Transmission-Based Precautions Policy

1. Policy Statement

It is the policy of this organization that Transmission-Based Precautions shall be implemented as supplementary infection prevention measures whenever patients are known or suspected to be infected or colonized with communicable pathogens requiring protection beyond Standard Precautions. These precautions are stratified according to the transmission characteristics of relevant pathogens and must be adapted to the care setting. Standard Precautions remain in full effect in all circumstances and are not replaced or diminished by Transmission-Based Precautions.

2. Purpose

This policy exists to:

• Define the three categories of Transmission-Based Precautions and their clinical indications.
• Establish requirements for PPE selection, donning, and doffing specific to each precaution category.
• Specify enhanced barrier precaution requirements for long-term care settings managing multidrug-resistant organisms.
• Address equipment management and patient transfer notification requirements for patients on Transmission-Based Precautions.
• Define crisis standards of care for pandemic and infectious disease emergency response.

3. Scope

This policy applies to:

• All clinical personnel providing care to patients with known or suspected communicable disease in any setting.
• All care settings, including inpatient, ambulatory, home care, and long-term care facilities.
• Organizational infection prevention, facility management, and leadership responsible for isolation infrastructure and supply availability.
• Transport and transfer personnel involved in moving patients on Transmission-Based Precautions.

4. Policy Requirements

4.1 Overview and Clinical Application

4.1.1 While Standard Precautions apply universally to all patient interactions, certain clinical situations require additional measures to interrupt transmission of specific infectious agents. Transmission-Based Precautions provide these supplementary safeguards, stratified according to the transmission characteristics of relevant pathogens.

4.1.2 The three categories of Transmission-Based Precautions address distinct transmission routes:

• Contact Precautions prevent transmission through direct or indirect physical contact with the patient or contaminated environment.
• Droplet Precautions address respiratory secretions that do not remain airborne for extended periods.
• Airborne Precautions protect against pathogens capable of remaining suspended in air over time and distance.

4.1.3 These precautions require adaptation based on care setting. While acute care facilities may implement comprehensive isolation protocols, long-term care facilities, home care, ambulatory settings, and other environments may require modified approaches that achieve protective goals within practical constraints.

4.2 Personal Protective Equipment Selection

4.2.1 PPE selection for Transmission-Based Precautions builds upon Standard Precautions requirements based on the nature of patient interaction and the relevant transmission route. Effective implementation requires that clinicians receive adequate training in proper donning and doffing sequences, as improper PPE removal represents a significant contamination risk.

4.2.2 Planning tasks to allow sufficient time for safe PPE handling supports compliance and reduces contamination events. Clinicians shall, where possible, consolidate necessary interventions to minimize repeated donning and doffing while maintaining therapeutic relationships with isolated patients.

4.2.3 Hand hygiene remains essential within the context of Transmission-Based Precautions. Clinicians shall perform hand hygiene:

• Before donning PPE.
• Immediately if hands become contaminated during PPE removal.
• Immediately after removing all PPE.
• Before leaving the patient’s environment.

4.3 Contact Precautions

4.3.1 Contact Precautions prevent transmission of organisms spread through direct contact with the patient or indirect contact with contaminated environmental surfaces. Excessive wound drainage, certain skin conditions, and colonization or infection with epidemiologically significant organisms commonly trigger Contact Precautions.

4.3.2 Implementation involves donning gown and gloves before entering the patient’s clinical environment when contact may occur. All PPE must be removed and hand hygiene performed before leaving the patient environment.

4.3.3 The evidence regarding Contact Precautions for endemic multidrug-resistant organisms continues to evolve, with some studies questioning their effectiveness compared to enhanced Standard Precautions with universal gloving and gowning. Clinicians shall remain current with organizational policies that reflect evolving evidence and institutional infection prevention guidance.

4.4 Droplet Precautions

4.4.1 Droplet Precautions address pathogens transmitted through respiratory droplets generated when infected patients cough, sneeze, or speak. These relatively large droplets typically travel short distances and do not remain suspended in air, distinguishing droplet transmission from true airborne transmission.

4.4.2 When potential contact with respiratory secretions or sprays of blood or body fluids exists, clinicians shall wear appropriate face masks and eye protection. The specific requirements align with organizational policy and current guidance for particular pathogens.

4.5 Airborne Precautions

4.5.1 Airborne Precautions address pathogens capable of remaining suspended in air for extended periods and traveling beyond the immediate vicinity of the infected patient. Tuberculosis, measles, chickenpox, and disseminated herpes zoster represent classic indications. Additionally, certain procedures that generate aerosols may temporarily render otherwise non-airborne pathogens capable of airborne transmission.

4.5.2 Implementation requires fit-tested, certified N95-or-higher respirators. Initial fit testing shall occur before first use of a respirator model, with annual retesting and additional testing if facial characteristics change significantly. Clinicians must perform a seal check with each use, adjusting the respirator as needed to achieve proper fit.

