccine in adults under development.

Pinworm infection (Enterobiasis) S

Plague (Yersinia pestis)

Bubonic S

Pneumonic D U 48 hrs Antimicrobial prophylaxis for exposed HCW 207.

Pneumonia

Adenovirus D, C DI Outbreaks in pediatric and institutional settings reported 376, 1084-1086 . In immunocompromised hosts, extend duration of Droplet and Contact Precautions due to prolonged shedding of virus 931

Bacterial not listed elsewhere (including gram-negative bacterial)

S

B. cepacia in patients with CF, including respiratory tract colonization

C Unknown Avoid exposure to other persons with CF; private room preferred. Criteria for D/C precautions not established. See CF Foundation guideline 20

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B. cepacia in patients without CF(see Multidrug-resistant organisms)

Chlamydia S

Fungal S

Haemophilus influenzae, type b

o Adults S

o Infants and children D U 24 hrs

Legionella spp. S

Meningococcal D U 24 hrs See meningococcal disease above

Multidrug-resistant bacterial (see multidrug-resistant organisms)

Mycoplasma (primary atypical pneumonia) D DI

Pneumococcal pneumonia S Use Droplet Precautions if evidence of transmission within a patient

care unit or facility 196-198, 1087

Pneumocystis jiroveci (Pneumocystis carinii ) S

Avoid placement in the same room with an immunocompromised patient.

Staphylococcus aureus S For MRSA, see MDROs

Streptococcus, group A

Adults D U 24 hrs See streptococcal disease (group A streptococcus) below Contact precautions if skin lesions present

Infants and young children D U 24 hrs Contact Precautions if skin lesions present

Varicella-zoster (See Varicella-Zoster)

Viral

Adults S

Infants and young children (see respiratory infectious disease, acute, or specific viral agent)

Poliomyelitis C DI

Pressure ulcer (decubitus ulcer, pressure sore) infected

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Major C DI If no dressing or containment of drainage; until drainage stops or can be contained by dressing

Minor or limited S If dressing covers and contains drainage

Prion disease (See Creutzfeld-Jacob Disease)

Psittacosis (ornithosis) (Chlamydia psittaci) S Not transmitted from person to person

Q fever S

Rabies S

Person to person transmission rare; transmission via corneal, tissue and organ transplants has been reported 539, 1088 . If patient has bitten another individual or saliva has contaminated an open wound or mucous membrane, wash exposed area thoroughly and administer postexposure prophylaxis. 1089

Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus disease)

S Not transmitted from person to person

Relapsing fever S Not transmitted from person to person

Resistant bacterial infection or colonization (see multidrug-resistant organisms)

Respiratory infectious disease, acute (if not covered elsewhere)

Adults S

Infants and young children C DI Also see syndromes or conditions listed in Table 2

Respiratory syncytial virus infection, in infants, young children and immunocompromised adults

C DI

Wear mask according to Standard Precautions 24

CB 116, 117 . In immunocompromised patients, extend the duration of Contact Precautions due to prolonged shedding

928) . Reliability of antigen testing to

determine when to remove patients with prolonged hospitalizations from Contact Precautions uncertain.

Reye's syndrome S Not an infectious condition

Rheumatic fever S Not an infectious condition

Rhinovirus D DI Droplet most important route of transmission 104 1090 . Outbreaks have

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occurred in NICUs and LTCFs 413, 1091, 1092. Add Contact Precautions if copious moist secretions and close contact likely to occur (e.g., young infants) 111, 833.

Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne typhus fever)

S

Not transmitted from person to person except through transfusion, rarely

Rickettsialpox (vesicular rickettsiosis) S Not transmitted from person to person

Ringworm (dermatophytosis, dermatomycosis, tinea) S

Rarely, outbreaks have occurred in healthcare settings, (e.g., NICU 1093 , rehabilitation hospital 1094 . Use Contact Precautions for outbreak.

Ritter's disease (staphylococcal scalded skin syndrome) C DI See staphylococcal disease, scalded skin syndrome below

Rocky Mountain spotted fever S

Not transmitted from person to person except through transfusion, rarely

Roseola infantum (exanthem subitum; caused by HHV-6) S

Rotavirus infection (see gastroenteritis)

Rubella (German measles) ( also see congenital rubella) D U 7 days

after onset of rash

Susceptible HCWs should not enter room if immune caregivers are available. No recommendation for wearing face protection (e.g., a surgical mask) if immune. Pregnant women who are not immune should not care for these patients 17, 33. Administer vaccine within three days of exposure to non-pregnant susceptible individuals. Place exposed susceptible patients on Droplet Precautions; exclude susceptible healthcare personnel from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine.

