Emergency Department Isolation Precautions

Transcription

1 Carolinas HealthCare System Department of Infection Prevention I. SCOPE Emergency Department Isolation Precautions This policy applies to all Carolinas HealthCare System Emergency Department (ED) locations (including freestanding EDs) except for Behavioral Health Emergency Departments. II. PURPOSE The ED, in cooperation with the Infection Prevention Committee, will implement appropriate infection prevention measures to reduce the risk for infection in patients, visitors, and healthcare workers. All teammates are expected to follow Infection Prevention policies pertinent to their job description as outlined in the Infection Prevention Manual, CHS Safety Manual and Lippincott for Nursing including, but not limited to: III. POLICY Hand Hygiene Standard Precautions Isolation Precautions (see Appendix A Isolation Precautions Quick Reference, refer to policy for additional details) General Infection Prevention Practices Policy TB Prevention & Control Plan Bloodborne Pathogens/Exposure Control Plan A. Respiratory Hygiene/Cough Etiquette a. Patients that present with upper respiratory symptoms of infection (e.g. cough, flu-like illness, increased production of respiratory secretions) should be instructed to: i. Wear a surgical mask if tolerated ii. Cover the nose and mouth when coughing/sneezing iii. Use tissues to contain respiratory secretions and dispose of them in the nearest receptacle after use iv. Perform hand hygiene after having contact with respiratory secretions or contaminated objects B. Isolation Precautions for Specific Conditions and Organisms a. Every attempt should be made to identify patients that require isolation on arrival to the Emergency Department (at the start of the initial patient encounter). b. Isolation precautions may be initiated or discontinued (unless otherwise specified) by any physician, advanced care practitioner (ACP), Infection Preventionist, or registered nurse. c. The following table should be used to determine the type of precautions necessary for specific conditions and organisms. Contact Infection Prevention at your facility for questions. Written: 3/2017 Emergency Department Page 1 of 6

2 Condition/Organism Isolation Type Additional Comments Chickenpox (acute varicella) Airborne N95/PAPR PLUS Contact Susceptible persons should not enter room if other immune caregivers are available. Isolation required until all lesions are dry and crusted. C. difficile (suspected or confirmed) Contact Enteric Initiate precautions: When C. diff testing is ordered If patient is already on treatment for C. diff (e.g. flagyl, PO Vancomycin, fidaxomicin) Based on clinical symptoms (see Appendix B - Acute Diarrhea) CRE - Carbapenem Resistant Enterobacteriaceae Contact Includes patients with a history at any time or those with an active infection. Diarrhea (acute) (see Appendix B - Acute Diarrhea) Diarrhea defined as passage of > 3 unformed (loose/liquid/watery) stools in 24 or fewer consecutive hours Does not include infants < 1 year of age Fifth Disease (Parvovirus B19, Erythema infectiosum) Gastroenteritis (See C. difficile section above) Droplet Avoid assignment of pregnant HCW to patient with known parvovirus or suspected parvovirus (i.e. immunosuppressed or sickle cell patient presenting with aplastic anemia). Herpes Zoster (varicella-zoster, shingles) Susceptible persons should not enter room if other immune caregivers are available. Localized in patient with intact immune system with lesions: - that can be covered - that cannot be covered Localized in immunocompromised patient if disseminated is ruled out Disseminated* disease in any patient or Primary VZV-Chickenpox Standard Contact Contact Airborne N95/PAPR PLUS Contact Maintain precautions until all lesions are crusted. Maintain precautions until all lesions are crusted. Maintain precautions until all lesions are crusted. *Disseminated defined as appearance of lesions outside the primary or adjacent dermatomes (e.g. more than 2 dermatomes or respiratory/cns specimens) Lice - Head (pediculosis), Body, Pubic Contact Isolation required for 24 hours after effective therapy started. Written: 7/2017 Emergency Department Page 2 of 6

3 Condition/Organism Isolation Type Additional Comments Measles Rubeola, all presentations Susceptible persons should not enter room if other immune caregivers are available. Airborne N-95/PAPR Isolation required until 4 days after onset of rash in otherwise healthy individuals. Maintain precautions for duration of illness in immunocompromised patients. Rubella (German measles) Droplet Isolation required until 7 days after onset of rash. Meningitis (suspected bacterial meningitis) Droplet Isolation required for 24 hours after effective therapy started. Middle East Respiratory Syndrome (MERS) MRSA, infection or colonization (all sites) Methicillin Resistant Staphylococcus aureus Multi-drug Resistant Organisms Does NOT include CRE for this policy: Carbapenem-Resistant Enterobacteriaceae (see CRE) Airborne N95/PAPR PLUS Contact PLUS eye protection Standard Standard Page Infection Prevention at for details. See MERS Toolkit on PeopleConnect for details. Standard precautions included for patients physically in the ED but on inpatient hold. Examples include but not limited to: ESBL: Extended-Spectrum Beta Lactamase producing organisms VISA: Vancomycin-Intermediate Staphylococcus aureus VRSA: Vancomycin-Resistant Staphylococcus aureus Mumps Droplet Isolation required for 5 days after onset of swelling, consult physician. Norovirus (suspected or confirmed) Contact Enteric Add droplet precautions for Norovirus when active vomiting or cleaning vomitus. Pertussis (whooping cough, Bordetella pertussis) Droplet Isolation required until 5 days after patient is placed on effective therapy. Respiratory Viral Illnesses (febrile) e.g. suspected or confirmed Influenza SARS (Severe Acute Respiratory Syndrome) Droplet Airborne N-95/PAPR PLUS Contact If Influenza suspected, wear a fit tested N-95/respiratory or PAPR for aerosolizing procedures such as bronchoscopy or open suctioning. Isolation required for duration of illness. Physician order required to discontinue precautions. Written: 7/2017 Emergency Department Page 3 of 6

