Standard &

Transmission-Based
Precautions

Basics of Infection
Prevention
2-Day Course
April 2019
Objectives
• Discuss hierarchy of infection control measures

• Discuss standard, enhanced and transmission-

based isolation precautions

• Discuss goal and appropriate use of personal

protective equipment

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There are two tiers of HICPAC/CDC
precautions to prevent transmission of
infectious agents

• Standard Precautions
• Transmission-Based Precautions

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 Hierarchy of Controls (with examples)
• Eliminate exposure being able to
result in disease
• Immunize HCWs against vaccine-
Elimination of Potential
preventable diseases Exposures
• Reduce/eliminate
source
exposure at the
Engineering Controls
• Airborne isolation rooms
• HEPA filter
• Rules are only as good as Administrative
enforcement Controls
• Policies/Procedures, Mandates
• Wear mask if not vaccinated PPE
against influenza
• Staff do not work when ill
• Least effective; depend upon
individual compliance
• Donning PPE
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Standard Precautions
• Basic practices that apply to all patient care,
regardless of a patient’s suspected or confirmed
infectious state

• Apply to all settings where care is delivered

• Protect healthcare personnel and prevent healthcare

personnel or the environment from transmitting
infections to other patients

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What is the Standard Precautions?
1. Hand Hygiene
2. Environmental cleaning and disinfection
3. Injection and medication safety
4. Personal protective equipment (e.g., gloves, gowns,
face masks)
5. Respiratory hygiene and cough etiquette
6. Reprocessing of reusable medical equipment
Core Infection Prevention and Control Practice-CDC HICPAC, 2016
https://www.cdc.gov/hicpac/pdf/core-practices.pdf 5
 1. Hand hygiene
Impact of Hand Hygiene on HAIs
• 722,000 patients acquire HAI every year1
– 75,000 die as a direct result
Image from ThinkStock

• Most common mode of transmission is via hands of

HCP2
• Studies show that some healthcare personnel (HCP)
perform hand hygiene less than half the times they
should2
1.http://www.cdc.gov/hai/surveillance/index.html
2.http://www.cdc.gov/features/handhygiene
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 Hand Hygiene (2)
• Unless hands are visibly soiled, an alcohol-
based hand rub is preferred over soap and
water in most clinical situations due to
evidence of better compliance compared to
soap and water.
• Hand rubs are generally less irritating to
hands and are effective in the absence of a
sink.

“CDC Guideline for Hand Hygiene in Health-Care Settings” or “Guideline for Isolation
Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007”

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Hand Hygiene (3) - Reasons for Poor Adherence
• Both individual and system factors contribute to poor
adherence with hand hygiene
– Lack of knowledge/value of handwashing
– Increased demands with less time
– Irritated and/or dry hands
– Shortage of soap, paper towels, and/or sinks
– Forgetfulness / “patient needs come first”
– Belief that wearing gloves avoided need for handwashing
– No consequences for not performing hand hygiene
1.Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386

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 Hand Hygiene (4) - Definition of Terms
• Hand hygiene:
– Performing hand washing, antiseptic hand wash, alcohol-
based hand rub, or surgical hand antisepsis
• Handwashing:
– Washing hands with water and plain soap
• Antiseptic hand wash:
– Washing hands with water and soap containing an antiseptic
agent (i.e. alcohols, chlorhexidine, iodine, triclosan1)
• Alcohol-based hand rub:
– Rubbing hands with alcohol-containing solution (60-95%)
1.http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm517478.htm

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 Hand Hygiene (5) - Techniques
• Alcohol-based rub:
1. Apply product (per manufacturer’s recommendation)
2. Rub all surfaces together until dry (15-20 seconds)
• Soap and water:
1. Wet hands with water
2. Apply product (per manufacturer’s recommendation)
3. Rub all surfaces together vigorously (at least 15 seconds)
4. Rinse hands until no product remains
5. Dry hands with disposable towel (use to turn off faucet)
1.Widmer, A. F., Dangel, M., & RN. (2007). Introducing alcohol-based hand rub for hand hygiene: the critical need for training. Infection
Control and Hospital Epidemiology, 28(1), 50-54.
2.Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

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Indications for Appropriate Hand Hygiene (I)
• Using soap and water:
– Hands visibly soiled or contaminated
– Before eating
– After using the bathroom
– Exposed to spore-forming bacteria (i.e. CDI), certain
non-enveloped viruses (i.e. norovirus), protozoan
oocysts, and prions.

