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Standard Precautions and Isolation (4.1.8)

Standard Precautions and Isolation (4.1.8) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.8


UW HEALTH CLINICAL POLICY 1
Policy Title: Standard Precautions and Isolation
Policy Number: 4.1.8
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: June 21, 2016

I. PURPOSE

To prevent the spread of infection among patients, hospital and clinic personnel, and visitors through
consistent use of Standard Precautions and Transmission-based Precautions (isolation).

II. POLICY ELEMENTS

A. Implementation of Standard Precautions and Transmission-based Precautions within UW Health will be
based, with some modifications, on the Center for Disease Control and Prevention’s Guideline for Isolation
Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, (hereafter referred
to as the Isolation Guideline) accessible at: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
B. Specifics of implementing Standard Precautions and Transmission-based Precautions (isolation) throughout
UW Health locations will be found in the UW Health Standard Precautions and Isolation Plan, accessible in
the related tab of this policy on U-Connect.
C. Standard Precautions will be observed for all patients at all times and requires use of barriers (e.g., gown,
gloves, face protection) to protect the mucosa and areas of skin from potential contact with moist patient
materials. Adequate supplies of personal protective equipment (PPE) for consistent application of Standard
Precautions will be maintained in all inpatient and ambulatory locations at all times.
i. Gloves must be worn for reasonably anticipated contact with a patient’s mucous membranes, non-
intact skin, or moist patient materials (blood, body fluids, secretions and all excretions except
sweat).
ii. Protective eyewear plus a mask, or a chin length face shield must be worn if there is a risk of
splash or spray of moist patient materials to the mucosa of the healthcare worker's eyes, nose
and/or mouth. (e.g. while intubating or suctioning a patient, accessing a hemodialysis fistula,
discarding body fluids into a hopper, etc.) Employee’s regular glasses are not adequate protection
and require additional eye protection.
iii. Isolation gown must be worn if soiling of clothing or skin with moist patient materials is likely.
iv. Central Services, or assigned ambulatory clinic staff will maintain a supply of PPE, to include face
shields, gowns and pocket resuscitation masks in locations on units where potential exposures to
moist patient materials may occur. Staff are expected to retrieve appropriate PPE from local unit
stock and don them prior to beginning procedures where exposure to blood, body fluids, secretions,
excretions, non-intact skin or mucous membranes may occur.
v. All sharps must be handled with utmost caution and discarded into a sharps container immediately
after use.
a. Safety designed sharp devices which the hospital provides must be used after proper
training.
b. Those safety designed sharp devices which require an activation step must be activated
immediately, using a one handed technique whenever possible, and then discarded
promptly into an appropriate sharps container.
D. Transmission-based Precautions (hereafter referred to as Isolation) will be used to prevent transmission of
communicable diseases in situations for which Standard Precautions alone are not sufficient to prevent
transmission. Isolation precautions include the following:
i. Contact Precautions
ii. Enhanced Contact Precautions
iii. Droplet Precautions
iv. Airborne Precautions
v. Emerging Pathogens Precautions
vi. Special Precautions
E. Empiric Isolation will be instituted when indicated by patient symptoms (e.g., draining wounds, diarrhea,
conjunctivitis, vesicular rash, severe cough, meningitis) or suspicion for a specific communicable disease
(e.g., measles, pertussis, tuberculosis). Institution of empiric precautions will not be delayed while tests for
specific pathogens are pending.
F. The need for isolation precautions will be consistently communicated through the use of color-coded signs
and the electronic medical record (Health Link), in accordance with the confidentiality and privacy required



UW HEALTH CLINICAL POLICY 2
Policy Title: Standard Precautions and Isolation
Policy Number: 4.1.8

by the Health Insurance Portability and Accountability Act (HIPAA).
G. Isolation precautions are effective in minimizing transmission risk and pregnant healthcare workers need not
be routinely exempted from the care of isolated patients. It is essential that healthcare workers observe
Standard Precautions for all patient contact and implement empiric isolation promptly to minimize exposure
to undiagnosed illness or to patients who are asymptomatic, but infectious.
H. Patients placed under isolation will be educated about the reason for isolation.
I. Family and visitors entering isolation rooms will be educated about the need for isolation and the proper use
of personal protective equipment, and are expected to follow indications on isolation signs. Depending on
the disease in question, narrow exemptions are made for some pediatric inpatients and for visitors who are
staying overnight in the patient’s room.
J. The Facilities and Engineering Department is responsible for preventive maintenance and monitoring of
special ventilation rooms (Airborne Infection Isolation and Protective Environment rooms) and for reporting
both anticipated and unanticipated interruptions of function to the Infection Control Department and the
affected location.
K. In the event of disagreement about whether isolation is needed or when it can be discontinued, the Hospital
Epidemiologist will have final authority to institute, continue, modify or discontinue isolation and to determine
patient priority for special ventilation rooms, should this resource become limiting.
L. Education of new employees, provided prior to their first day of work in an at-risk setting, will include basic
information regarding the risks of occupationally acquired infection and how to minimize this risk by
consistent adherence to Standard Precautions and Isolation practices.

III. PROCEDURE

A. The UW Health Standard Precautions and Isolation Plan will be followed by staff as the procedure for
preventing communicable disease transmission from infectious patients in all areas of UW Health. Specific
information provided within the Plan includes, but is not limited to:
i. Consistent use of Standard Precautions.
ii. Indications for empiric isolation.
iii. Implementing and discontinuing isolation in inpatient and ambulatory locations.
iv. Details of each type of isolation to include specific personal protective equipment required.
v. Details of implementing isolation for specific multidrug resistant organisms.
vi. Requirements for special ventilation rooms.
vii. Exclusion of staff or visitor entry in specific circumstances.
viii. Patient ambulation and transport.
ix. Appropriate disinfection of patient care items.
x. Population-specific modifications (e.g., Pediatrics, Cystic Fibrosis patients).
B. Non urgent questions about Standard Precautions or Isolation Precautions may be submitted to the Infection
Control Department via email to infectioncontrol@uwhealth.org
C. Urgent questions about proper implementation of isolation, or concerns about possible communicable
disease exposure may be directed to the Infection Control Practitioner on call at pager #2570.

IV. FORMS

Contact Precautions sign, Badger Graphics # U001458
Droplet Precautions sign, Badger Graphics # U001459
Airborne Precautions sign, Badger Graphics # U001460
Enhanced Contact Precautions Sign, Badger Graphics # U001461

V. COORDINATION

Author: Infection Control Practitioner
Senior Management Sponsor: SVP/Chief Nurse Executive
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: May 16, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs



UW HEALTH CLINICAL POLICY 3
Policy Title: Standard Precautions and Isolation
Policy Number: 4.1.8

administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UW Health Standard Precautions and Isolation Plan
UW Health Bloodborne Pathogens Exposure Control Plan
UW Health Administrative Policy #13.04, "Communicable Disease Reporting."
UW Health Clinical Policy 4.1.1, Control of Tuberculosis.
UW Health Tuberculosis Exposure Control Plan
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
2007. http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

VIII. REVIEW DETAILS

Version: Revision
Next Revision Due: June 2019
Formerly Known as: Hospital administrative policies #13.07, #13.28; UW Health clinical policy #4.1.3
(formerly #13.29); Surgical Services policy #5.04; MF policy #104.036, Standard Precautions.