TRANSMISSION-BASED PRECAUTIONS FOR COMMUNICABLE DISEASES *

Effective Date: 
Thu, 01/01/2004
Reviewed: 
Fri, 02/26/2021
Revised: 
Fri, 02/26/2021
Policy: 

The Transmission-Based Precautions policy intends to prevent transmission of infectious agents which are spread through various mechanisms of contamination.  Three types of transmission mechanisms and their corresponding precautions will be defined and addressed here.

*Many infectious agents can be transmitted via more than one mode.  For example, Influenza is primarily transmitted from person to person via large virus-laden droplets (particles more than 5 microns in diameter) that are generated when infected persons cough or sneeze. These large droplets can then settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are near (within 3 feet) infected persons. Transmission may also occur through direct contact or indirect contact with respiratory secretions such as when touching surfaces contaminated with influenza virus and then touching the eyes, nose or mouth.  (See CDC Epidemiology and Prevention of Vaccine-Preventable Diseases The Pink Book: Course Textbook - 12th Edition Second Printing, May 2012)

Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. Since the infecting agent often is not known at the time of admission to the SHC, Transmission-Based Precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or a transmissible infectious etiology is ruled out.

With the onset of COVID-19, Student Health Services (SHS) initiated new, more rigorous precautions.  Students that present to SHS with potentially infectious conditions are directed to a separate waiting area where they don a mask and self-check-in and wait.   Staff rooming or examining patients coming from the designated “sick” waiting area should wear full PPE:  gown, gloves, face shield, N95 mask. 

In an effort to decrease the risk of spreading infection, movement in and out of the exam room should be minimized as much as possible.  For example, prepare to perform vitals, procedures, labs during a single room entry.  Don appropriate PPE before entering the room and doff used PPE immediately upon exiting the exam room, and before moving to any other surrounding areas.  If a staff member needs something for a student while in the exam room, open the door, ask for help and stay in the room.  Staff should try to do as much in the room as possible to avoid having to leave, doff and re-don.  When feasible, results should be given to the student outside, over the phone or via Health e-Messenger. 

In order to minimize the spread of infection, exam rooms used for potentially communicable diseases will have dedicated equipment that will be processed per policy after any exposure.

 

Transmission-Based Precautions are also for all SHS personnel with respiratory symptoms - See Respiratory Hygiene / Cough Etiquette (linked).  Staff are encouraged to stay home when they are ill with respiratory symptoms.  Personnel who are coughing, but are not infectious will observe respiratory hygiene and cough measures and are expected to wear a mask while at work.

Procedure: 

DEFINITIONS and PROCEDURES

Contact PrecautionsContact precautions are put in place when a patient presents with an apparently infected wound, gastrointestinal symptoms or parasites.  Some of the common patient presentations associated with infectious pathogens include:

Conjunctivitis            Uncontained Abscess               Enterovirus          Impetigo                  Hepatitis A           MRSA

Herpes Simplex (cutaneous)            Scabies                Cellulitis          Shingles (Herpes Zoster)     Parvovirus

*Influenza, Varicella, COVID-19                 **Clostridium Difficile           **Norovirus     

  1. Contact Precautions are intended to prevent transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment.  Patients are seated on papered or washable surfaces.  A Tidi Towel is placed between the blood pressure cuff and any rash or non-intact skin.  All personnel practice hand hygiene upon entering and upon leaving the patient care area.
  2. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission.
  3. All personnel caring for patients on Contact Precautions wear appropriate PPE for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.
  4. Donning appropriate PPE upon room entry and discarding PPE before exiting the patient room is done to contain pathogens.  It is important for personnel to practice excellent and consistent hand hygiene.
  5. The patient-contact surfaces in the room and clinician work areas/equipment are then disinfected using approved agents with friction action (may use 10% bleach solution = 1 part bleach and 9 parts water).  Personnel wear PPE when cleaning room, disposes of PPE appropriately, and washes hands thoroughly when done.   Once the room has been cleaned, it is available for patient use.

**For C. difficile and norvirus a 1:10 bleach solution should be used for cleaning surfaces and soap & water used for hand washing. For more information, see link to "C. diff and Norovirus Information" at end of policy.

Droplet Precautions

Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.  Droplet pathogen are carried by secretions such as saliva, sputum, nasal discharge, etc.  These droplets are “heavier” than airborne pathogens and they tend to land on surfaces, i.e., hands, tables, doorknobs, pencils, etc.  Always think ‘Contact Precautions’ when you think ‘Droplet Precautions.’

Indications for instituting Droplet Precautions include such infectious agents as:

Pertussis          Mumps            Diphtheria                  *Influenza, Rubeola (Measles), Varicella, COVID-19

Rubella            Meningitis                   SARS

1.      Healthcare personnel wear a surgical mask (a respirator is not necessary) for close contact with an infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of the room should wear a [regular] mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.

2.      If one of the above illnesses is diagnosed, the exam room is closed down for “Isolation” for 60 minutes following the patient discharge. After this time staff may enter room to disinfect surfaces and open room for re-use.