Rubeola (see measles)

Salmonellosis (see gastroenteritis)

Scabies C U 24

Scalded skin syndrome, staphylococcal C DI See staphylococcal disease, scalded skin syndrome below)

Schistosomiasis (bilharziasis) S

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Severe acute respiratory syndrome (SARS) A, D,C

DI plus 10 days after resolution of fever, provided respiratory symptoms are absent or improving

Airborne Precautions preferred; D if AIIR unavailable. N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosol-generating procedures and “supershedders” highest risk for transmission via small droplet nuclei and large droplets 93, 94,

96.Vigilant environmental

disinfection (see www.cdc.gov/ncidod/sars)

Shigellosis (see gastroenteritis)

Smallpox (variola; see vaccinia for management of vaccinated persons)

A,C DI Until all scabs have crusted and separated (3-4 weeks). Non-vaccinated HCWs should not provide care when immune HCWs are available; N95 or higher respiratory protection for susceptible and successfully vaccinated individuals; postexposure vaccine within 4 days of exposure protective 108, 129, 1038-1040.

Sporotrichosis S

Spirilum minor disease (rat-bite fever) S Not transmitted from person to person

Staphylococcal disease (S aureus)

Skin, wound, or burn

o Major C DI No dressing or dressing does not contain drainage adequately

o Minor or limited S Dressing covers and contains drainage adequately

Enterocolitis S

Use Contact Precautions for diapered or incontinent children for duration of illness

Multidrug-resistant (see multidrug-resistant organisms)

Pneumonia S

Scalded skin syndrome C DI Consider healthcare personnel as potential source of nursery, NICU outbreak 1095.

Toxic shock syndrome S

Streptobacillus moniiformis disease (rat-bite fever) S Not transmitted from person to person

http://www.cdc.gov/ncidod/sars)

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Streptococcal disease (group A streptococcus)

Skin, wound, or burn

o Major C,D U 24 hrs No dressing or dressing does not contain drainage adequately

o Minor or limited S Dressing covers and contains drainage adequately

Endometritis (puerperal sepsis) S

Pharyngitis in infants and young children D U 24 hrs

Pneumonia D U 24 hrs

Scarlet fever in infants and young children D U 24 hrs

Serious invasive disease D U24 hrs

Outbreaks of serious invasive disease have occurred secondary to transmission among patients and healthcare personnel 162, 972, 1096-1098

Contact Precautions for draining wound as above; follow rec. for antimicrobial prophylaxis in selected conditions 160.

Streptococcal disease (group B streptococcus), neonatal S

Streptococcal disease (not group A or B) unless covered elsewhere S

Multidrug-resistant (see multidrug-resistant organisms)

Strongyloidiasis S

Syphilis

Latent (tertiary) and seropositivity without lesions S

Skin and mucous membrane, including congenital, primary, Secondary

S

Tapeworm disease

Hymenolepis nana S Not transmitted from person to person

Taenia solium (pork) S

Other S

Tetanus S Not transmitted from person to person

Tinea (e.g., dermatophytosis, dermatomycosis, ringworm) S Rare episodes of person-to-person transmission

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Toxoplasmosis S

Transmission from person to person is rare; vertical transmission from mother to child, transmission through organs and blood transfusion rare

Toxic shock syndrome (staphylococcal disease, streptococcal disease)

S Droplet Precautions for the first 24 hours after implementation of antibiotic therapy if Group A

streptococcus is a likely etiology

Trachoma, acute S

Transmissible spongiform encephalopathy (see Creutzfeld-Jacob disease, CJD, vCJD)

Trench mouth (Vincent's angina) S

Trichinosis S

Trichomoniasis S

Trichuriasis (whipworm disease) S

Tuberculosis (M. tuberculosis)

Extrapulmonary, draining lesion) A,C

Discontinue precautions only when patient is improving clinically, and drainage has ceased or there are three consecutive negative cultures of continued drainage 1025, 1026. Examine for evidence of active pulmonary tuberculosis.

