Isolation (health care)

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This illustration of a TB ward from OSHA demonstrates several aspects of hospital infection control and isolation: engineering controls (dedicated air ductwork), PPE (N95 respirators), warning signs and labels (controlled entry), dedicated disposal container, and enhanced housekeeping practices. Tb ward.jpg
This illustration of a TB ward from OSHA demonstrates several aspects of hospital infection control and isolation: engineering controls (dedicated air ductwork), PPE (N95 respirators), warning signs and labels (controlled entry), dedicated disposal container, and enhanced housekeeping practices.

In health care facilities, isolation represents one of several measures that can be taken to implement in infection control: the prevention of communicable diseases from being transmitted from a patient to other patients, health care workers, and visitors, or from outsiders to a particular patient (reverse isolation). Various forms of isolation exist, in some of which contact procedures are modified, and others in which the patient is kept away from all other people. In a system devised, and periodically revised, by the U.S. Centers for Disease Control and Prevention (CDC), various levels of patient isolation comprise application of one or more formally described "precaution".

Contents

Isolation is most commonly used when a patient is known to have a contagious (transmissible from person-to-person) viral or bacterial illness. [1] Special equipment is used in the management of patients in the various forms of isolation. These most commonly include items of personal protective equipment (gowns, masks, and gloves) and engineering controls (positive pressure rooms, negative pressure rooms, laminar air flow equipment, and various mechanical and structural barriers). [2] Dedicated isolation wards may be pre-built into hospitals, or isolation units may be temporarily designated in facilities in the midst of an epidemic emergency.

Isolation should not be confused with quarantine or biocontainment. Quarantine is the compulsory separation and confinement, with restriction of movement, of individuals or groups who have potentially been exposed to an infectious microorganism, to prevent further infections, should infection occur. Biocontainment refers to laboratory biosafety in microbiology laboratories in which the physical containment (BSL-3, BSL-4) of highly pathogenic organisms is accomplished through built-in engineering controls. [3]

When isolation is applied to a community or a geographic area it is known as a cordon sanitaire . Reverse isolation of a community, to protect its inhabitants from coming into contact with an infectious disease, is known as protective sequestration. [4]

Importance

Contagious diseases can spread to others through various forms. Four types of infectious disease transmission can occur:

  1. contact transmission, which can be through direct physical contact, indirect contact through fomites, or droplet contact in which airborne infections spread short distances,
  2. vehicular transmission, which involves contaminated objects,
  3. airborne transmission, which involves spread of infectious particles through air,
  4. vector transmission, which is spread through insects or animals. [5]

Depending on the contagious disease, transmission can occur within a person's home, school, worksite, health care facility, and other shared spaces within the community. Even if a person takes all necessary precautions to protect oneself from disease, such as being up-to-date with vaccines and practicing good hygiene, he or she can still get sick. Some people may not be able to protect themselves from diseases and may develop serious complications if they contract the disease. Therefore, disease isolation is an important infection prevention and control practice used to protect others from disease. [6] Disease isolation can prevent healthcare-acquired infections of hospital-acquired infections (HCAIs), reduce threats of antibiotic resistance infections, and respond to new and emerging infectious disease threats globally. [7]

Types of precautions

The U.S. Centers for Disease Control and Prevention (CDC) created various levels of disease isolation (also described "precaution"). These precautions are also reviewed and revised by the CDC. [8]

Universal/standard

Universal precautions refer to the practice, in medicine, of avoiding contact with patients' bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields. The practice was widely introduced in 1985–88. [9] [10] In 1987, the practice of universal precautions was adjusted by a set of rules known as body substance isolation. In 1996, both practices were replaced by the latest approach known as standard precautions. Use of personal protective equipment is now recommended in all health settings.[ citation needed ]

One of the most standard practices for all medical professionals to reduce spread of disease is hand hygiene, or removing microorganisms from your hands. [11] Frequent hand hygiene is essential for protection of healthcare workers and patients from hospital-acquired infection. [12] Hospitals have specific approved disinfectants and approved methods for hand washing; defined by the American Nursing Association (ANA) and American Association of Nurse Anesthetists (AANA), proper hand washing with soap and water is defined as, splash water on hands, apply antiseptic soap, and scrub for at least 20 seconds. Approved hand washing with alcohol based sanitizers is, apply sanitizer to middle of hand and rub hands together covering all surfaces and fingernails until dry without touching anything. [11]

Transmission-based

Transmission-based precautions are additional infection control precautions – over and above universal/standard precautions – and the latest routine infection prevention and control practices applied for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens. The latter require additional control measures to effectively prevent transmission. [13] [14] There are three types of transmission-based precautions:

Isolation

According to the CDC, isolation is the act of separating a sick individual with a contagious disease from healthy individuals without that contagious disease in order to protect the general public from exposure of a contagious disease. [15]

Special equipment is used in the management of patients in the various forms of isolation. These most commonly include items of personal protective equipment (gowns, masks, and gloves) and engineering controls (positive pressure rooms, negative pressure rooms, laminar air flow equipment, and various mechanical and structural barriers). Dedicated isolation wards may be pre-built into hospitals, or isolation units may be temporarily designated in facilities in the midst of an epidemic emergency. [16]

Many forms of isolation exist.

