With the publication in 2007 of the CDC Guideline for Isolation Precautions (see http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf) and then in 2009 the publication of the Cal/OSHA Aerosol Transmissible Diseases Standard (see http://www.dir.ca.gov/title8/5199.html), both Standard Precautions and Transmission-based Precautions (Contact, Droplet, and Airborne) underwent major changes. The greatest change and challenge occurred with Contact Precautions. In 2009 Cal/OSHA instituted a new category which may be called “Aerosol Transmission” based Precautions, which subsumed Droplet and Airborne Precautions and largely ignored Contact Precautions. Standard Precautions as stipulated in the 2007 CDC Guideline had already been elevated to a level of what some termed “modified” Contact Precautions. In some facilities Standard Precautions is at such a high and successful level that Contact Precautions had been obviated. While the presence of parasites, infestations, and active manifestations of infection transmission, such as excessive wound drainage, are certainly reasons to enforce Contact Precautions, the major confusion seems to be – what to do with patients colonized with a known pathogen or environmental contaminant, such as MRSA or C.difficile.
Colonization refers to when a patient harbors a pathogen, but is asymptomatic and not suffering from the agent’s presence. This is a clinical term, not a laboratory term since the laboratory cannot determine colonization; laboratory tests can only determine if the specimen submitted contains one or more organisms. The health care practitioner must use his/her own clinical judgment when examining the whole patient to determine if symptoms are present and warrant attention. In general “colonized” patients do not require treatment, isolation, or re-testing. They should, however, be encouraged to practice good personal and respiratory hygiene, wear clean clothes, bathe frequently, and wash their hands frequently and before leaving their rooms. In some cases cohorting, separate toileting facilities, or dedicated personal care equipment (e.g. stethoscopes and BP cuffs), may be needed to maximize independence and minimize isolation procedures.
The application and discontinuance of Isolation Precautions or Transmission-based Precautions should be outlined in the facility policy and procedures manual. Unless the facility is clear as to what level or kind of Precautions is being enforced, there will be confusion among the employees as to what PPE is required, which may be to the facility’s detriment during a Survey. For example, the treatment nurse changing a dressing may consider the patient on Contact Precautions and don gown and gloves, while CNAs and others consider the same patient on Standard Precautions and not don any PPE. Here the question becomes – Is the treatment nurse applying Standard Precautions or should the facility be enforcing Contact Precautions by everyone? According to the 2007 CDC Guidelines, Isolation Precautions should be applied on a “case by case” basis. This precludes the facility has an effective system for early identification of patients with an infection, rapid assessment of what Isolation Precautions is needed, monitoring and enforcing Isolation Precautions, procedures for determining the soonest to discontinue Isolation Precautions, as well as what post-isolation procedures should be undertaken, e.g. terminal cleaning of the room.
If you have specific questions regarding Isolation Precautions, your MuirLab Infection Preventionist will be happy to help you. Call Gloria Escalona or Mary Payne at (800) 677-4525.