Extrapulmonary, no draining lesion, meningitis S

Examine for evidence of pulmonary tuberculosis. For infants and children, use Airborne Precautions until active pulmonary tuberculosis in visiting family members ruled out

42

Pulmonary or laryngeal disease, confirmed A

Discontinue precautions only when patient on effective therapy is improving clinically and has three consecutive sputum smears negative for acid-fast bacilli collected on separate days(MMWR 2005; 54: RR-17 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s

Pulmonary or laryngeal disease, suspected A

Discontinue precautions only when the likelihood of infectious TB disease is deemed negligible,

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s

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and either 1) there is another diagnosis that explains the clinical syndrome or 2) the results of three sputum smears for AFB are negative. Each of the three sputum specimens should be collected 8-24 hours apart, and at least one should be an early morning specimen

Skin-test positive with no evidence of current active disease S

Tularemia

Draining lesion S Not transmitted from person to person

Pulmonary S Not transmitted from person to person

Typhoid (Salmonella typhi) fever (see gastroenteritis)

Typhus

Rickettsia pro wazekii (Epidemic or Louse-borne typhus) S

Transmitted from person to person through close personal or clothing contact

Rickettsia typhi S Not transmitted from person to person

Urinary tract infection (including pyelonephritis), with or without urinary catheter

S

Vaccinia (vaccination site, adverse events following vaccination) *

Only vaccinated HCWs have contact with active vaccination sites and care for persons with adverse vaccinia events; if unvaccinated, only HCWs without contraindications to vaccine may provide care.

Vaccination site care (including autoinoculated areas) S

Vaccination recommended for vaccinators; for newly vaccinated HCWs: semi-permeable dressing over gauze until scab separates, with dressing change as fluid accumulates, ~3-5 days; gloves, hand hygiene for dressing change; vaccinated HCW or HCW without contraindication to vaccine for dressing changes 205, 221, 225.

o Eczema vaccinatum C Until lesions dry and crusted, scabs separated

For contact with virus-containing lesions and exudative material

o Fetal vaccinia C

o Generalized vaccinia C

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Type

* Duration

† Comments

o Progressive vaccinia C

o Postvaccinia encephalitis S

o Blepharitis or conjunctivitis S/C Use Contact Precautions if there is copious drainage

o Iritis or keratitis S

o Vaccinia-associated erythema multiforme (Stevens Johnson Syndrome)

S Not an infectious condition

Secondary bacterial infection (e.g., S. aureus, group A beta hemolytic streptococcus

S/C

Follow organism-specific (strep, staph most frequent) recommendations and consider magnitude of drainage

Varicella Zoster A,C Until lesions

dry and

crusted

Susceptible HCWs should not enter room if immune caregivers are available. In immunocompromised host with varicella pneumonia, prolong duration of precautions for duration of illness. Post-exposure prophylaxis: provide post-exposure vaccine ASAP but within 120 hours; for susceptible exposed persons for whom vaccine is contraindicated (immunocompromised persons, pregnant women, newborns whose mother’s varicella onset is <5days before delivery or within 48 hrs after delivery) provide VZIG, when available, within 96 hours; if unavailable, use IVIG, Use Airborne Precautions for exposed susceptible persons and exclude exposed susceptible healthcare workers beginning 8 days after first exposure until 21 days after last exposure or 28 if received VZIG, regardless of postexposure

Variola (see smallpox)

VRSA (Vancomycin Resistant Staphylococcus aureus) C See attachment (V) for additional measures that must be followed

Vibrio parahaemolyticus (see gastroenteritis)

Vincent's angina (trench mouth) S

Viral hemorrhagic fevers S, D, C

DI Single-patient room preferred. Emphasize: 1) use of sharps safety

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due to Lassa, Ebola, Marburg, Crimean-Congo fever viruses

devices and safe work practices, 2) hand hygiene; 3) barrier protection against blood and body fluids upon entry into room (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields); and 4) appropriate waste handling. Use N95 or higher respirators when performing aerosol-generating procedures. Largest viral load in final stages of illness when hemorrhage may occur; additional PPE, including double gloves, leg and shoe coverings may be used, especially in resource-limited settings where options for cleaning and laundry are limited. Notify public health officials immediately if Ebola is suspected 212, 314, 740,

772Also see Table 3 for Ebola as a

bioterrorism agent

Viral respiratory diseases (not covered elsewhere)

Adult S

Infants and young children (see respiratory infectious disease, acute)

VISA (Vancomycin Intermediate Staphylococcus aureus) C See attachment (V) for additional measures that must be followed.

VRE (Vancomycin Resistant Enterococcus) C Cohorting of infected and colonized patients may be indicated if private rooms

are not available. Whooping cough (see pertussis)

Wound infections

Major C DI No dressing or dressing does not contain drainage adequately

Minor or limited S Dressing covers and contains drainage adequately

Yersinia enterocolitica gastroenteritis (see gastroenteritis)

Zoster (varicella-zoster) (see herpes zoster)

Zygomycosis (phycomycosis, mucormycosis) S Not transmitted person-to-person

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Attachment: VII Respiratory Hygiene/Cough Etiquette

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Attachment: VIII Components of a Protective Environment

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Attachment: IX Isolation Signs

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Attachment: X - Guidelines for Transporting Patients on Isolation Precautions.

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