Types of Isolation*
There are two tiers of transmission isolation precautions recommended by the Hospital Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease Control and Prevention (CDC). The tiers include standard precautions, for use with all clients, and expanded precautions (transmission-based precautions) added for clients with known or suspected infections with pathogens requiring contact precautions, droplet precautions, and airborne infection isolation (AII). Expanded precautions also include creating a protective environment (PE) for severely immunocompromised clients.
Standard precautions, the primary tier in the control of microorganism transmission, combine the major features of universal precautions and body substance isolation. HAND HYGIENE IS REQUIRED WITH ALL CLIENT CONTACT AND WITH ALL FORMS OF ISOLATION.
In addition to hand hygiene, standard precautions involve the use of personal protective equipment (PPE)—barriers and respirators used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. Standard precautions are applied to blood; all body fluids, secretions, and excretions except sweat, regardless of the presence of visible blood, nonintact skin, and mucous membranes. Standard precautions are based on the principle that not all clients infected with blood-borne pathogens can be reliably identified before the possible exposure of health care workers (HCWs). HCWs are instructed to use standard precautions with all clients and to add expanded precautions when indicated.
Expanded precautions include four types of precautions—airborne, droplet, contact, and protective environment (PE).
Expanded precautions are employed if a client is known to have an infection involving highly transmissible pathogens, or if the client is immunosuppressed, to interrupt transmission of infection or exposure to pathogens. Creating a PE differs from other types of precautions in that the goal of placing a highrisk client in a PE is to prevent the immunosuppressed client from acquiring infections from the environment. The goals of droplet, contact, and airborne precautions are to protect HCWs, visitors, and other clients from acquiring infectious agents from infected clients (see table for PPE required).
Respiratory Hygiene/Cough Etiquette was specifically added to precautions and invo1ves (a) the covering of the nose and mouth when coughing or sneezing, (b) using disposable napkins or tissues to contain respiratory secretions with immediate discard into a touch-free receptacle, (c) providing a surgical mask for persons who are coughing to reduce contamination of the environment, (d) turning face away from others and maintaining space of at least 3 feet from others when coughing, and (e) hand hygiene with possible soiling with secretions.
Pamphlets, fact sheets, or other materials should be prepared to inform the client and significant others of the purpose of expanded precautions, when used. A notice is posted on the door of the client's room requesting all visitors to see the nurse before entering the room. Expanded precautions involve the use of isolation procedures and appropriate protective equipment when caring for clients with diseases caused by specific microorganisms that are identified by the mode of disease transmission.
Gloves are used when handling any body part with broken skin, body secretions, or any secretion-soiled item. A gown is added when soiling of clothing is likely. A mask and goggles are worn whenever secretions are projectile or when an infection with a microorganism that is transmitted through air droplet transmission is suspected (an additional maskprecautions notice may be posted). All linens are handled with care to prevent contamination of the nurse's clothing. Reusable items that clients with known infections have used are tagged accordingly when sent for disinfecting.
Many facilities design isolation precaution signs that identify the necessary equipment (e.g., the use of gloves, gowns, masks, goggles, or special disposal of contaminated materials) in a yes/no format. The following table includes information found on most cards.
Precautions Used by Health Care Workers
| Isolation/Precaution Systems | Gloves | Gown | Mask | Goggles | Special Handling of Reusable Equipment |
|---|---|---|---|---|---|
| Standard precautions | Y | With possible soiling | If splashing likely | Y with projectile secretions | Y if contaminated with body substances |
| Expanded precautions | D | D | D | D | D |
| Contact | Y | Y | Y | Y with secretions | Y |
| Droplet | Y | Y | Y | Y if splashing | Y if soiled |
| Airborne | N | Y/D | Y | Y with secretions | Y if soiled |
D, depends on disease; N, no, item is not generally required; Y, yes, item is needed in most circumstances (some listed). Some agencies require double bagging of soiled materials before removal from the room; isolation card should identify these requirements.
* Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 (http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/isolation2007.pdf).