isolation precautions: guidelines for perioperative services

Previous Slide Next Slide

Isolation Precautions:Isolation Precautions:

Guidelines for Guidelines for Perioperative ServicesPerioperative Services


What are Isolation What are Isolation Precautions?Precautions?

Practices Practices that prevent transmission of certain that prevent transmission of certain diseases from patients to staff, and from staff to diseases from patients to staff, and from staff to other patientsother patients

Type of isolation precautions is determined by Type of isolation precautions is determined by how a disease is transmitted (passed) how a disease is transmitted (passed)

Isolation Precautions are done Isolation Precautions are done in additionin addition to to Standard Precautions and include:Standard Precautions and include: Strict adherence to hand hygieneStrict adherence to hand hygiene Personal protective equipment (PPE) appropriate for the Personal protective equipment (PPE) appropriate for the

type of isolation precautions in placetype of isolation precautions in place Environmental disinfectionEnvironmental disinfection Special air handling for tuberculosisSpecial air handling for tuberculosis


I - Contact PrecautionsI - Contact Precautions


Contact PrecautionsContact Precautions Contact PrecautionsContact Precautions apply to apply to

diseases transmitted by diseases transmitted by direct contactdirect contact with the patient’s skin and/or with the patient’s skin and/or infectious substance and by infectious substance and by indirect indirect contactcontact with the patient’s environment with the patient’s environment

Gloves Gloves andand gowns are used gowns are used

Masks are used in certain Masks are used in certain circumstances circumstances


Diseases Requiring Diseases Requiring Contact PrecautionsContact Precautions

Clostridium difficile Clostridium difficile Congenital rubellaCongenital rubella LiceLice ScabiesScabies Large woundsLarge wounds Burn patients in ICUBurn patients in ICU


Specific Information on Specific Information on AcinetobacterAcinetobacter

Acinetobacter is a group of bacteria commonly Acinetobacter is a group of bacteria commonly found in soil, water, food, and sewagefound in soil, water, food, and sewage

Loves the GI tract – the “gut” flora/bugLoves the GI tract – the “gut” flora/bug

May also be found on the skin of healthy people, May also be found on the skin of healthy people, especially healthcare workersespecially healthcare workers

Resulting infections are often resistant to many Resulting infections are often resistant to many commonly prescribed antibiotics – treatment may commonly prescribed antibiotics – treatment may be limited to very toxic drugsbe limited to very toxic drugs



Acinetobacter can be spread to Acinetobacter can be spread to susceptible individuals through direct susceptible individuals through direct person-to-person contact, contact with person-to-person contact, contact with contaminated surfaces, or exposure in the contaminated surfaces, or exposure in the environmentenvironment

Bacteria can survive for days on inanimate Bacteria can survive for days on inanimate objects such as mattresses, bedrails, IV objects such as mattresses, bedrails, IV poles, computer keyboards, and phonespoles, computer keyboards, and phones

Also may colonize in the nose or on handsAlso may colonize in the nose or on hands



Outbreaks of Acinetobacter may occur in ICUs and in Outbreaks of Acinetobacter may occur in ICUs and in other hospital units that house patients with other hospital units that house patients with weakened immune systems or chronic illnessesweakened immune systems or chronic illnesses

May cause pneumonia, bloodstream or urinary tract May cause pneumonia, bloodstream or urinary tract infections, and skin/wound infectionsinfections, and skin/wound infections

Endocarditits, secondary meningitis, and ventriculitis Endocarditits, secondary meningitis, and ventriculitis may also resultmay also result

Patients placed on Patients placed on Contact PrecautionsContact Precautions for for Acinetobacter infection remain on isolation Acinetobacter infection remain on isolation precautions throughout their hospitalizationprecautions throughout their hospitalization


Specific Information Specific Information on MRSAon MRSA

Methicillin-resistant Methicillin-resistant Staphylococcus aureusStaphylococcus aureus (MRSA) is the commonly called “staph” bacteria (MRSA) is the commonly called “staph” bacteria that has become resistant to many antibioticsthat has become resistant to many antibiotics

Patients who have invasive procedures, lengthy Patients who have invasive procedures, lengthy hospital stays, weakened immune systems, or hospital stays, weakened immune systems, or who receive dialysis are at increased risk of who receive dialysis are at increased risk of developing MRSAdeveloping MRSA

Community-acquired MRSA (CA-MRSA) is Community-acquired MRSA (CA-MRSA) is increasing among patients who have increasing among patients who have nevernever been been hospitalized hospitalized


