Transmission-Based Precautions and PPE

Standard precautions cover everyone. Some infections need more. Transmission-based precautions are the extra steps used when a person has, or may have, an infection that spreads by touch, droplets or the air. They are based on the Centers for Disease Control and Prevention (CDC) isolation guideline. Getting them wrong can spread the infection to other patients, to your family and to you.

What You Will Be Able to Do

• Tell the difference between contact, droplet and airborne spread.
• Choose the personal protective equipment (PPE) each kind of precaution calls for.
• Explain why an N95 respirator needs a fit test.
• Put on and take off PPE in the correct order.
• Handle equipment and waste around a person on precautions.

The Three Kinds of Precautions

Some germs need more than one type, so read the sign on the door or the care plan each time. Follow your facility's current policy for illnesses such as COVID-19, because it may call for several kinds of protection at once.

Contact Precautions

• Put on a gown and gloves before you enter the room, even if you do not plan to touch the patient. The room itself can be contaminated.
• Use equipment that stays in the room, or clean and disinfect it before it leaves.
• For C. difficile, clean your hands with soap and water after care, and clean surfaces with a product that kills spores.
• Limit moving the patient out of the room, and cover any wound.

Droplet Precautions

• Put on a surgical mask when you enter the room.
• Add eye protection if you could be sprayed.
• Give the patient a surgical mask when they leave the room.

Airborne Precautions

• Wear a fit-tested N95 or higher respirator before you enter.
• The patient stays in an airborne infection isolation room, a negative-pressure room that keeps the air from leaking out. Keep the door closed.
• Give the patient a surgical mask if they have to leave the room.
• Workers who are not immune to measles or chickenpox should not enter if someone else can.

In a home, where no special room exists, the nurse will give you instructions. You may be told to keep doors closed, open windows or limit visits.

Enhanced Barrier Precautions

In nursing homes, the CDC recommends enhanced barrier precautions for residents who have wounds, medical devices or certain drug-resistant germs. You wear a gown and gloves during high-contact care, such as bathing, dressing, helping with the toilet and wound or device care. The resident does not need to stay in their room.

N95 Respirators and Fit Testing

An N95 filters at least 95 percent of tiny airborne particles, but only if it seals to your face. A surgical mask does not seal, so it does not protect against airborne germs. Under OSHA's respiratory protection standard, you need a medical evaluation and a fit test before you use a respirator at work, and you must repeat the fit test every year. The test checks that the mask forms a tight seal against your face. Facial hair where the mask seals is not allowed. Do a seal check every time you put one on.

Putting On PPE

Before you begin, clean your hands and gather everything you need. Follow this order:

1. Gown. Cover your body from neck to knees and arms to wrists, and tie it in the back.
2. Mask or respirator. Fit the nose piece and do a seal check if you are using a respirator.
3. Goggles or face shield.
4. Gloves. Pull them over the gown cuffs. Gloves go on last.

Taking Off PPE

The outside of your PPE is contaminated. Most self-contamination happens during removal, so go slowly. The CDC sequence is:

1. Gloves. Peel the first off inside out, hold it in the other hand, then slide a bare finger under the second cuff to remove it.
2. Goggles or face shield. Take them off from the back by lifting the band or earpieces.
3. Gown. Untie it, pull it away from your neck and shoulders, touching only the inside, turn it inside out and roll it up.
4. Mask or respirator. Touch only the ties or straps, and do not touch the front.
5. Clean your hands right away.

Take off PPE at the doorway or inside the room before you leave. A respirator comes off after you leave the room and close the door. If your hands get contaminated at any step, stop and clean them. Some employers train workers to remove the gown and gloves together, so follow your own procedure.

Warning: Never reuse a disposable gown, and never leave used PPE on furniture or the floor. It is contaminated and can spread germs to anyone who touches it.

Keeping the Room Safe

• Dedicate items such as blood pressure cuffs and thermometers to one patient when you can.
• Clean and disinfect any shared equipment before it goes to another person.
• Put linens directly in the bag at the bedside, without shaking them.
• Explain the precautions to visitors, and tell the nurse if they refuse to follow them.
• Isolation is hard for patients. Keep visits friendly, and do not avoid the room.

Common Mistakes

Check Your Understanding

1. A patient with MRSA has a sign on the door. You are only dropping off a meal tray. What do you do?

Put on a gown and gloves before you enter, even though you do not expect to touch the patient. Take them off before you leave, and clean your hands.

2. You are bringing a lunch tray to a resident with a droplet sign on the door. What must you have on when you enter?

A surgical mask when you enter the room.

3. Your new patient has suspected tuberculosis, and you have a surgical mask handy. Can you use it?

No. Airborne precautions need a fit-tested N95 or higher respirator.

4. You have on a gown, mask, goggles and gloves. What is the removal order?

Gloves, goggles, gown and mask, then clean your hands.

Key Takeaways

• Contact means gown and gloves, droplet means a surgical mask, and airborne means a fit-tested respirator.
• Read the sign or the care plan every time.
• Gloves go on last and come off first.
• Fit testing confirms the respirator seals to your face, and it must be done yearly.
• Finish by cleaning your hands, right away.