KING FAHAD HOSPITAL AL BAHA

NURSING administration

Policy Name

: ISOLATION PRECAUTION

Policy Number

MS. DEVAKRUPA
GUNDI

MS. MARIA ANGELA

PATINO

MS. ATHENA MANAO

Infection Control Head

Nurse

Prepared by

DR. MOHAMMAD
TAYFOUR

Edition

Type of Edition

DR ALI DAMMAS

EDGA for Medical Affairs

Infection Control Director

Revised by

4th

MR RAED MOHD
BABA

Revised by

1/ 10/ 2009

Date of revision

Director of Nursing

Approved by

1/ 11 / 2009

Effective date

Approved by

1/ 10// 2011

Review date

 PURPOSE :
1. To minimize the transmission of infectious agents to, from and between
patients, staff and visitors in the hospital.

SCOPE :

1st Step : Identification or early detection of patients that present an infection

risks to the rest of hospital.
Last Step : Documentation of nursing care rendered using isolation precaution
and transmission based precaution guidelines.

ABBREVIATIONS :
TB Tuberculosis
HEPA High efficiency particulate air filters

POLICY :

1. Activity Description:
1.1
Isolation becomes necessary when the patient presents an
infection risk to the rest of the hospital.
2.1
Notify the infection control practitioner, when decision to isolate
a patient has been made.
3.1
The reason for isolation must be fully explained to the patient
and family.
4.1
Remember isolate the disease and not the patient.
2. Standard Precaution :
For blood and body fluids, excretions, mucous membranes and non-intact
skin shall be used in the care of all patients.
2.1

2.2

2.3

Hand washing :
2.1.1 Before and after patient contact ;
2.1.2 After using gloves ;
2.1.3 Immediately after contact with blood, body fluids, secretions,
excretion, non-intact skin or mucous membrane
Masks :
2.2.1 Anytime the Health Care worker anticipates the possibility of
being splashed with blood, body fluids, secretions and
excretions.
Protective Eye Wear and/or Face Shields :

2.3.1 Anytime the Health Care worker anticipates the possibility of

being splashed with blood, body fluids, secretions and
excretions.
2.4
Gloves (Clean, non sterile) :
2.4.1 Anytime contact with blood, body fluids, secretions,
excretions, membranes, non-intact skin or surfaces soiled with
visible blood or bloody fluids is anticipated.
2.4.2 When performing vascular access procedures.
2.5
Gown :
2.5.1 Anytime that clothing is likely to be soiled by splattering of
blood, body fluids, secretions and excretions.
2.6
Handling needles and small sharps :
2.6.1 Do not recap needles.
2.6.2 Dispose of used needle and small sharps in puncture-resistant
containers which are located as close as possible to the area
of use.
2.7
Cleaning Spills :
2.7.1 Wear gloves
2.7.2 Wipe up the spill
2.7.3 Apply disinfectant appropriate to the size and surface (e.g.
Clorox )
2.8
Patient Placement :
2.8.1. Place a patient who contaminates the environment or who
does not
assist in maintaining the appropriate hygiene in a single
room.
2.8.2. If a single room is not available, consult infection control
group of
other alternatives.
3. Transmission Based Precaution :
3.1
The measures designed for patients documented or suspected to
be infected or colonized with highly transmissible or epidemiologically
important pathogens for which additional precautions, beyond standard
precautions, are needed to interrupt transmission in hospitals.
3.1.1 There are three types of transmission based precautions :
3.1.1.1 Airborne precautions
3.1.1.2 Droplet precautions
3.1.1.3 Contact precautions
3.1.2 Whether the three types of transmission based precautions
are used singly or in combination, they are to be used in
addition to standard precautions.
TRANSMISSION BASED PRECAUTIONS

1. Airborne Precautions
In addition to standard precautions, use airborne precautions for patients
known or suspected to be infected with microorganisms transmitted by the
airborne droplet nuclei (small particle size [5 microns or smaller] or
evaporated droplet containing microorganisms which remain suspended in
the air and can be widely dispersed by air currents within a room or over a
long distance). e.g. TB, chicken pox, measles, rubella
1.1 Patient Placement :
1.1.1 Place patient in a single room which has:
1.1.1.1 Monitored negative for air pressure in relation to the
surrounding areas.
1.1.1.2 A minimum of six air changes per hour.
1.1.1.3 Appropriate discharge of air outdoors or monitored high
efficiency filtration of room air before the air is circulated
to other areas of the hospital.
1.1.2 Keep the door closed.
When a single room is not available, place a patient in a room
with a patient who has active infection with the same
microorganism, unless otherwise recommended by the Infection
Control Group, but with no other infection (cohorting).
1.2 Consult Infection Control Group staff before patient placement when a
single room is not available and cohorting is not available.
1.2.1 Respiratory Protection :
1.2.1.1 Wear respiratory protection (HEPA respirators) when
entering the room to medically essential purposes only.
1.2.1.2 Do not enter the room of patients of known or suspected
to have measles (rubeola) or chicken pox (varicella) if
susceptible to these infections.
1.2.2 Patient Transport :
1.2.2.1 Limit the movement and transport of the patient from the
room to medically essential purposes only.
1.2.2.2 If transport or movement is necessary, minimize patient
dispersal of droplet nuclei by placing a surgical mask on
the patient.
2. Droplet Precautions :
In addition to standard precautions, use droplet precautions for a patient
known or suspected to be infected with microorganisms transmitted by
droplets (large particle droplets [>5u in size] which can be generated by the
patient during coughing, sneezing or talking or in the performance of