About 30% of the US population have “staph” About 30% of the US population have “staph” bacteria that normally live on the skin and in bacteria that normally live on the skin and in nasal passages without causing harm (colonized)nasal passages without causing harm (colonized)

Common infections caused by MRSA include skin Common infections caused by MRSA include skin abscesses, boils, and impetigoabscesses, boils, and impetigo

More serious infections that may develop include More serious infections that may develop include deep soft tissue abscess, blood stream infections, deep soft tissue abscess, blood stream infections, pneumonia, endocarditis (heart valves, inner pneumonia, endocarditis (heart valves, inner lining of the heart), and toxic shock lining of the heart), and toxic shock



MRSA is spread by worker hands that pick up MRSA is spread by worker hands that pick up the bacteria from skin-to-skin contact with a the bacteria from skin-to-skin contact with a colonized or infected patient, then care for colonized or infected patient, then care for another patient without first performing another patient without first performing adequate hand hygieneadequate hand hygiene

Contact with contaminated substances or Contact with contaminated substances or items such as computer keyboards, bedrails, items such as computer keyboards, bedrails, or medical equipment can also lead to or medical equipment can also lead to transmissiontransmission

MRSA may survive for weeks to months on MRSA may survive for weeks to months on various surfaces!various surfaces!



Specific Information Specific Information on VREon VRE

Enterococci bacteria are normally found in the Enterococci bacteria are normally found in the human intestines, the female genital tract, human intestines, the female genital tract, and the environment and may not cause and the environment and may not cause diseasedisease

Vancomycin is a drug commonly used to treat Vancomycin is a drug commonly used to treat enterococci infections. In some instances the enterococci infections. In some instances the bacteria is resistant to the drug and is bacteria is resistant to the drug and is therefore called vancomycin-resistant therefore called vancomycin-resistant entercocci (VRE)entercocci (VRE)

Patients can be colonized Patients can be colonized oror have an active have an active infection involving the urinary tract, blood infection involving the urinary tract, blood stream or wounds stream or wounds


Risk factors for developing VRE include: persons Risk factors for developing VRE include: persons previously treated with vancomycin or combinations previously treated with vancomycin or combinations of other drugs, persons receiving prolonged of other drugs, persons receiving prolonged antibiotic therapy, weak immune system, surgery to antibiotic therapy, weak immune system, surgery to abdomen or chest, and use of indwelling cathetersabdomen or chest, and use of indwelling catheters

VRE is spread by direct contact with infected stool, VRE is spread by direct contact with infected stool, urine, or blood containing VRE urine, or blood containing VRE

Can also spread indirectly by hands or via Can also spread indirectly by hands or via contaminated environmental surfacescontaminated environmental surfaces

Specific Information Specific Information on VREon VRE


Circulator Responsibilities for Circulator Responsibilities for aa Contact Precautions Contact Precautions CaseCase

Post the Post the RED Contact PrecautionsRED Contact Precautions signsign on the on the OR door, along with the OR door, along with the red “No Traffic” sign red “No Traffic” sign

Ensure that all staff don gloves, gowns, and Ensure that all staff don gloves, gowns, and masks masks beforebefore the patient enters the OR the patient enters the OR

Inform the receiving department of the patient’s Inform the receiving department of the patient’s isolation status isolation status prior to transferring the patient!prior to transferring the patient!


II - Airborne PrecautionsII - Airborne Precautions


Airborne PrecautionsAirborne Precautions

Airborne PrecautionsAirborne Precautions apply to diseases apply to diseases transmitted by the airborne routetransmitted by the airborne route

Bacteria or viruses are released into the air when Bacteria or viruses are released into the air when

an infected patient talks, coughs, or sneezesan infected patient talks, coughs, or sneezes

These droplets float on air currents and/or remain These droplets float on air currents and/or remain in the air for long periods of timein the air for long periods of time

A susceptible person who does not wear A susceptible person who does not wear respiratory protection can breathe in the droplets respiratory protection can breathe in the droplets and potentially become infectedand potentially become infected


Diseases Requiring Diseases Requiring Airborne PrecautionsAirborne Precautions

1. Pulmonary Tuberculosis (TB)1. Pulmonary Tuberculosis (TB)

2. Measles2. Measles

3. Chicken Pox3. Chicken Pox

Unusual bioterrorism agents and others such as …Unusual bioterrorism agents and others such as …- Smallpox (Bioterrorism)- Smallpox (Bioterrorism)- Viral hemorrhagic fevers - Viral hemorrhagic fevers (Bioterrorism)(Bioterrorism)

- SARS- SARS

Patients are placed on droplet precautions when any of Patients are placed on droplet precautions when any of these diseases are suspected these diseases are suspected oror confirmed confirmed


N-95 RespiratorsN-95 Respirators

ALLALL STAFFSTAFF providing care to patients on providing care to patients on Airborne PrecautionsAirborne Precautions mustmust wear an wear an

N-95 respiratorN-95 respirator!!!!