3.      Proactive Isolation" signage is placed on the exam room door.  (signs in drawers in both Nurses stations) . Staff member placing sign on door writes time room closed as well as the time it should be disinfected and reopened.

4.     In the event the illness is suspected Rubeola (measles), the room should be closed down for 2 hours before staff enter for cleaning.

 

Airborne Precautions

Airborne Precautions prevent transmission of infectious agents (viral and bacterial) that remain infectious over long distances when suspended in the air (e.g., rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS).  These pathogens are able to be suspended in the air for prolonged periods of time and travel easily on air currents.

Patients presenting to the clinic for treatment may exhibit signs and symptoms consistent with the following airborne transmitted pathogens:

Tuberculosis               * Rubeola (measles)                   *Varicella (chicken pox)       *Influenza

1.      The patient is given a surgical mask to be placed over his/her nose and mouth.  Staff wear the N-95 mask when indicated.

2.      Patients often have to remove their mask once they are in the exam room in order for the staff to provide care (thermometer, peak flow, etc.).  All personnel providing service to the patient will wear an N-95 mask while in the exam room until advised by the clinician that masking is no longer indicated.  If the staff member has immunity to the causative pathogen, it is not necessary for them to wear a mask. 

3.      Excellent hand hygiene is practiced when entering and leaving the patient’s room.

4.      The door is kept closed as much as possible.  "Proactive Isolation" signage is placed on the exam room door. Staff member placing sign on door writes time room closed as well as the time it should be disinfected and reopened.

5.      Whenever possible, non-immune personnel should not care for patients with vaccine-preventable airborne diseases (e.g., measles, chickenpox).

6.      All patient care rooms have an air exchange rate of 6 per hour with air exhausted directly vented to the outside.  Once the room has been vacated for 60 minutes, staff may enter to clean as is protocol. (signs in drawers in both Nurses stations) . Staff member placing sign on door also writes time room will be available.  In the event the illness is suspected Rubeola (measles), the room should be closed down for 2 hours before staff enter for cleaning.

7.  In the situation in which a patient has informed the office prior to arrival of symptoms suggestive of Airborne transmissible disease, the patient is instructed to:

  • Come to the Health Center's basement entrance and wait outside
  • Call the Health Center's main number 459-2211, ext. 5.  Inform the receptionist that they are waiting outside the basement entrance with a possible communicable disease.
  • The receptionist will instruct the student to wait outside for an escort.
  • The receptionist will contact the Charge Nurse to arrange for escort.
  • The patient will be masked with a regular mask (not an N-95 mask) and escorted directly to a patient care room
  • The escort will place the "Proactive Isolation" sign on the outside of the exam room door as a notice to other staff members.

*Many infectious agents can be transmitted via more than one mode.  For example, Influenza is primarily transmitted from person to person via large virus-laden droplets (particles more than 5 microns in diameter) that are generated when infected persons cough or sneeze. These large droplets can then settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are near (within 3 feet) infected persons. Transmission may also occur through direct contact or indirect contact with respiratory secretions such as when touching surfaces contaminated with influenza virus and then touching the eyes, nose or mouth.  (See CDC Epidemiology and Prevention of Vaccine-Preventable Diseases The Pink Book: Course Textbook - 12th Edition Second Printing, May 2012)

Key Points: 
  1. Since specific infection may not be diagnosed until patient has been roomed, examined and even tested, transmission based precautions are instituted as soon as possible upon entry into our system of patient care.
  • Patients with cough, especially with fever are provided with a mask as soon as they present to the registration and personnel are aware of a potentially infectious illness.  Healthcare personnel must evaluate the situation and protect themselves with an N-95 respirator if there is an indication of airborne illness.
  • Patients suspicious for airborne or droplet infection are masked and escorted directly to an exam room for isolation. The door is kept closed as much as possible.
  • Patients suspicious for contact transmission are escorted to an exam room and asked to sit on non-cloth chair or put directly on exam table.
  • After the patient is discharged and the appropriate room isolation time has elapsed, staff using standard precautions and PPE, decontaminate the room as per end of day cleaning guidelines. 

    2. Many viruses and bacteria have more than one route of transmission.

    • Respiratory viruses are known to be spread by person-to-person contact, the airborne route, and contaminated surfaces or fomites.  Enteric viruses are spread by the fecal-oral route via environmental and person-to-person contact.
    • Respiratory viruses spread faster, have a short incubation period (1-8 days) and greater infectivity (a lower dose of virus causes infection).  On the other hand, enteric viruses spread more slowly (water or food), have a longer incubation time (1-60 days), and require a higher viral dosage.
    • Person-to-person contact and environmental contamination are common routes of transmission for both types of viruses.  Consequently, interrupting disease spread via contaminated surfaces is one of the more practical methods for limiting or preventing enteric and respiratory viral infections. A majority of respiratory viruses survive on surfaces from hours to days. In contrast, most enteric viruses survive on fomites from weeks to months.