1.Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Image from ThinkStock 11

 Indications for Appropriate Hand Hygiene (II)
WHO 5 Moments for Hand Hygiene
• Using alcohol-based hand rub:
– Before and after patient care
– Before donning sterile gloves
– Before inserting invasive devices
– After contact with patient’s skin (intact and non-intact),
body fluids, and wound dressings
– After removing gloves
– After contact with close objects/equipment
– Moving from contaminated to clean site on same patient

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

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WHO Hand Hygiene • CDC Hand Hygiene
Educational Material

https://www.cdc.gov/handhygiene/campaign/promoti
onal.html
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 Skin and Nail Care

• Provide HCP with hand lotions or creams to minimize

dryness/irritation
• Select products that do not decrease efficacy of alcohol-
based hand rub or antimicrobial soaps
• No:
– personal lotions/creams
– artificial nails in clinical areas

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 Hand Hygiene - Dispenser Location
• Must strategize placement for convenience and to
improve compliance
• Use National Fire Protection Association Life Safety
Code for safe placement of dispensers
– Check with local authorities for restrictions

Image from ThinkStock 15

 2. Environmental cleaning and disinfection
• Require routine and targeted cleaning of environmental
surfaces as indicated by the level of patient contact and degree
of soiling.
– Clean and disinfect surfaces in close proximity to the patient
and frequently touched surfaces in the patient care
environment
• Cleaning- removal of visible soil and organic contamination using
the physical action of scrubbing
• Disinfect- use of a chemical procedures that eliminates virtually all
recognized pathogenic microorganisms except certain spore
forming bacteria (e.g., C. Diff)

– Promptly clean and decontaminate spills of blood or other

potentially infectious materials.
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 2. Environmental cleaning and disinfection (2)
• Select EPA-registered disinfectants that have microbiocidal
activity against the pathogens most likely to contaminate the
patient-care environment.
• Certain pathogens (e.g., rotavirus, noroviruses, C. difficile) may
be resistant to some routinely used hospital disinfectants-
recommend 1:10 dilution of 5.25% sodium hypochlorite
(household bleach) and water
• Follow manufacturers’ instructions for proper use of cleaning
and disinfecting products (e.g., dilution, contact time, material
compatibility, storage, shelf-life, safe use and disposal).
• Check for contact time (wet time) on the disinfectant bottle.
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 3. Injection and Medication Safety

• Use aseptic technique when preparing and administering

medications
• Disinfect the access diaphragms of medication vials before
inserting a device into the vial
• Use needles and syringes for one patient only (this includes
manufactured prefilled syringes and cartridge devices such as
insulin pens).
• Enter medication containers with a new needle and a new
syringe, even when obtaining additional doses for the same
patient.

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 3. Injection and Medication Safety (2)

• Ensure single-dose or single-use vials, ampules, and bags or

bottles of parenteral solution are used for one patient only.
• Use fluid infusion or administration sets (e.g., intravenous
tubing) for one patient only
• Dedicate multidose vials to a single patient whenever possible.
If multidose vials are used for more than one patient, restrict
the medication vials to a centralized medication area and do
not bring them into the immediate patient treatment area
(e.g., patient room)

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4. Use of Personal Protective Equipment (PPE)
• Proper selection and use of PPE based on
– the nature of the patient interaction
– potential for exposure to blood, body fluids and/or
infectious material
• PPE can be effective barriers to transmission of
infections but are secondary to the more effective
measures such as administrative and engineering
controls.
• PPE are regulated by OSHA, CMS, TJC

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 Personal Protective Equipment

Goal: Improve personnel safety in the healthcare

environment through appropriate use of PPE.
• Types of PPE
Gloves
Gowns
Face masks and respirators
Goggles and face shields

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 PPE- Gloves
• Wear gloves when it can be reasonably anticipated
that contact with
• blood or other potentially infectious materials
• mucous membranes
• non-intact skin
• potentially contaminated skin or
• Potentially contaminated equipment
• Change gloves during patient care if the hands will
move from a contaminated body-site (e.g., perineal
area) to a clean body-site (e.g., face).
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 PPE- Gowns
• Wear a gown during procedures and activities that
could cause contact with blood, body fluids,
secretions, or excretions.
– Appropriate to the task
– To protect skin
– To prevent soiling of clothing
• Do not use the same gown or pair of gloves for care
of more than one patient.

