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Principles of transmission-based precautions

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The essentials of patient isolation are summarised in this article. They are also available as a learning resource in our learning unit on patient isolation. Scroll down to read the article or download a print-friendly PDF here

Introduction

To minimise the risk of transmitting infectious agents, patients may be isolated in single rooms. Previously, patient isolation was called “isolation precautions” or “barrier nursing” and, while it can be adapted to other health and social care settings, it is more commonly related to acute hospitals.

In current practice, more specific terminology is used to describe isolation precautions; these are included under the umbrella term “transmission-based precautions” (TBPs). This term refers to a set of practices undertaken when patients are suspected of having, or are known to be infected with, an infectious agent, for example, MRSA (Health Protection Scotland, 2014).

Transmission-based precautions

TBPs comprise specific precautions depending on the mode of spread, namely by contact, droplet or airborne (HPS, 2014). Some diseases might have multiple routes of transmission, in which case all three sets of precautions may apply (Department of Health, Social Services and Public Safety, 2008). TBPs are not to be confused with standard precautions, which should be applied consistently for all patients at all times.

Contact precautions

Contact precautions aim to prevent the spread of an infectious agent by direct or indirect contact with patients or service users and healthcare workers who are providing care-related activities. An example of bacteria that might be spread by contact transmission is MRSA or a gastrointestinal infection such as Salmonella spp (HPS, 2014).

Droplet precautions

Droplet precautions relate to infectious agents that may be spread from the respiratory tract by coughing, sneezing or even talking. Their ability to spread is limited, as they only remain in the air for short periods of time and cannot travel further than a metre. This means the spread is limited to close contact (Health Protection Agency, 2012). Examples of infectious diseases that would require droplet precautions include influenza and bacterial meningitis (HPS, 2014).

Airborne precautions

Airborne precautions help to prevent the spread of infectious agents that have the ability to travel distances and remain infectious when suspended in the air (HPA, 2012). These include bacteria such as Mycobacterium tuberculosis and viruses such as measles (HPS, 2014). Negative-pressure rooms are required for patients who have, or are suspected of having, multidrug-resistant Mycobacterium tuberculosis (National Institute for Health and Care Excellence, 2011).

Protective isolation

Protective isolation may be necessary for patients who are severely immune compromised and need to be nursed in a protective environment (DHSSPS, 2008). This may include the use of a positive-pressure isolation room. Refer to local guidelines about protective isolation and positive/negative-pressure rooms.

Caring for patients in isolation

It is important that staff are aware of the known or suspected infectious agents involved when considering the care and management of patients nursed in isolation. Standard precautions (SICPs) should be applied, as well as the appropriate TBPs.

Single rooms should be en-suite, with a toilet and hand-wash sink as a minimum requirement. Cleaning should be undertaken at least daily, referring to local guidelines on the specific regime.

It is important that rooms are as clutter free as possible to allow thorough cleaning. Equipment should be single patient and cleaned after each use or single use, wherever possible, and disposed of. Any equipment that is not suitable for single-patient use should be left in the room, cleaned after each use and decontaminated before returning to general use (Royal College of Nursing, 2012).

Transmission of micro-organisms by the hands of healthcare workers is the most likely method of contributing to the spread of infections in hospitals (Loveday et al, 2014), and the World Health Organization (2009) has stated that “clean hands prevent patient suffering and save lives”. Hand hygiene refers to either hand washing or the use of alcohol-based hand gels. Read the WHO’s Your Five Moments for Hand Hygiene (WHO, 2014).

Personal protective equipment

Personal protective equipment (PPE) is needed to protect healthcare workers and their patients (RCN, 2012).

HPS (2014) states: “Before undertaking any procedure, staff should assess any likely exposure and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.”

PPE should be stored in a clean, dry area and protected from contamination. It should be:

  • Available at the point of use;
  • Single use;
  • Disposed of in the correct waste stream;
  • Applied and removed in the correct way to prevent cross-contamination (HPS, 2014).

The equipment that is used depends on the task and the type of precautions required. For contact precautions, if contact with the patient and/or the environment is anticipated, aprons should be worn. The use of gloves will depend on the nature of the task but, generally, non-sterile gloves should be worn when there is anticipated exposure to blood and body fluid, or when handling sharps or contaminated devices.

Sterile gloves should be worn when undertaking an invasive procedure, or there is any contact with sterile sites. However, gloves are not a substitute for good hand hygiene (Loveday et al, 2014). When taking droplet or airborne precautions, extra PPE is needed, such as surgical face masks, FFP3 respirator masks and facial protection.

FFP3 respirator masks

The FFP3 respirator masks are designed to fit closely to the face to prevent transmission of particulates via the airborne route. Before using FFP3 masks for the first time, each staff member should have the fit tested, and then undertake regular fit checks. Guidelines are available from Public Health England (2013).

Local guidelines should be followed for infections spread by the droplet and/or airborne route. HPS advises that FFP3 masks and facial protection must be considered for anyone admitted with, or suspected of having, an infectious agent that is airborne or spread by droplet, especially with any aerosol-generating procedures.

PPE for specific infectious agents

Certain infectious agents, including ebola, require specific PPE that may not fit into the usual guidance for contact, droplet or airborne precautions. Specific guidance is usually provided at the time by health organisations and government departments; for example, in the case of ebola.

Psychosocial concerns

Patients who are isolated in a single room may become anxious, withdrawn and/or depressed; good communication with both patient and relatives can minimise distress. If the door cannot be closed due to safeguarding issues, this will need careful consideration and discussion with the infection prevention and control team.

Availability of isolation rooms can also be limited (Kilpatrick et al, 2008); if too few are available, cohort nursing of patients in designated areas may be necessary. Again, liaison with the infection prevention and control team will be needed.

Boost your CPD and work towards your next revalidation with our learning unit on patient isolation

Nursing Times subscribers have free access to a range of learning units, including one on Patient Isolation: Transmission-based Precautions. This unit, developed in association with the Infection Prevention Society, focuses on the management of adults with infections that require isolation in a single room. It aims to equip nurses and other health professionals with the knowledge and skills needed to assess and manage patients presenting with an infection that requires transmission-based precautions.

After studying this unit you will be able to:

  • List common infectious conditions that may require the patient to be isolated in a single room
  • Explain the different reasons for isolating a patient
  • Describe the key principles of transmission-based precautions
  • Compare and contrast aspects of the different types of transmission-based precautions
  • Describe the psychosocial impact isolation may have on patients
  • Describe the key strategies needed to effectively manage patients with infections requiring isolation
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