4.2: Transmission-Based Precautions & PPE

Transmission-Based Precautions & PPE

Introduction to Transmission-Based Precautions

While Standard Precautions are used for all residents, Transmission-Based Precautions (also known as Isolation Precautions) are implemented when a resident is known or suspected to be infected with highly transmissible pathogens. These precautions are dictated by the Centers for Disease Control and Prevention (CDC) and enforced by the Oregon Health Authority (OHA). The type of precaution depends on the pathogen's mode of transmission. There are three categories of Transmission-Based Precautions: Contact, Droplet, and Airborne. When these precautions are in place, a sign is posted on the resident's door to instruct staff and visitors on the required safety measures before entering. CNAs must strictly adhere to these instructions to prevent carrying pathogens to other residents or themselves.

Contact Precautions

Contact Precautions are used for pathogens that are spread by direct contact with the resident or indirect contact with contaminated objects and surfaces in the resident's room. Common infections requiring contact precautions include Methicillin-Resistant Staphylococcus aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE), scabies, lice, and Clostridium difficile (C. diff).

When caring for a resident on Contact Precautions, the CNA must:

• Wear gloves and a gown before entering the resident's room.
• Remove all PPE and perform hand hygiene immediately before exiting the room.
• Use dedicated resident-care equipment (such as a thermometer, stethoscope, and blood pressure cuff) that remains in the resident's room. If equipment must be shared, it must be thoroughly cleaned and disinfected according to facility protocols.
• Ensure the resident has a private room, or is cohorted (housed) with another resident who has the same infection.

Droplet Precautions

Droplet Precautions are implemented for pathogens transmitted by large respiratory droplets that are expelled when a person coughs, sneezes, laughs, or talks. These droplets are heavy and do not remain suspended in the air; they typically travel only 3 to 6 feet before falling to the ground. Diseases requiring droplet precautions include Influenza, Pertussis (whooping cough), Bacterial Meningitis, Mumps, and Streptococcal Pharyngitis (strep throat).

CNA responsibilities for Droplet Precautions include:

• Wearing a standard surgical mask upon entering the resident's room.
• Ensuring the resident wears a surgical mask if they must be transported outside of their room for essential medical procedures.
• Encouraging the resident to cover their mouth and nose with a tissue when coughing or sneezing, and disposing of the tissue immediately.

Airborne Precautions

Airborne Precautions are used for pathogens that are transmitted through very small, lightweight particles that remain suspended in the air for long periods and can be carried by air currents over long distances. The most common diseases requiring airborne precautions are Tuberculosis (TB), Measles (rubeola), and Chickenpox (varicella).

Special requirements for Airborne Precautions include:

• N95 Respirator or HEPA Mask: The CNA must wear a specialized respirator mask, which filters out at least 95% of airborne particles. Under Oregon OSHA (OR-OSHA) guidelines, all healthcare workers who wear N95 respirators must undergo annual fit-testing to ensure an airtight seal around the face.
• Negative Pressure Room: The resident must be placed in an Airborne Infection Isolation Room (AIIR). This room uses a specialized ventilation system that pulls air into the room and exhausts it directly outside or through high-efficiency particulate air (HEPA) filters, preventing contaminated air from escaping into the hallway.
• Closed Door: The door to the isolation room must remain closed at all times to maintain the negative pressure gradient.

Personal Protective Equipment (PPE) Guidelines

Personal Protective Equipment (PPE) is specialized clothing or equipment worn by healthcare workers to protect against infectious materials. It includes gowns, gloves, masks, goggles, and face shields. Under OSBN regulations and facility safety guidelines, the CNA must correctly select, apply, and remove PPE.

For the Oregon TMU/Headmaster skills exam, the sequence for putting on (donning) and removing (doffing) PPE is heavily graded. The candidate must demonstrate proper technique to avoid contamination.

Donning Sequence (Putting On PPE)

1. Hand Hygiene: Wash hands or use alcohol-based hand rub.
2. Gown: Open the gown and place arms through the sleeves. Pull the gown up and secure it at the neck. Pull the gown around the back to ensure full coverage of the uniform, then tie it securely at the waist.
3. Mask or Respirator: Secure ties or elastic bands at the middle of the head and neck. Fit the flexible band to the nose bridge and snug the mask to the face and below the chin.
4. Goggles or Face Shield: Place over the face and eyes, adjusting the headband for a secure fit.
5. Gloves: Pull the gloves on. The key step is to stretch the cuffs of the gloves over the cuffs of the gown's sleeves, leaving no skin exposed.

Doffing Sequence (Removing PPE)

The outside of the gloves and gown are considered contaminated, while the inside of the gown, gown ties, and the back of the mask/goggles are considered clean.

1. Gloves: Remove gloves first. Pinch the palm of one gloved hand and peel off the glove, turning it inside out. Hold the removed glove in the remaining gloved hand. Slide the fingers of the bare hand under the cuff of the remaining glove and peel it off inside out, creating a bag containing both gloves. Discard them in a waste container.
2. Gown: Unfasten the waist ties, then the neck ties. Reach inside the gown at the shoulders and pull the gown down and away from the body. Touch only the clean inside of the gown. Fold or roll the gown into a bundle with the contaminated outside facing inward, and discard it in the designated container.
3. Goggles/Face Shield: Remove from the back by lifting the headband, without touching the front of the goggles.
4. Mask: Untie or pull the bottom strap over the head, then the top strap, and discard. Do not touch the front of the mask.
5. Hand Hygiene: Wash hands immediately with soap and water.

Isolation Room Environmental Safety

Living in an isolation room can be psychologically challenging for residents. They may experience feelings of loneliness, depression, and stigmatization due to the limited contact with others and the sight of staff wearing protective gear. The CNA must provide emotional support by checking on the resident frequently, speaking in a warm and respectful tone, and ensuring they have access to activities, reading materials, and communication with family. When handling laundry or trash from an isolation room, follow facility policy. In some settings, double-bagging is required if the outside of the primary bag is contaminated or if the bag is leaking, ensuring a clean staff member outside the room receives the bag.