N-95 respirators must be fit tested N-95 respirators must be fit tested annually by Vanderbilt Environmental annually by Vanderbilt Environmental Health and Safety (VEHS) – your mask size Health and Safety (VEHS) – your mask size can change over timecan change over time


Airborne PrecautionsAirborne Precautions Post the Post the blue Airborne Precautions signblue Airborne Precautions sign on on

the OR door before the patient arrives, along with the OR door before the patient arrives, along with the the red “No Traffic” signred “No Traffic” sign

Patients coming to the OR who are on Patients coming to the OR who are on Airborne Airborne PrecautionsPrecautions should be scheduled as the last should be scheduled as the last case of the day whenever possiblecase of the day whenever possible

Limit traffic through the OR during the caseLimit traffic through the OR during the case


Airborne PrecautionsAirborne Precautions Patients should be placed in negative pressure Patients should be placed in negative pressure

rooms while on their designated floor/unitrooms while on their designated floor/unit

Keep the door closed!!!Keep the door closed!!!

Limit transport of patient from room except for Limit transport of patient from room except for essential purposesessential purposes

Have the patient wear a regular surgical mask Have the patient wear a regular surgical mask any time they are transported from their roomany time they are transported from their room

Inform the receiving department of the patient’s Inform the receiving department of the patient’s isolation status isolation status prior to transferring the patientprior to transferring the patient


Airborne PrecautionsAirborne Precautions - - Responsibilities for Responsibilities for

Anesthesia ProvidersAnesthesia Providers

Non-ICU patients on Non-ICU patients on AAirborne Precautionsirborne Precautions will be will be recovered in the ORrecovered in the OR after the completion of the surgical after the completion of the surgical procedure – procedure – notnot in PACU! in PACU!

ICU patients may be recovered in a negative pressure ICU patients may be recovered in a negative pressure room on their assigned unitroom on their assigned unit

The patient will then be transported back to their The patient will then be transported back to their designated floor/unitdesignated floor/unit

Anesthesia machine filters will be changed out after the Anesthesia machine filters will be changed out after the case (same procedure as for any case)case (same procedure as for any case)


Airborne PrecautionsAirborne Precautions - -Responsibilities for Responsibilities for OR Charge NursesOR Charge Nurses

When an When an Airborne PrecautionsAirborne Precautions case is case is boarded, the OR Charge Nurse will order boarded, the OR Charge Nurse will order the portable HEPA Unit from Central the portable HEPA Unit from Central Supply so that it will be ready to use Supply so that it will be ready to use immediately after the caseimmediately after the case


Airborne PrecautionsAirborne Precautions - -Responsibilities for CT-I StaffResponsibilities for CT-I Staff

After patient leaves the After patient leaves the OR, bring in the HEPA OR, bring in the HEPA UnitUnit

Place HEPA Unit in the Place HEPA Unit in the center of the OR, away center of the OR, away from the return air ventfrom the return air vent

Plug HEPA Unit into Plug HEPA Unit into electrical outlet and electrical outlet and turn the Unit “on”turn the Unit “on”

Allow HEPA Unit to run Allow HEPA Unit to run for for ONE HOURONE HOUR before before cleaning the roomcleaning the room

OR may then be OR may then be cleaned with standard cleaned with standard germicidal agentgermicidal agent

Portable Portable

HEPA UnitHEPA Unit


III - Droplet PrecautionsIII - Droplet Precautions


Droplet PrecautionsDroplet Precautions

Applies to diseases transmitted by close Applies to diseases transmitted by close contact with respiratory secretionscontact with respiratory secretions

Infectious droplets are expelled when a Infectious droplets are expelled when a patient coughs or sneezespatient coughs or sneezes

Droplets remain airborne for about 3 feet, Droplets remain airborne for about 3 feet, then fall to the floorthen fall to the floor


