Historically the terms ‘isolation’ and ‘barrier nursing’ have been used by nurses to describe the physical separation of persons suspected or known to be infected with a communicable disease from those who are not. Today most patients with infective conditions can be nursed in a general hospital with modern wards and single rooms using ‘Standard Precautions’ (Department of Health and Hospital Infection Society 2001). However, there are certain infections that require a higher level of containment, e.g. new or ‘novel’ infections, or those that are extremely resistant, e.g. multi-drug resistant tuberculosis. These patients would usually be transferred to an Infectious Disease Unit where specialised accommodation and equipment would be provided according to the category of the infection.
‘Protective isolation’
This is the term used to describe nursing precautions taken to keep a vulnerable patient, e.g. a person with compromised immunity, free from infection risks that might be encountered in the normal ward environment.
Different precautions may also be used to ‘isolate’ non-infective patients such as those who are undergoing radiotherapy treatments that render the person a radioactive hazard to fellow patients.
This section consists of three parts:
1 Source isolation
2 Protective isolation
3 Radioactive hazard isolation
Learning outcomes
By the end of this section you should know how to:
▪ prevent the spread of infection while nursing a patient with a specific communicable disease (source isolation)
▪ protect a patient from infection when he or she may be at a greater risk than normal (protective isolation)
▪ prevent hazard to carers and visitors when radioactive substances are used.
Background knowledge required
Revision of the modes of transmission of infection and related microbiology
Awareness of standards and legislation on infection control (Department of Health 2004)
Review of health service policy in relation to the control of infection in both institutional and community settings
Knowledge of the role of the infection control team in your work area
Review of local health service policy in relation to the handling of radioactive substances.
Indications and rationale for nursing patients in an isolation area
The aim of this nursing practice is to create an effective barrier between an infected area and a non-infected area, to prevent the occurrence of cross-infection, or to use appropriate measures to prevent contamination from radioactive substances.
Isolation precautions are often a combination of national guidance and local experience: always check the local policy. In general, it is advised that all practitioners use the same general prevention strategies with all patients at all times (Department of Health 2004). The application of standard infection control precautions (see ‘Infection prevention and control’, p. 151) is the foundation for this and includes:
▪ an appropriate hand-hygiene technique
▪ the use of gloves for clinical practices
▪ the protection of any broken skin
▪ the prevention and treatment of needlestick injuries
▪ the use of protective clothing/equipment (aprons, gowns, eye goggles) when required
▪ the use and disposal of ‘sharps’
▪ the management of spillages
▪ the collection and disposal of waste products.
1. SOURCE ISOLATION
In this instance, the ‘infected’ area is the isolation area where the infected patient is being nursed, the ‘non-infected’ area being that outside the isolation area.
Indications and rationale for source isolation
This is carried out to prevent the spread of infection from patients who have or are suspected of having a specific communicable infection, for example:
▪ an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). This infection, especially if present in the bloodstream, poses the greatest problem for patients who are already at high risk, e.g. those with invasive devices or being ventilated. Guidelines for care of persons with MRSA vary between acute, community and domestic care settings. Precautions are based on an individual risk assessment and the type of healthcare setting (Working Party on MRSA 1998)
▪ a respiratory infection caused by untreated Mycobacterium tuberculosis (National Institute for Clinical Excellence 2006)
▪ an active enteric infection caused by Salmonella or E. coli O157 verocytotoxin(VTEC) (Scottish Infection Standards and Strategy Group 2004).
The environment and equipment required will depend on the infection, the patient’s condition and the local health policies. It will usually include the following:
1. Single room with toilet facilities and sometimes an anteroom with protective clothing storage and washhand basin
2. Handwashing facilities for personnel inside and outside the isolation area
3. Alcohol-based hand gel (Ritchie et al 2005)
4. Personal protective clothing, which may include:
— cap
— filter-type mask or respirator
— gown or fluid repellent clothing
— plastic apron
— gloves
— protective washable shoes
— face protection/goggles
[Many of these items are disposable and a supply of them should be kept in an adjacent area outside the isolation area]
5. Linen for the bed, and personal towels for the patient
6. Individual crockery and cutlery, which can be processed in a dishwasher should be routinely used. However, in some circumstances, disposable items may be required (please check with the local infection control policy or infection control team)
7. Facilities for the treatment, or disposal of, infected linen and rubbish
8. Equipment needed for appropriate personal and nursing care should remain within the isolation area for the duration of the isolation precautions to prevent the transmission of infection. All items used must be decontaminated and disinfected before reuse according to local control of infection policy
9. Thermometer, sphygmomanometer, stethoscope and watch or clock with a second hand as required for recording vital signs
10. Special containers for the collection of laboratory specimens if required
11. The patient’s documentation should remain outside the isolation area and details of recordings and care be completed by ‘uncontaminated’ personnel to maintain a safe environment.