4 Condition/Organism Isolation Type Additional Comments Scabies Contact For typical/non-crusted scabies, isolation required for 24 hours after effective therapy started. For Norwegian/crusted scabies, keep patient on Contact Precautions until negative skin scraping or cleared by Infection Prevention/ID physician. Tuberculosis/TB (M. tuberculosis) suspected or confirmed Airborne N-95/PAPR Patients suspected of having TB can wear a surgical mask for source containment, if tolerated, and should be placed in an exam room, preferably an AIIR, as soon as possible. If this is not possible, having the patient wear a mask and segregate him/herself from other patients in the waiting area will reduce opportunities to expose others. Since the person(s) accompanying the patient also may be infectious, application of the same precautions may need to be extended to these persons if they are symptomatic. Refer to TB Control Plan for additional guidelines IV. REFERENCES Siegel JD., Rhinehart E., Jackson M., Chiarello L., and the Healthcare Infection Control Practices Advisory Committee. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. American Journal of Infection Control, 35 (10), Supplement 2, S 65 - S164. V. REVISION HISTORY Written: 7/2017 Written: 7/2017 Emergency Department Page 4 of 6

5 Appendix A Isolation Precautions Quick Reference (see Isolation Precautions Policy for additional details) Contact Droplet Airborne N-95/PAPR Room Assignment - Private room is preferred - Private room is preferred (does NOT require negative pressure) - Door may remain open - > 3 feet must be maintained between patients if not in a private room PPE for Teammates - Gloves & gown are required - Surgical masks upon entry (surgical masks for droplet precautions are one time use only) - For aerosolizing procedures (intubation/extubation, open tracheal suctions, bronchoscopy, and sputum induction) with suspected or confirmed influenza, N95/PAPR required Equipment/Room Cleaning Patient Transport Visitors - Routine room cleaning - Dedicate the use of non-critical patient care equipment to a single patient whenever possible (e.g. stethoscope, blood pressure cuff) - All reusable equipment including portable vital signs machines and nondisposable thermometers MUST be disinfected after each use - Assist the patient in performing hand hygiene prior to leaving room - Instruct visitors to perform hand hygiene upon entering and before leaving room - Encourage, offer, and educate visitors on the use of gloves and gown *See Appendix B for Contact Enteric Precautions (see TB Prevention & Control Plan) - Negative pressure required - Door must remain closed - At discharge: close room for 70 minutes before next patient (time may be less for rooms with more air exchanges, consult infection prevention) - N95/PAPR required upon entry for all teammates - Routine equipment & room cleaning - Routine equipment & room cleaning - While cleaning room, teammates (including EVS) must wear N95/PAPR even if patient is not in the room (and during the 70 minutes after discharge, cleaning of room can be performed during this time if N95/PAPR is worn) - Patient must wear a surgical mask when outside of room - Instruct visitors to perform hand hygiene upon entering and before leaving room - Provide and encourage use of surgical mask for visitors when entering the patient room (instruct visitors to place the mask securely over the nose and mouth) - Patient must wear a surgical mask when outside of room - Instruct visitors to perform hand hygiene upon entering and before leaving room - Visitation is discouraged but provide and encourage use of an N95 mask for visitors when entering the patient room (fit testing is not required for visitors) Written: 7/2017 Emergency Department Page 5 of 6

6 Appendix B Acute Diarrhea (Does not include infants < 1 year of age) Isolation Criteria Initiate Contact Enteric Precautions if patient meets the following criteria: > 3 episodes of loose/liquid/watery stool within the past 24hrs with unknown cause (or a significant increase in baseline diarrhea) AND one of the following Fever > o F in the last 48 hours (if known) Received any antibiotic within the last 60 days (if known) History of C. diff (if reported by the patient or noted in medical record) Transferred from other facility, nursing home, LTC/Assisted Living, Group Home, or Jail WBC count > 12,000 within the last 24 hours (if available, do not perform additional blood work to obtain for this purpose) Contact Enteric Precautions (refer to Infection Prevention policy, Isolation Precautions, for additional details) Hand Hygiene PPE Room Assignment Bathroom Patient Equipment Room Cleaning Handwashing must be performed using SOAP & WATER for at least seconds upon room exit and between glove changes while caring for the patient. Gloves and gown should be worn when caring for the patient or touching equipment in the patient room/bay. Private room is preferred Dedicated bedside commode preferred. If the patient uses a shared bathroom, it is recommended to clean the high touch surfaces (including toilet seat & handle) with a bleach wipe or sporicidal disinfectant after each use. Dedicate the use of non-critical patient care equipment to a single patient whenever possible (e.g. stethoscope, blood pressure cuff). For patients requiring RECTAL temperatures a dedicated, disposable (single patient use) thermometer is required. All reusable equipment including portable vital signs machines and non-disposable thermometers MUST be disinfected with a bleach wipe or sporicidal disinfectant prior to use on another patient. Non-EVS Teammates: bleach wipe or other sporicidal disinfectant EVS: EPA approved hospital sporicidal disinfectant Written: 7/2017 Emergency Department Page 6 of 6