Diseases Requiring Diseases Requiring Droplet PrecautionsDroplet Precautions

InfluenzaInfluenza

Pertussis (Whooping Cough)Pertussis (Whooping Cough)

MumpsMumps

Meningitis caused by Meningitis caused by H. influenzaeH. influenzae or or N. N. meningiditis meningiditis

Fifth Disease (Parvovirus B-19)Fifth Disease (Parvovirus B-19)

Patients are placed on droplet precautions when any of Patients are placed on droplet precautions when any of these diseases are suspected these diseases are suspected oror confirmed confirmed


More onMore on Droplet Droplet PrecautionsPrecautions

Post the Post the green Droplet Precautionsgreen Droplet Precautions signsign on on the OR door, along with the the OR door, along with the red “No Traffic” signred “No Traffic” sign

Limit traffic through the OR during the caseLimit traffic through the OR during the case

Wear a Wear a regular surgical maskregular surgical mask when providing when providing patient care – patient care – notnot an N-95 respirator an N-95 respirator


More on More on Droplet Droplet PrecautionsPrecautions

Wear gloves when handling items Wear gloves when handling items contaminated with respiratory contaminated with respiratory secretionssecretions

Wash hands after removing glovesWash hands after removing gloves


More on More on Droplet Droplet PrecautionsPrecautions

After the patient leaves the OR/PACU/etc., the After the patient leaves the OR/PACU/etc., the room can be cleaned with the standard room can be cleaned with the standard germicidal agentgermicidal agent

Patients should be placed in private rooms while Patients should be placed in private rooms while on their designated floor/unit, but negative on their designated floor/unit, but negative pressure rooms are unnecessarypressure rooms are unnecessary

During transport, patients wear a regular During transport, patients wear a regular

surgical masksurgical mask


Common Tasks for Common Tasks for ALLALL Isolation Precautions Isolation Precautions

CasesCases

The following slides describe The following slides describe steps that are taken for steps that are taken for everyevery

case involving isolation case involving isolation precautions precautions


Scheduling any Scheduling any Isolation PrecautionsIsolation Precautions Case Case

Surgeon or resident boards the caseSurgeon or resident boards the case

Surgery scheduler determines whether or not the Surgery scheduler determines whether or not the patient is on isolation precautions (if uncertain, patient is on isolation precautions (if uncertain, scheduler contacts the patient care unit)scheduler contacts the patient care unit)

Surgery scheduler documents isolation status in Surgery scheduler documents isolation status in ORMIS, which feeds onto the eOR board and the ORMIS, which feeds onto the eOR board and the electronic White Boardelectronic White Board

There are 4 possible choices for isolation status:There are 4 possible choices for isolation status:- - NoneNone - - AirborneAirborne- - DropletDroplet - - ContactContact


Circulator Responsibilities for Circulator Responsibilities for anyany Isolation PrecautionsIsolation Precautions CaseCase

Post the appropriatePost the appropriate “Isolation Precautions”“Isolation Precautions” sign and the sign and the “No Traffic”“No Traffic” sign on OR doorsign on OR door

Ensure all needed supplies Ensure all needed supplies and equipment are and equipment are available in the ORavailable in the OR

Remove all unnecessary Remove all unnecessary equipment from the OR equipment from the OR before the case beginsbefore the case begins

Close all cabinets (cannot Close all cabinets (cannot open cabinets during the open cabinets during the case!)case!)

Ensure ALL staff involved Ensure ALL staff involved in the case don gown, in the case don gown, gloves, and masks gloves, and masks beforebefore the patient enters the OR the patient enters the OR (if patient is on airborne (if patient is on airborne precautions, use N-95 precautions, use N-95 respirators instead of respirators instead of surgical masks)surgical masks)

Isolation CartIsolation Cart with gowns, with gowns, gloves and other isolation gloves and other isolation supplies is supplies is kept kept outsideoutside the the OR doorOR door


Assigns a “runner” to the OR, who Assigns a “runner” to the OR, who will assist in obtaining additional will assist in obtaining additional supplies for the case (this person will supplies for the case (this person will NOT enter the OR at any time!)NOT enter the OR at any time!)

