I. Isolation for patients with an EID or possible EID
A. Patients with an EID or a possible EID will be isolated using All Barrier Precautions (ABP).
B. All Barrier Precautions include Universal Precautions, Airborne and Contact Precautions.
C. All Barrier Precautions include the following:
1. Personal Protective Equipment (PPE)
a. N-95 Mask (fit tested)
b. Goggles
c. Gown
d. Gloves
2. All healthcare workers (HCWs) who may have contact with an EID patient must be fit tested for their N-95 mask.
3. For suctioning patients’ endotracheal tubes with a closed system suctioning device, a face shield will be added to the above ABP PPE.
4. Powered Air Purifying Respirators (PAPRs) will be worn when performing high risk procedures.
a. Endotracheal intubation
b. Endotracheal tube suctioning without using a closed system suctioning device
c. Bronchoscopy
d. Aerosolized medication treatments
5. All Barrier Precautions stickers will be placed on specimens or items that may be contaminated with the EID microorganism. These stickers will have the same color as All Barrier Precautions signs. The letters ABP will be printed on the stickers.
II. Procedures for using All Barrier Precautions.
A. All HCWs must don PPE prior to entering the isolation room
1. N-95 mask (fit tested)
2. Goggles
3. Disposable gown
4. Disposable gloves
B. Donning PPE
1. All rings, watches, bracelets, pagers, or any other personal items, should be removed prior to entering the room. Think ahead regarding where you want to place these items, whether it be in your pocket, locker, etc.
2. Place the N-95 mask on and fit check it for a good seal on your face.
3. Place goggles over your eyes and make sure they fit snuggly on your face.
4. Don the disposable gown and make sure that it is secured behind your neck and around your waste.
5. Don a pair of nonsterile, disposable clean gloves and pull them up over the cuffs of the sleeves on the gown. Check gloves for holes and replace non-intact gloves immediately.
C. Removing PPE
1. PPE must be removed in such a manner as to avoid touching the outside of the mask, goggles, gown and gloves, because the outside surfaces of these barriers may be contaminated with infectious secretions from EID patients.
2. Remove gloves without touching the outside of the gloves (this should be done slowly and carefully) and dispose of in regular trash.
3. Remove goggles carefully without touching the front of the goggles. The goggles will be disposed of in the regular trash.
4. Untie the strings and remove the gown so that the outside of the gown is now on the inside and dispose of in the regular trash.
5. Exit the room, wash your hands with an antiseptic soap or apply an alcohol hand gel and then remove the N-95 mask by carefully bringing the lower strap forward over the head, then grasp the upper strap with both hands on the sides of the face (without touching the mask itself) and bring the mask away from the face by holding the strap and discard the mask in the regular trash.
6. Again wash hands with an antiseptic (foam) soap and water or, alternatively, apply an alcohol hand gel.
7. Unlike tuberculosis, N-95 masks for EIDs will not be reused, because the outside of the mask may be contaminated.
8. At this time, watches, rings, bracelets, pagers, etc. may be replaced.
9. Do not touch face or eyes while wearing or removing PPE. This includes not inadvertently reaching up to adjust your goggles or mask.
10. Do not inadvertently touch surfaces in the patient’s room before exiting.
D. Disposition of trash and linen from isolation rooms.
1. Trash will be placed in a large trash can lined with a regular trash bag in the patient’s room. When the trash bag is full, it will be removed closed and secured at the top. Then at the door it will be double-bagged into another regular trash bag and placed in the dirty utility room.
2. Linen will be placed into a laundry bag in the patient’s room and then at the door, will be double-bagged into a color-coded bag and placed in the dirty utility room.
3. When trash or linen are being double-bagged, the person in the room holding the trash or linen bag will be wearing an N-95 mask, goggles, gown and gloves.
4. When trash or linen are being double-bagged, the person outside the room holding the bag to receive the trash or linen will wear an N95 mask, gown and gloves.
E. Pictorial demonstrations for the proper methods of removing PPE and double-bagging trash and linens can be viewed on the Department of Healthcare Epidemiology Web Site http://www.utmb.edu/hce or click on Healthcare Epidemiology under Clinical on the UTMB Home Page, followed by clicking on EID and then the Instructions for all Healthcare Providers. The procedures for donning and removing ABP equipment should be practiced so that the procedures will be “second nature” during response to an epidemic.
F. Protection of HCWs caring for EID patients on mechanical ventilation.
1. All ventilators are equipped with HEPA filters on the expiratory limb of the ventilator circuit.
2. All patients with an EID will be suctioned only with the closed suction catheter device.
3. For suctioning the endotracheal tube or oropharyngeal secretions, the HCW will wear, in addition to the N-95 mask, goggles, gown and gloves, a face shield covering the N-95 mask and goggles.