4.5.3 Organizations may elect to utilize reusable elastomeric respirators, which offer protection against supply chain disruptions. These devices require maintenance programs ensuring proper cleaning and filter replacement according to manufacturer specifications. When elastomeric respirators include exhalation valves, additional measures become necessary if source control is simultaneously indicated.

4.5.4 Healthcare facilities shall maintain formal Respiratory Protection Programs addressing all aspects of respiratory protection including device selection, fit testing, seal checking, maintenance, and staff training.

4.5.5 For aerosol-generating procedures when airborne-transmitted disease is not suspected, staff shall minimally wear one of the following: a face shield providing full frontal and lateral coverage, a mask with attached shield, or a mask combined with goggles.

4.6 Enhanced Barrier Precautions in Long-Term Care

4.6.1 Skilled nursing facilities face particular challenges with multidrug-resistant organism transmission due to resident proximity, shared caregiving, and the extended duration of resident stays. Enhanced barrier precautions represent a specific containment strategy for these settings when novel or targeted multidrug-resistant organisms are identified.

4.6.2 Under enhanced barrier precautions, clinicians shall don gloves and gown when performing high-contact care activities. These activities include care involving wounds or indwelling medical devices such as central vascular access devices, urinary catheters, feeding tubes, or tracheostomies. This requirement applies when the resident resides on a unit or wing where a resident known to be infected or colonized with a targeted organism also resides.

4.7 Equipment Management and Patient Transfer

4.7.1 Whenever feasible, dedicated equipment shall remain with the isolated patient until precautions are discontinued. Equipment that must be shared requires thorough cleaning and disinfection before removal from the patient environment, or alternatively, placement in appropriate containers for transport to cleaning facilities.

4.7.2 In home care settings, disposable patient care equipment may be preferable for patients on Transmission-Based Precautions. When reusable equipment is necessary, it shall be dedicated to the patient throughout the care episode. Decontamination rendering equipment safe for handling shall occur at the point of use, with subsequent transport for thorough cleaning and disinfection before reuse.

4.7.3 When patients on Transmission-Based Precautions require transfer to other facilities or transport services, advance notification regarding suspected infections and precaution requirements shall be provided to the receiving facility and transport personnel to support continuity of appropriate protective measures.

4.8 Crisis Standards and Pandemic Response

4.8.1 Infectious disease crises such as pandemics may necessitate adaptation of standard Transmission-Based Precautions. Modifications aim to reduce healthcare facility risk through measures such as visitor limitations and elective procedure cancellation, prompt isolation of symptomatic patients, and protection of clinical staff through enhanced barriers, technology adoption that reduces exposure, and PPE prioritization.

4.8.2 Crisis standards of care emerge through collaboration among healthcare organizations, clinical professionals, policy makers, and affected communities. PPE conservation strategies may become necessary based on local supply circumstances, with compliance requirements adjusted according to current authoritative recommendations that may evolve rapidly.

4.8.3 Clinicians practicing during crises shall maintain awareness of current guidance from relevant authorities including national and international public health organizations, recognizing that recommendations may change as understanding of the pathogen and available resources evolve.

5. Compliance

5.1 Monitoring. Compliance shall be monitored through direct observation of PPE donning and doffing practices, audit of isolation precaution signage and supply availability, Respiratory Protection Program records including fit testing documentation, and HAI surveillance data including MDRO transmission events.

5.2 Key Performance Indicators.

• Isolation precaution compliance rate on direct observation audit (target: ≥95%).
• N95 fit testing completion rate for all applicable personnel (target: 100% annually).
• Respiratory Protection Program documentation compliance rate.
• MDRO transmission events in long-term care settings trended quarterly.

5.3 Enforcement. Non-compliance with Transmission-Based Precautions shall be addressed through immediate coaching and, for repeated violations, through the organization’s performance management processes. Failure to wear appropriate respirators in Airborne Precaution settings constitutes a serious safety violation and shall be escalated immediately to clinical leadership. Fit testing non-compliance shall result in exclusion from direct care of airborne-precaution patients until testing is completed.

6. Exceptions

6.1 In life-threatening emergencies requiring immediate patient intervention, full precaution implementation may be momentarily delayed. The minimum protective equipment feasible shall be applied, with full compliance restored as soon as possible. The exception shall be documented in the patient record.

6.2 During declared public health emergencies or supply crises, crisis standards of care approved by appropriate authorities may modify PPE requirements as specified in Section 4.8. All such modifications shall be documented and communicated to clinical staff in writing with leadership authorization.

7. Related Documents

• Hand Hygiene Policy (this collection)
• Standard Precautions Policy (this collection)
• ANTT® Policy (this collection)
• POL-006: Interprofessional Safety and Care Transitions
• POL-013: Adverse Event Management and Reporting
• Bloodborne Pathogen Exposure Control Plan
• Organizational Respiratory Protection Program
• CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007, updated 2023)
• OSHA Standard 29 CFR 1910.1030 — Bloodborne Pathogens
• CDC NIOSH Hospital Respiratory Protection Program Toolkit
• CMS Infection Control F-Tags (Long-Term Care)

8. Revision History