OR Charge Nurse OR Charge Nurse ResponsibilitiesResponsibilities for anyfor any

Isolation PrecautionsIsolation Precautions Case Case


Anesthesia Provider Anesthesia Provider Responsibilities for any Responsibilities for any

Isolation PrecautionsIsolation Precautions Case Case

When transporting a patient direct to the OR:When transporting a patient direct to the OR:

-don appropriate PPE -don appropriate PPE priorprior to entering to entering patient’s roompatient’s room

- assess patient’s condition and equipment - assess patient’s condition and equipment needed for transportneeded for transport

- conduct handoff with bedside nurse, - conduct handoff with bedside nurse, including including verification of the patient’s verification of the patient’s isolation statusisolation status


Responsibilities for Other Staff Responsibilities for Other Staff Assisting with Transport to the ORAssisting with Transport to the OR

Don PPE Don PPE priorprior to entering the patient’s room to entering the patient’s room

Verify the patient’s isolation status with the bedside nurseVerify the patient’s isolation status with the bedside nurse

Team places a clean sheet over the patientTeam places a clean sheet over the patient

Place patient charts in a plastic bag (obtain a plastic Place patient charts in a plastic bag (obtain a plastic Isolation Bag from the yellow Isolation Cart)Isolation Bag from the yellow Isolation Cart)

Place monitors, charts, etc. on top of the clean sheet for Place monitors, charts, etc. on top of the clean sheet for transport to the ORtransport to the OR

Have a “clean” person available (one who has not touched Have a “clean” person available (one who has not touched the patient or patient’s bed/belongings) to push elevator the patient or patient’s bed/belongings) to push elevator buttons and open doorsbuttons and open doors


During the Case…During the Case…Responsibilities for CT-I Responsibilities for CT-I

StaffStaff Saturate a rag with germicidal disinfectant agent Saturate a rag with germicidal disinfectant agent

and wipe down patient’s bed in hallway (includes and wipe down patient’s bed in hallway (includes mattress, side rails, headboard and footboard)mattress, side rails, headboard and footboard)

Wait Wait 10 minutes10 minutes for the bed to dry – place an for the bed to dry – place an isolation bag on bed during the drying phase so isolation bag on bed during the drying phase so others know it belongs to a patient on isolation others know it belongs to a patient on isolation precautionsprecautions

Make patient bed as usualMake patient bed as usual

Drape bed with clear plastic Drape bed with clear plastic

Put isolation sign on bedPut isolation sign on bed


Communication Regarding Communication Regarding Return of Patient to the Unit Return of Patient to the Unit

Circulator calls unit charge nurse to inform them Circulator calls unit charge nurse to inform them of impending transfer and verifies isolation statusof impending transfer and verifies isolation status

Anesthesia provider calls report to the patient’s Anesthesia provider calls report to the patient’s bedside nurse and verifies isolation statusbedside nurse and verifies isolation status

Circulator conducts “rolling call” to unit as the Circulator conducts “rolling call” to unit as the patient leaves the ORpatient leaves the OR

Unit receives call and notifies charge nurse and Unit receives call and notifies charge nurse and bedside nurse that patient is in transit and bedside nurse that patient is in transit and verifies isolation statusverifies isolation status


Responsibilities for Staff Responsibilities for Staff Assisting with Transfer Back Assisting with Transfer Back

to the Unitto the Unit All staff involved in patient All staff involved in patient

transport don new PPE transport don new PPE before transfer beginsbefore transfer begins

Have a “clean” person Have a “clean” person available (one who has not available (one who has not touched the patient or touched the patient or patient’s bed/belongings) patient’s bed/belongings) to push elevator buttons to push elevator buttons and open doorsand open doors

Anesthesia provider and Anesthesia provider and bedside nurse conduct bedside nurse conduct report/handoff and verify report/handoff and verify isolation statusisolation status

Transport monitors and Transport monitors and other equipment are wiped other equipment are wiped down with a germicidal down with a germicidal disinfectant agent before disinfectant agent before leaving the patient’s roomleaving the patient’s room

Staff remove PPE prior to Staff remove PPE prior to exiting patient’s roomexiting patient’s room


After the caseAfter the case

The OR should be cleaned with germicidal The OR should be cleaned with germicidal disinfectant agent according to normal disinfectant agent according to normal standardsstandards

All linen and trash from the room are All linen and trash from the room are handled in the same manner as from any handled in the same manner as from any case case


Questions or Concerns?Questions or Concerns?

Contact Contact

Infection Control & Infection Control & PreventionPrevention

Phone: 60725Phone: 60725

Pager: 835-1205Pager: 835-1205

isolation precautions: guidelines for perioperative services

Documents