4. Since it may not be possible to determine whether the patient needs suctioning prior to entering the room, HCWs entering the room of a patient on mechanical ventilation must always don a face shield over their mask and goggles prior to entering the room.
5. Remove face shield (if worn) by pulling the strap over the head and carefully removing without touching the front of the face shield. Dispose of the face shield in the trash.
G. Protection for HCWs during endotracheal intubation and bronchoscopy will include a PAPR, gown and gloves. (See policy 3.8 Protection During the Conduct of High-Risk Respiratory Procedures in Patients with an Emerging Infectious Disease (EID).
III. Discontinuation of isolation for patients on All Barrier Precautions.
A. For SARS, patients will be isolated until 10 days after resolution of fever given that respiratory symptoms are absent or resolving. For avian influenza, patients will be isolated for 14 days after onset of symptoms. Patients who are immunosuppressed should be isolated for the duration of hospitalization (for both SARS and avian influenza).
B. Patients who are discharged from the hospital before they meet criteria for discontinuation of isolation will be moved through the hospital as any infectious patient with an EID.
1. Patients will be covered by a sheet and will wear a surgical mask whether transported by stretcher or wheelchair.
2. Patients will be moved through the designated EID route to minimize contact with other persons.
3. If the patient is moved by EMS, the ambulance crew will be notified ahead of time that the patient is still considered infectious.
4. The Galveston County Health District (GCHD) will be notified that a patient who is still infectious is being discharged. (See policy 3.10 Communication on Emerging Infectious Diseases (EIDs) between the Department of Healthcare Epidemiology and the Galveston County Health District).
IV. Adult patients with an EID or a possible EID will be hospitalized on 9D. This unit will be under negative pressure and will be equipped to provide care for all patients including those who require intensive care.
A. All patients with an EID will be initially admitted to 9D, regardless of level of care required.
B. The primary care providers for all EID patients will be faculty and fellows from the Division of Pulmonary and Critical Care Medicine.
C. When 9D has reached capacity and another patient with an EID or a possible EID is admitted, the patient will be placed in one of four isolation rooms on 9B. When these rooms have been filled, the next four patients with an EID or a possible EID will be placed in the four isolation rooms on 10B.
D. Carrying out isolation precautions for EID patients.
1. Wear PPE for All Barrier Precautions (ABP) as above.
2. Doors to all patient rooms must be kept closed except for entry or exit.
3. Doors between 9D and 9C will be kept closed except for entry or exit from 9D.
4. HCWs assigned to work with patients with an EID or a possible EID will work only with these patients.
5. Only HCWs who have been fit tested for their N-95 mask or who have been assigned a PAPR will be permitted to work with EID patients.
E. Movement of patient care devices and specimens used for monitoring and diagnosis in and/or out of patient rooms.
1. Reusable monitoring devices must be thoroughly cleaned and disinfected between uses on patients.
2. Personnel who hand devices to HCWs in patient rooms and take devices from HCWs in patient rooms must wear an N95 mask and gloves.
3. Devices should be checked and prepared for use prior to handing them into patient rooms.
4. When collecting laboratory specimens, the lids for specimen containers should be applied tightly and the containers should be decontaminated in the room using a hospital grade disinfectant and then placed in a specimen bag.
5. The specimen bag must be folded so that it will more easily fit into the second specimen bag held by an HCW outside the door.
6. After taking an item from an HCW in the room, the HCW outside the room must clean and disinfect the item. Then the HCW must remove their gloves and wash their hands or apply an alcohol hand gel, carefully remove their mask so as to avoid flipping or touching the outside of the mask, discard the mask and again wash their hands or apply an alcohol hand gel.
F. Adult patients with an EID who need intensive care will be admitted to 9D. Patients on 9D who do not need intensive care will be moved to other isolation rooms outside of 9D as more isolation beds are needed for patients who require intensive care.
1. The door to the room must be kept closed except for entry or exit.
2. Healthcare workers assigned to care for EID patients will care only for EID patients.
3. HCWs who have not been fit tested for their N-95 mask or assigned a PAPR will not be permitted to care for EID patients.
V. All pediatric patients with an EID will be admitted to a unit in Children’s Hospital. (See Policy 3.5 Emerging Infectious Diseases (EID) Protocol for Pediatric Patients)
A. Four South (4S) is the nursing unit where EID patients will be isolated.
1. Doors to rooms where patients are isolated must remain closed at all times except for entry or exit.
2. HCWs assigned to care for EID patients will care only for EID patients.
3. HCWs who have not been fit tested for their N-95 mask or assigned a PAPR, will not be permitted to care for EID patients.
B. Pediatric patients who need ICU care.
1. Patients who need ICU care will be admitted to one of the two isolation rooms with negative pressure in the PICU.
2. HCWs who are assigned to care for EID patients will care only for EID patients.
3. HCWs who have not been fit tested for their N-95 mask or assigned a PAPR will not be permitted to care for EID patients.
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