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 PPE- Masks and Protective Shields
• Use protective eyewear and a mask, or a face shield
– to protect the mucous membranes of the eyes, nose
and mouth
– during procedures and activities that could generate
splashes or sprays of blood, body fluids, secretions and
excretions.
• Select masks, goggles, face shields, and combinations of
each according to the need anticipated by the task
performed.

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 How to Safely Use PPE

• Keep gloved hands away from face

• Avoid touching or adjusting other PPE
• Remove gloves if they become torn; perform
hand hygiene before donning new gloves
• Limit surfaces and items touched
• Perform hand hygiene
Sequence* for Donning
(Putting on) PPE

1. Gown first
2. Mask or respirator
3. Goggles or face
shield
4. Gloves

*Combination of PPE will affect

sequence – be practical
“Contaminated” and “Clean” Areas of PPE

• Contaminated – gown front, sleeves, the outside of

gloves, outside of goggles or face shield, front of
mask/respirator
• Areas of PPE that have or are likely to have been in
contact with body sites, materials, or environmental
surfaces where the infectious organism may reside

• Clean – inside, outside back, ties on head and back

• Areas of PPE that are not likely to have been in contact
with the infectious organism
 PPE Removal
• Remove and discard PPE, other than respirators, upon
completing a task before leaving the patient’s room
or care area.
- If a respirator is used, remove respirator outside
room, after door has been closed
• Perform hand hygiene between steps if hands
become contaminated and immediately after
removing all PPE
• Ensure that hand hygiene facilities are available at the
point needed, e.g., sink or alcohol-based hand rub
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Sequence for Removing
PPE (Example 1)
1. Gloves
2. Face shield or
goggles
3. Gown
4. Mask or respirator
5. Hand Hygiene

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Sequence for Removing
PPE (Example 2)

1. Gown and Gloves

2. Goggles of Face shield
3. Mask or respirator
4. Hand Hygiene
Removing a Particulate Respirator
• Follow manufacturer
instructions
• DO NOT TOUCH the front of
the respirator! It may be
contaminated!
• Remove by pulling the
bottom strap over back of
head, followed by the top
strap, without touching the
respirator
• Discard
 5. Minimizing Potential Exposures
(e.g. respiratory hygiene and cough etiquette)
• Prompt patients and visitors to
– Contain their respiratory
secretions
– Perform hand hygiene after
contact with respiratory
secretions
• Provide
– Tissues, masks, hand hygiene
supplies
– Instructional signage at point of
entry and throughout facility
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6. Reprocessing of reusable medical equipment
between each patient and when soiled
• Clean and reprocess (disinfect or sterilize) reusable medical
equipment (e.g., blood glucose meters and other point-of-
care devices, blood pressure cuffs, oximeter probes) prior to
use on another patient and when soiled.
– a. Consult and adhere to manufacturers’ instructions for
reprocessing.

• Maintain separation between clean

and soiled equipment to prevent
cross contamination.

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Transmission-Based Precautions
• Used in addition to Standard Precautions when SP may
be insufficient to prevent transmission
• Implemented for patients with documented or suspected
diagnosis where contact with the patient, their body
fluids, or environment presents a substantial transmission
risk despite adherence to SP
• Include
• Contact precautions
• Droplet precautions
• Airborne precautions
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Implementation of Transmission-Based Precautions

• Implementation may differ depending on

– Patient care settings (e.g., inpatient, outpatient,
long-term care)
– Facility design characteristics
– Type of patient interaction

• Should be adapted to the specific healthcare setting

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Implementation of Transmission-Based Precautions (2)
• Based on the patient’s clinical presentation and likely
infection diagnoses (e.g., syndromes suggestive of
transmissible infections such as diarrhea, fever and rash,
respiratory infection)
• As soon as possible after the patient enters the
healthcare facility or identified at the facility
• Adjust or discontinue precautions when more clinical
information becomes available (e.g., confirmatory
laboratory results).

