Section 4.2: Transmission-Based Precautions & PPE Sequence

Section 4.2: Transmission-Based Precautions & PPE Sequence

Understanding Transmission-Based Precautions

Standard Precautions apply to all residents, but Transmission-Based Precautions are used in addition for residents known or suspected to be infected or colonized with highly transmissible pathogens. These precautions are categorized by the route of transmission: contact, droplet, and airborne. In Iowa, nursing facilities are regulated under Iowa Administrative Code (IAC) 481 Chapter 58, which requires facilities to implement isolation protocols to control infectious disease outbreaks (such as influenza, norovirus, or COVID-19). CNAs must understand the specific requirements of each category and follow them meticulously to prevent cross-contamination.

Contact Precautions

Contact Precautions are used for pathogens spread by direct or indirect contact with the resident or their environment.

• Clinical Indications: Used for infections such as Clostridioides difficile (C. diff), Methicillin-resistant Staphylococcus aureus (MRSA) wound infections, Vancomycin-resistant Enterococcus (VRE), and scabies.
• PPE Requirements: A gown and gloves are required upon entering the resident's room. CNAs must put these on before entering and discard them before exiting.
• Room Assignment: A private room is preferred. Residents may be cohorted with another resident who has the same infection if private rooms are unavailable.
• Equipment: Dedicated resident-care equipment (such as blood pressure cuffs, stethoscopes, and thermometers) must remain in the room and be disinfected before being used on other residents.

Droplet Precautions

Droplet Precautions are used for pathogens spread through large respiratory droplets generated by coughing, sneezing, or talking. These droplets travel only 3 to 6 feet before falling.

• Clinical Indications: Used for influenza, pertussis (whooping cough), mumps, and bacterial meningitis.
• PPE Requirements: A surgical mask is required when entering the room or working within 6 feet of the resident. Gloves and gowns should be worn if contact with respiratory secretions is expected.
• Resident Movement: The resident should remain in their room. If transport is necessary, the resident must wear a surgical mask.
• Droplet Dynamics: Unlike airborne particles, droplets are heavy and do not remain suspended in the air. They settle onto environmental surfaces quickly, meaning specialized air handling is not required.

Airborne Precautions

Airborne Precautions are used for pathogens that remain infectious over long distances when suspended in the air.

• Clinical Indications: Used for active Tuberculosis (TB), measles (rubeola), and varicella (chickenpox).
• PPE Requirements: An N95 respirator is required for all healthcare workers entering the room. CNAs must be fit-tested annually to ensure the N95 forms an airtight seal.
• Room Assignment: The resident must be placed in an Airborne Infection Isolation Room (AIIR). This is a private room with negative air pressure that prevents air from escaping. The door must remain closed.
• Resident Movement: The resident should not leave the room unless medically necessary. If transport is required, the resident must wear a surgical mask.

The Sequence for Donning PPE

Putting on Personal Protective Equipment (PPE) in the correct sequence reduces the risk of contaminating clean garments. The CDC-recommended donning sequence is:

1. Gown: Cover the torso from neck to knees and arms to wrists. Fasten the gown securely at the back of the neck and waist.
2. Mask or Respirator: Secure ties or bands. Fit the flexible band to the nose bridge and snug the mask below your chin. For N95, perform a fit check.
3. Goggles or Face Shield: Place over the eyes or face and adjust.
4. Gloves: Pull gloves on, extending them to cover the wrists of the gown. Ensure no skin is exposed.

The Sequence for Doffing PPE

Removing PPE in the correct sequence is critical because the outside of the PPE is contaminated. The CDC-recommended doffing sequence is:

1. Gloves: Grasp the outside of one glove with the opposite gloved hand and peel it off, turning it inside out. Hold the removed glove in the remaining gloved hand. Slide a finger of the ungloved hand under the remaining glove at the wrist, and peel it off over the first glove. Discard them.
2. Goggles or Face Shield: Remove from the back by lifting the headband or ear pieces. Do not touch the front.
3. Gown: Unfasten ties. Pull the gown away from neck and shoulders, touching only the inside. Fold or roll the gown into a bundle with the contaminated outside facing inward, and discard.
4. Mask or Respirator: Lift the bottom strap, then the top strap, and remove without touching the front. Note: If removing an N95 respirator, you must step outside the room and close the door before removing it to avoid inhaling airborne pathogens.
5. Hand Hygiene: Perform hand hygiene immediately after removing all PPE.

State Licensing and Outbreak Protocols

Under IAC 481 Chapter 58, Iowa nursing facilities must have a designated infection control coordinator and clear policies for isolation and cohorting. During a state survey, DIAL inspectors observe CNAs to verify they follow correct PPE sequences and do not cross-contaminate clean areas. Failure to follow isolation procedures can result in a state citation, indicating jeopardy to resident health.

Realistic Exam Traps and Tips

• N95 Removal: The N95 respirator must be removed outside the resident's room after closing the door. Other PPE (gloves, gown, goggles) is removed inside the room before exiting.
• Gloves Order: Gloves go on last during donning and come off first during doffing.
• Contamination: Never touch the front of the mask, gown, or goggles during doffing.