3.2 Transmission-Based Precautions (Contact, Droplet, Airborne)
Key Takeaways
Transmission-based precautions are used IN ADDITION to standard precautions, never as a replacement
Contact precautions (gown and gloves) are used for MRSA, VRE, C. diff, RSV, and skin infections - remember MRS. WEE
Droplet precautions (a mask on entering the room; eye protection only as Standard Precautions require) are for pathogens spread by large respiratory droplets, traditionally >5 microns - remember SPIDERMAN, but check each organism
Airborne precautions (N95 respirator, negative pressure room) are for pathogens spread by droplet nuclei <5 microns - remember MTV
Patients on airborne precautions must be in an Airborne Infection Isolation Room (AIIR) with negative pressure
Transmission-Based Precautions
When standard precautions alone are insufficient, transmission-based precautions provide additional protection. These are used for patients with documented or suspected infections spread by specific routes.
Key Principle
Transmission-based precautions are used IN ADDITION TO standard precautions, never as a replacement. A patient on contact precautions still requires hand hygiene, PPE selection based on task, and all other standard precaution elements.
The Three Categories
| Category | Transmission Route | Key PPE | Room Requirement |
|---|---|---|---|
| Contact | Direct/indirect touch | Gown + Gloves | Private room or cohort |
| Droplet | Large respiratory droplets (>5 microns) | Mask on room entry | Private room, door may remain open |
| Airborne | Droplet nuclei (<5 microns) | N95 respirator | Negative pressure AIIR, door closed |
Contact Precautions
Contact precautions prevent transmission of organisms spread through direct contact with the patient or indirect contact with contaminated surfaces.
When to Use
Use the mnemonic MRS. WEE to remember contact precaution pathogens:
| Letter | Pathogen |
|---|---|
| M | Multidrug-resistant organisms (MRSA, VRE) |
| R | Respiratory infection (RSV) |
| S | Skin infections (Impetigo, Scabies, Lice; Herpes Simplex when neonatal or severe/disseminated mucocutaneous) |
| W | Wound infections (draining, not contained) |
| E | Enteric infections (C. difficile, Rotavirus; Hepatitis A only in diapered or incontinent patients) |
| E | Eye infections (Conjunctivitis/Pink eye) |
Required PPE and Environment
- Gown and gloves upon room entry
- Private room or cohort with patient with same organism
- Dedicated equipment (stethoscope, BP cuff) left in room
- Hand hygiene immediately after removing PPE
Critical Points
- Remove gown and gloves BEFORE leaving the room
- For C. diff: use soap and water for hand hygiene (spores!)
- Equipment that must leave the room must be disinfected
Droplet Precautions
Droplet precautions prevent transmission of organisms spread through large respiratory droplets (>5 microns) that travel short distances (historically defined as 3 feet or less, although some have reached 6 feet or more).
When to Use
Use the mnemonic SPIDERMAN to remember droplet precaution pathogens:
| Letter | Pathogen |
|---|---|
| S | Sepsis (meningococcal), Scarlet fever and Streptococcal pharyngitis (group A, in infants and young children) |
| P | Pertussis (whooping cough), Pneumonia (only certain agents, such as adenovirus, H. influenzae type b in children, meningococcus, Mycoplasma) |
| I | Influenza |
| D | Diphtheria (pharyngeal) |
| E | Epiglottitis |
| R | Rubella (German measles) |
| M | Mumps, Meningitis (H. influenzae type b or N. meningitidis, until 24 hours of effective therapy) |
| A | Adenovirus |
| N | Rhinovirus (common cold) |
Exam Tip: Rubella (German measles) is DROPLET. Rubeola (regular measles) is AIRBORNE. This distinction is frequently tested!
Required PPE and Environment
- Mask upon entry into the patient's room (3 feet is only an example of "close", not the rule for when to mask)
- Eye protection if splash/spray risk
- Private room preferred; door may remain open
- Patient wears surgical mask during transport
Key Difference from Airborne
Droplets are large and heavy - they travel only short distances before falling. They do NOT remain suspended in the air. A regular surgical mask provides adequate protection because the particles cannot be inhaled from distance.
Airborne Precautions
Airborne precautions prevent transmission of organisms spread through droplet nuclei (<5 microns) that remain suspended in the air and can travel long distances through air currents.
When to Use
Use the mnemonic MTV to remember airborne precaution pathogens:
| Letter | Pathogen |
|---|---|
| M | Measles (Rubeola) |
| T | Tuberculosis (TB) |
| V | Varicella (Chickenpox) and disseminated Herpes Zoster (Shingles) |
Required PPE and Environment
- N95 respirator (must be fit-tested) or PAPR
- Airborne Infection Isolation Room (AIIR) with:
- Negative pressure (air flows INTO the room)
- Minimum 6-12 air changes per hour
- Direct exhaust to outside or HEPA filtration
- Door must remain CLOSED
- Patient wears surgical mask during transport (not N95)
N95 Respirator Requirements
- Must be fit-tested annually for each user
- Requires seal check with each use
- Higher level of filtration than surgical mask
- Filters 95% of airborne particles
Room Assignment and Cohorting
| Precaution Type | Room Requirements | Cohorting |
|---|---|---|
| Contact | Private or cohort | Yes, with same organism |
| Droplet | Private preferred | Yes, with same organism |
| Airborne | AIIR (negative pressure) | No - single patient only |
Combining Precautions
Some patients require multiple precaution types:
| Condition | Precautions Required |
|---|---|
| Chickenpox (Varicella) | Airborne + Contact (vesicles contain virus) |
| Disseminated Shingles | Airborne + Contact |
| Extrapulmonary TB with a draining lesion | Airborne + Contact (pulmonary or laryngeal TB, drug-resistant or not, is Airborne) |
Transport of Patients on Isolation
| Precaution Type | Patient Requirements |
|---|---|
| Contact | Cover infected areas; staff maintain precautions |
| Droplet | Patient wears surgical mask |
| Airborne | Patient wears surgical mask (NOT N95); notify receiving department |
On the NCLEX
Common testing points include:
- Matching pathogens to correct precaution type
- Distinguishing between Rubella (droplet) and Rubeola (airborne)
- Understanding N95 vs surgical mask requirements
- Knowing that airborne requires negative pressure rooms
- Recognizing when to use soap and water vs. alcohol-based hand rub
A patient is diagnosed with active pulmonary tuberculosis (TB). Which type of isolation precautions should the nurse implement?
Contact precautions with gown and gloves
Droplet precautions with surgical mask
Airborne precautions with N95 respirator in a negative pressure room
Standard precautions only
Which mnemonic helps the nurse remember pathogens requiring DROPLET precautions?
MRS. WEE
SPIDERMAN
MTV
RACE
A nurse is assigned to care for a patient with Rubella (German measles) and a patient with Rubeola (measles). Which statement about isolation precautions is correct?
Both patients require airborne precautions
Both patients require droplet precautions
Rubella requires droplet precautions; Rubeola requires airborne precautions
Rubella requires airborne precautions; Rubeola requires droplet precautions
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