Guidelines and rationale for this nursing practice▪ consult appropriate personnel to obtain advice and guidance. All health authorities and hospitals have a member of staff designated to be responsible for the control of infection in that area, for example an infection control nurse (Clinical Standards Board for Scotland 2001)
▪ carry out a risk assessment of infection (Department of Health 2004)
▪ plan the nursing so that everything required is carried out during one period of time in the isolation area: personnel continually entering and leaving the area greatly increase the risk of cross-infection
▪ if possible, choose personnel with known immunity to care for patients with specific infections as they will be resistant to the infection, e.g. persons who have had chickenpox or are protected against varicella, may care for patients with chickenpox or shingles
▪ explain the importance of the precautions to the patient to gain consent and co-operation, and encourage participation in care
▪ don personal protective clothing as required to create an effective barrier against the infection
▪ enter the isolation area
▪ perform all necessary nursing care. Two nurses may be needed for certain nursing practices for example passing equipment, the patient’s meals or prescribed medication in from outside the isolation area. One nurse should remain in protective clothing within the area. The second nurse should remain at the entrance of the area and transfer articles to the nurse within the area without allowing any contamination to occur. This prevents the transmission of infection
▪ observe the patient throughout this activity to monitor any change in condition
▪ ensure that the patient is left feeling as comfortable as possible to help to promote the healing process
▪ ensure that the patient has means of local communication, such as a nurse call system, since patients and staff can feel very isolated in this situation (Rees et al 2000, Maunder at al 2003). If isolation precautions are to be maintained for a long period of time and the patient’s general condition allows, a bedside telephone or media system may be provided
▪ safely dispose of any infected material according to local policy to prevent cross-infection
▪ wash the hands within the isolation area to prevent the infection being transferred out of the area
▪ remove protective clothing without touching the outside of the garments and dispose of them safely to prevent any cross-infection and maintain a safe environment for all
▪ leave the isolation area once all the nursing care has been completed
▪ repeat handwashing outside the isolation area and apply alcohol hand gel to further ensure no contamination occurs
▪ document the nursing practices appropriately, monitor any after-effects and report abnormal findings immediately so that care can be evaluated and any nursing or medical interventions altered as required
▪ explain the precautions to visitors, who should be restricted to close relatives and friends, to obtain their co-operation in maintaining isolation for the patient by wearing any recommended protective clothing and undertaking hand hygiene
▪ in undertaking this practice, nurses are accountable for their actions, the quality of care delivered and record-keeping according to the Code of Professional Conduct: Standards for Conduct, Performance and Ethics (Nursing and Midwifery Council 2004), Guidelines for Records and Record Keeping (Nursing and Midwifery Council 2005) and Healthcare Associated Infection Task Force Code of Practice (Scottish Executive Health Department 2004).
Disposal of infected material
Local guidelines should be followed regarding the disposal of contaminated waste. In an institutional setting, two nurses are required: one to remain in protective clothing within the isolation area, the second nurse to remain free from contamination outside it.
This should be put in a clinical waste disposal bag and closed as appropriate inside the isolation area by the isolation nurse before being passed out to the second ward nurse. All waste bags must be securely fastened with a permanent closure using tape and ‘swan-neck’ fastening (Figure 22.1 or a self-locking tag. The bag must be marked with the ward or unit name and date to ensure that it complies with waste disposal and health and safety legislation. Bags are usually stored in locked secure containers or areas prior to uplift and consignment for processing by heat disinfection or incineration.
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