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Implementation of Transmission-Based Precautions (3)

• To the extent possible, place patients who may need

transmission-based precautions into a single-patient
room while awaiting clinical assessment.
• Notify accepting facilities and the transporting agency
about suspected infections and the need for
transmission-based precautions when patients are
transferred.

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 Contact Precautions
• Intended to prevent transmission of infectious agents
via contact with a patient
- CRE colonized/infected
- C. Diff, Norovirus, Scabies
• Used for “epidemiologically important”
microorganisms
• Used in addition to Standard Precautions
• Places a barrier between the HCW and infectious
agent
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Contact Precautions (2)
Includes
• Gown and gloves should
be donned prior to entry
into room, discarded
prior to exit
– Hand hygiene prior to
donning gloves and
after removing gloves
• Single room preferred;
alternatives are spatial
separation or cohorting
with the same infection
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 Droplet Precautions
• Intended to prevent
transmission of pathogens via
respiratory or mucous
membrane contact with
respiratory secretions
– Influenza virus, adenovirus,
rhinovirus, N. meningitides,
and group A streptococcus
• No special air handling or
ventilation required
• Used in addition to Standard
Precaution
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 40
(2007) Last update: October, 2017
 Droplet Precautions (2)
Includes:
• Surgical or procedure mask donned prior to entry into room
and discarded prior to exit (a respirator is not necessary)
• Single room preferred, however if a single-patient room is not
available, assess the various risks associated with other patient
placement options (e.g., cohorting, keeping the patient with
an existing roommate)
– Spatial separation of ≥3 feet and drawing the curtain
between patient beds is especially important for patients in
multi-bed rooms with infections transmitted by the droplet
route
• Transporting patient in a surgical mask
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Airborne Precautions
• Intended to prevent
transmission by inhalation or
infectious agents that can
remain suspended in the air
– Tuberculosis, Measles,
Chickenpox
• Requirements include
– Increased ventilation rate
– Air exhausted directly to the
outside or through HEPA
filtration
– Facility respiratory protection
program (education, fit-testing,
user seal checks in place)
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 Airborne Precautions (2)
Includes: used in addition to Standard Precautions

• Respirator (N-95 or PAPR) donned prior to entry into

room and removed after exit
• A single-patient room that is equipped with special air
handling and ventilation capacity
• Transport patient in a surgical mask

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 LTCF Enhanced Standard Precautions
(Revision Coming Soon)
• Enhanced standard precautions guidance specific to Long-term
care facilities in California: AFL 10-27

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 LTCF Enhanced Standard Precautions (2)
(Revision Coming Soon)

• Developed in 2010 by CDPH and the California Association of

Health Facilities (CAHF)
• To create a single-tiered approach to prevent transmission of
all infectious agents in California
- Use in addition to Standard Precautions when Standard
precautions may be insufficient to prevent transmission
- Incorporates aspects of contact, droplet, and airborne
precautions
• Facilitate transfer of patients on contact precautions
between acute care hospitals and LTCFs
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 Summary
• Standard precautions are basic practices that apply to all care
setting and all patient care (regardless of a patient’s suspected
or confirmed infectious state)
Hand Hygiene personal protective equipment
Environmental cleaning and respiratory hygiene and cough etiquette
disinfection
Injection and medication safety Reprocessing of reusable medical
equipment
• Transmission-Based Precautions used in addition to SP when
SP may be insufficient to prevent transmission- Contact,
Droplet, Airborne
• Correct use of Standard and Transmission-based precautions
prevent disease transmission
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References
• Core Infection Prevention and Control Practice-CDC HICPAC, 2016
https://www.cdc.gov/hicpac/pdf/core-practices.pdf
• CDC Guideline for Hand Hygiene in Health-Care Settings
https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
• CDC Guidelines for Environmental Infection Control in Health-Care Facilities (Last
update: February 15, 2017- online version)
https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf
• CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (Last update:
February 15, 2017-online version)
https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf
• CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings, 2007 (Last update: October 2017 -online version)
https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf
• Occupational Safety and Health Administration (OSHA) requirements
https://www.osha.gov/SLTC/healthcarefacilities/infectious_diseases.html

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Acknowledgments

• California Department of Public Health Center for Health Care

Quality Healthcare-Associated Infections Program

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Questions?

Thank you

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