procedures) e.g. Neisseria Meningitidis, Bordetella pertussis, Adenovirus in

infant Heamophilus influenza, Rubella, Adenovirus, Scarlet fever in infant.
2.1 Patient Placement :
2.1.1 Place the patient in a single room.
2.1.1.1 When a single room is not available, place the patient
in a room with a patient who has active infection with
the same microorganisms but no other infection.
(cohorting)
2.1.1.2 When a single room is not available and cohoritn is not
achievable, maintain spatial separation of at least
three feet between the infected patient on other
patients or visitors.
2.2 Mask :
2.2.1 In addition to standard precautions, wear a mask when
entering the room.
2.3 Patient Transport :
2.3.1 Limit the movement and transport of the patient from the room
to medically essential purposes only.
2.3.2. If transport or movement is necessary, minimize patient
dispersal of droplets by having the patient wear a mask.
3.

Contact Precautions

In addition to standard precautions, use contact precautions for specified

patient known or suspected to be infected or colonized with
epidemiologically important microorganisms which can be transmitted by
direct contact with the patient (hand or skin to skin contact which occurs
when performing procedures). E.g. Abscess, cellulitis, Clostridium difficile,
Furunculosis, Staphylococci in infants, Hemorrhagic fever, multi-drug
resistant organism.
3.1 Patient Placement :
3.1.1

Place the patient in a single room.

3.1.2 When a single room is not available, place the patient in a

room with a patient who has active infection with the same
microorganisms, but with no other infection (cohorting).

3.1.3 When a single room is not available and cohorting is not

achievable, contact Infection Control Group staff before patient
placement.
3.2 Gloves and Hand washing :
3.2.1 In addition to wearing gloves (as described in standard
precautions) wear gloves (clean, non-sterile) when entering the
room.
3.2.2 During patient care, change gloves after contact with infective
material which may contain high concentrations of microorganisms
(fecal material and wound drainage)
3.2.3 After glove removal and hand washing, ensure that hands do
not touch potentially contaminated environmental surfaces or items
in the patients room or environment.
3.3 Gown :
3.3.1 In addition to wearing a gown as described in standard
precautions,
wear a gown (clean, non-sterile, is adequate)
when entering the room, if substantial contact with the patient,
environmental surfaces or items.
3.3.2 If the patient is incontinent or has diarrhea, an ileostomy, a
colostomy or wound drainage not contained by a dressing.
3.3.3 After the gown removal, discard the gown (inside the room)
and ensure that clothing does not come into contact with potentially
contaminated environmental surfaces, in order to avoid transfer of
microorganisms to other patient or environments.
3.4 Patient transport :
3.4.1 Limit the movement and transport of the patient from the room
to
medically essential purposes only.
3.4.2. If the patient is transported out of the room, ensure that
precautions are maintained, in order to minimize the risk of
transmission of microorganisms to other patients and contamination of
environmental surfaces or equipment.
3.5 Environmental Control :

3.5.1 All patients care items, bedside equipment and frequently

touched surfaces shall be cleaned daily and whenever heavily soiled.
3.6 Patient Care Equipment :
3.6.1 If possible to avoid sharing between patients, dedicate the use of
non-critical patient care equipment and items such as stethoscopes,
electronic rectal thermometers and sphygmomanometers to a single
patient or cohort of patients infected or colonized with a pathogen
requiring precautions.
3.6.2 If use of common equipment or items is unavoidable, adequate
cleaning and disinfection between patient uses is essential.

MEASUREMENTS :

1. 100% of nurses will adhere to the isolation precaution and transmission

based precaution guidelines according to hospitals policies and procedures
and will effectively apply all principles in all patient care areas.
2. All new nursing staff will complete the nursing orientation and unit specific
orientation.
3. 100% of nurses will complete general and unit specific competencies.

ACCOUNTABILITY :
It is the responsibility of the Infection Control Committee and Infection
Control Nurse to ensure that isolation precaution and transmission based
precaution are being observed in the hospital by all nursing staff.
It is the responsibility of the Infection Control Committee to provide
guidelines for the nursing department to follow according to hospitals policy.
It is the responsibility of the head nurses, charge nurses, and staff nurses to
collaborate with the Infection Control Practitioner in proper management of
patients with the need for transmission based and isolation precaution using
the available resources of the hospital.
REFERENCES :
1. Infection Control Manual Quality Department King Fahad Hospital in
Albaha
2. Infection Control Policy and Procedure- King Fahad Hospital in Albaha
3. King Faisal Specialist Hospital and Research Center Jeddah Internal
Policy and Procedure

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