Standard Precautions & Isolation Procedures

1. Standard Precautions&Isolation Procedures July 21, 2004 Susan Neufeld RN, MN

2. What Was SARs? • Severe Acute Respiratory Syndrome • SARS is a type of viral pneumonia • Death may result from progressive respiratory failure due to alveolar damage. • The typical clinical course of SARS involved an improvement in symptoms during the first week of infection, followed by a worsening during the second week. • Most likely from the healthy masked palm civet from the province of Guangdong • http://www-micro.msb.le.ac.uk/3035/Coronaviruses.html Corona Virus http://news.nationalgeographic.com/news/2003/04/0409_030409_sars.html http://www.lioncrusher.com/images/Paguma_larvata.jpg

3. SARs or Acute Respiratory Infection Non-outbreak Screening Question all clients at first encounter to a health care institution. 1) Shortness of breath? 2) Fever/chills? 3) Have you been to China, Taiwan, Hong Kong in last 14 days? 4) Contact with sick person that has travelled in last 14 days? If Yes: Don surgical mask and consider eye protection PT & company to don mask & wash hands Move pt to separate area

4. SARs or Acute Respiratory Infection Outbreak Screening Question all clients at first encounter to a health care institution. 1) Shortness of breath? 2) Fever/chills? If Yes: Don N95 respirator and consider eye protection PT & company to don mask & wash hands Move pt to separate area & ask: 3) Have you been to China, Taiwan, Hong Kong in last 14 days? 4) Contact with sick person that has travelled in last 14 days? On admission repeat the above and add: Are you a health care worker? Have you worked, visited, or been admitted to a hospital that has SARs pts?

5. Post SARs: What Did We Learn? • Enhanced Surveillance • Improve Public Health Response • Timely Laboratory Testing “The focus during this period  is on vigilant surveillance for severe respiratory illness of unknown etiology, stringent infection control practices and efficient communication between all stakeholders.” (PPHB, 2004). 

6. Evolution of Standard Precautions • 1870s- Pts with ID Separate Facilty • 1910s- Cubicle system – separate gowns, handwashing & disinfecting • 1950/60s-Single pt. isolation rooms in hospitals • 1970s – CDC: “Isolation Techniques in Hospital”. • Seven Categories of Isolation: • Strict • Respiratory • Protective • Enteric • Wound and Skin • Discharge • Blood

7. Evolution Continued • 1983 – CDC revised again to include category or disease specific & remove protective isolation. • 1985 – HIV = Blood & Body fluid precautions (Universal Precautions) • 1987 Body substance isolation – all body fluids: simple to implement but neglected droplet or airbourne transmission. • 1990s – AROs, confusion need for simplification Standard Precautions + Route of Transmission

8. Standard Precautions • Apply to all clients regardless of ID status. Wash Hands Wear Gloves Mask/Eye Protection Gown Patient Care Equipment Environmental Control Linen http://www.uvsystems.co.uk/assets/gfx/hand-wash.jpg Needles Occupational Health & Bloodborne Pathogens CPR

9. Masks • Wear within 1m of coughing patient. • Surgical Masks for filtration of particles >5 microns. • N95 Masks filter particles 1 micron in size, have a 95% filter efficacy, and provide a tight seal. • Read manufacture instructions. • Remove carefully using straps so you do not contaminate yourself. • Discard crushed or if in contact with secretions. • Wash hands after removal.

10. Gloves • Not a substitute for HANDWASHING • Wash hands before donning and after removal. • Must wear for contact with mucus membranes, non intact skin, rashes, blood collection, & as per isolation protocols. • Cover gown cuffs with gloves • Never wash or reuse • Meant to be used for specific tasks and then discarded NOT for routine activities. If worn for long periods of time get holes and tears.

11. Eye Protection • Don’t touch your eyes during patient care. • Wear safety glasses, goggles or face shield if there is a POTENTIAL for splatter • In pediatric patients because they have limited manners (shown to prevent RSV & Adenovirus which are transmitted by large droplets). • Over prescription glasses • Clean between use • Wash hands after removing

12. Route of Transmission Precautions • Contact • Droplet • Airborne http://students.washington.edu/grant/random/sneeze.jpg

13. Contact Precautions Transmission through: Direct Contact Indirect Contact through contaminated: • Hands to new client • Equipment • Environmental surfaces C. diff, Rotavirus, Hep A, Herpes, RSV, MRSA, VRE, Serratia, ESBLs (extended spectrum betalactamases ie. e-coli & klebsiella)

14. Droplet Precautions • Released from coughing, sneezing, suctioning • Micro organisms bound to particles >5 microns & settle to surfaces where they survive (up to 12hrs for RSV on nonporous surface) • Can inhale if within 3 feet of cough otherwise falls to the ground. • Pertussus, Neisseria Mennigitis, Group A strep, Mumps, Influenza virus, RSV, Rubella http://www.mja.com.au/public/issues/176_08_150402/bea10248_fm-1.jpg

15. Back to SARs • Droplet transmission… • Why N95 Masks? • Who knows? Philosophy: Better to overprotect than underprotect?

16. Airborne Transmission • Micro organisms transmitted through coughing, sneezing, laughing • Trapped in particles <5microns in size • Can be suspended in air up to 8hrs • Can drift to unsuspecting hosts • Need air filtration and N95 masks • TB, Chicken Pox, Red Measles http://www.med.sc.edu:85/fox/myc-tub-dk.jpg (SEM x40,000)

17. Issues In Pediatrics • Family visitation • Feelings of Fear & Loneliness • Need for social interaction • NICU/PICU – proximity • Client teaching & compliance

18. Protection of Clients who areImmuno- compromised • Proper handwashingmost important thing! • Separate oncology/transplant units in pediatrics. • Filtered/positive pressure air rooms for neutropenic clients. • Practices vary among institutions but limited evidence of need for “isolation”.

19. Long-Term Care Facilities What are the issues? • it is the resident’s home • cognitive impairment is common • difficult to diagnose • epidemiology of infection unclear (ie. AROs common but pneumonia causes morbidity) • fewer resources, private vs public **Limited evidence of effectiveness of Infection Control in LTCFs**

20. What Works in LTCFs? HAND WASHING + Immunization Smith PW et al. AJIC 1997;25:488-512

21. References Health Canada (2003). Infection control precautions for respiratory infections transmitted by large droplet and contact. PPHB (2004). Severe Respiratory Illness in the SARs Post-Outbreak Period. http://www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/sri.html. Smith, P.W. et al. Infection prevention and control in the longterm care facility. AJIC 1997:25: 488-512 Vancouver Island Health Authority (2001). Handwashing and gloves.