5.2 Transmission-Based Precautions and PPE

Transmission-Based Precautions and PPE

Quick Answer: Three layers of Transmission-Based Precautions sit on top of Standard Precautions: Contact (gown + gloves), Droplet (surgical mask within 3-6 ft), and Airborne (fit-tested N95 + negative-pressure room). The CDC PPE sequence is gown -> mask -> goggles -> gloves to put on, and gloves -> goggles -> gown -> mask -> hand hygiene to take off.

When You Need More Than Standard Precautions

The CDC's 2007 Guideline for Isolation Precautions defines three categories that are added when a resident is known or suspected to have a transmissible infection. The nurse will post a colored sign on the door identifying the precaution category.

Contact Precautions (Yellow / Brown Sign)

Used for organisms spread by direct touch (skin-to-skin) or indirect touch (contaminated bed rails, BP cuff, stethoscope, call light, etc.).

Diseases requiring Contact Precautions:

• MRSA (methicillin-resistant Staphylococcus aureus)
• VRE (vancomycin-resistant Enterococcus)
• C. difficile
• Scabies and lice (until 24 hours after treatment)
• RSV (respiratory syncytial virus) in young children
• Norovirus, E. coli O157:H7, Shigella, hepatitis A
• Open wounds with copious uncontained drainage

CNA actions:

1. Private room (or cohort with same-organism residents).
2. Don gown and gloves before entering. Many facilities require these even for brief social contact.
3. Dedicate equipment (BP cuff, thermometer, stethoscope) to the room.
4. Remove gown and gloves inside the room before leaving and perform hand hygiene immediately.
5. For C. diff and norovirus, use soap and water for hand hygiene (alcohol rub will not kill spores).

Droplet Precautions (Pink / Green Sign)

Large respiratory droplets (>5 microns) travel only 3-6 feet before settling. They do not stay airborne on currents, so a regular surgical mask is sufficient.

Diseases requiring Droplet Precautions:

• Influenza
• Pertussis (whooping cough)
• Mumps
• Rubella
• Meningococcal disease (Neisseria meningitidis)
• Group A Streptococcus (pharyngitis, scarlet fever) until 24 hours of antibiotics

CNA actions:

1. Private room (or 3+ feet separation between cohort beds with a curtain).
2. Don a surgical mask before entering, or whenever within 3-6 ft of the resident.
3. Mask the RESIDENT with a surgical mask whenever they leave the room (transport to dialysis, X-ray, etc.).
4. Limit movement of the resident outside the room.

Airborne Precautions (Blue Sign)

Small droplet nuclei (<5 microns) and aerosols can drift on air currents and stay suspended for hours - a surgical mask is NOT enough.

Diseases requiring Airborne Precautions:

• Tuberculosis (M. tuberculosis)
• Measles (rubeola)
• Varicella (chickenpox) and disseminated zoster (shingles)
• SARS-CoV-2 (COVID-19) during aerosol-generating procedures such as intubation, bronchoscopy, or nebulizer treatments

CNA actions:

1. Airborne Infection Isolation Room (AIIR) - negative pressure, 6-12 air changes per hour, air exhausted outside or HEPA filtered, door kept closed.
2. Wear a fit-tested N95 respirator (or higher, such as a PAPR) - NOT a surgical mask.
3. Per OSHA's Respiratory Protection Standard (29 CFR 1910.134), an N95 must be fit-tested at hire and annually thereafter, plus whenever weight, facial structure, or dentition change. CNAs who have not been fit-tested cannot rely on an N95 for protection.
4. If the resident must leave the room, place a surgical mask on the resident and notify the receiving department in advance.
5. For measles or varicella, ideally only immune (vaccinated) staff should enter.

Combined Precautions

Some diseases require more than one category. For example, chickenpox requires both Airborne and Contact, and SARS-CoV-2 during aerosol-generating procedures requires Airborne + Contact + Eye Protection. Always read the door sign rather than relying on memory.

PPE Donning Sequence (Putting On)

The CDC's PPE sequence (which OBRA also expects on the NNAAP skills test) is:

PPE Doffing Sequence (Taking Off)

Doffing is where most self-contamination happens. The CDC sequence assumes the gown and gloves are the most contaminated items.

Memory aid: "GGGG-H" to doff - Gloves, Goggles, Gown, mask (Goes off last with one hand on each strap), Hand hygiene.

Disposal

Single-use PPE is disposed of inside the resident's room in a lined trash can or, when contaminated with blood or OPIM, in a biohazard bag. Reusable eye protection is cleaned and disinfected per facility protocol. Never wear PPE out of the room into the hallway.