Contact isolation is used to prevent the spread of diseases that can be spread through contact with open wounds. Health care workers making contact with a patient on contact isolation are required to wear gloves, and in some cases, a gown. [17]

Respiratory isolation is used for diseases that are spread through particles that are exhaled. [2] Those having contact with or exposure to such a patient are required to wear a mask.

The Aeromedical Biological Containment System (ABCS) is an air-transportable high isolation module for movement of highly contagious patients. Aeromedical Biological Containment System (ABCS).jpg
The Aeromedical Biological Containment System (ABCS) is an air-transportable high isolation module for movement of highly contagious patients.

Reverse isolation is a way to prevent a patient in a compromised health situation from being contaminated by other people or objects. It often involves the use of laminar air flow and mechanical barriers (to avoid physical contact with others) to isolate the patient from any harmful pathogens present in the external environment. [18]

High isolation is used to prevent the spread of unusually highly contagious, or high consequence, infectious diseases (e.g., smallpox, Ebola virus). [19] It stipulates mandatory use of: (1) gloves (or double gloves if appropriate), (2) protective eyewear (goggles or face shield), (3) a waterproof gown (or total body Tyvek suit, if appropriate), and (4) a respirator (at least FFP2 or N95 NIOSH equivalent), not simply a surgical mask. [20] Sometimes negative pressure rooms or powered air-purifying respirators (PAPRs) are also used.[ citation needed ]

Strict isolation[ dubious – discuss ] is used for diseases spread through the air and in some cases by contact. [2] Patients must be placed in isolation to prevent the spread of infectious diseases. [21] Those who are kept in strict isolation are often kept in a special room at the facility designed for that purpose. Such rooms are equipped with a special lavatory and caregiving equipment, and a sink and waste disposal are provided for workers upon leaving the area. [22]

Self-isolation

Traffic sign in South Carolina encouraging people to 'stay home' during the COVID-19 pandemic. COVID-19 Warning Mount Pleasant South Carolina.jpg
Traffic sign in South Carolina encouraging people to 'stay home' during the COVID-19 pandemic.

Self-isolation, seclusion or home isolation [23] is the act of quarantining oneself to prevent infection of oneself or others, [24] either voluntarily or to comply with relevant regulations or guidance. The practice became notable during the COVID-19 pandemic. [25] [26] Key features are:

  • staying at home
  • separating oneself from other people –for example, trying not to be in the same room as other people at the same time
  • asking friends, family members or delivery services to carry out errands, such as getting groceries, medicines or other shopping
  • asking delivery drivers to leave items outside for collection. [27] [28]

The Irish Health Service Executive recommends regularly monitoring symptoms and not disposing of rubbish until the self-isolation ends, [29] warning also that "self-isolation can be boring or frustrating. It may affect your mood and feelings. You may feel low, worried or have problems sleeping. You may find it helps to stay in touch with friends or relatives by phone or on social media." [29]

The UK Government states that anyone who is self-isolating should "not go to work, school, or public areas, and do not use public transport or taxis. Nobody should go out even to buy food or other essentials, and any exercise must be taken within your home". [30] As of March 2020 UK employers may provide sick pay to support self-isolation. Citizens Advice says that people on zero-hours contracts can also receive sick pay. [31] For the purposes of people who have traveled to the UK, "self-isolate" and "self-isolation" are legally defined terms whose meaning is set out in the Health Protection (Coronavirus, International Travel) (England) Regulations 2020. [32]

Isolation of health care workers

Isolation wards may need to be hastily improvised during epidemics such as in this image of WHO workers in Lagos, Nigeria managing Ebola patients in 2014. WHO in PPE.jpg
Isolation wards may need to be hastily improvised during epidemics such as in this image of WHO workers in Lagos, Nigeria managing Ebola patients in 2014.

Disease isolation is relevant to the work and safety of health care workers. Health care workers may be regularly exposed to various types of illnesses and are at risk of getting sick. Disease spread can occur between a patient and a health care worker, even if the health care workers take all necessary precautions to minimize transmission, including proper hygiene and being up-to-date with vaccines. If a health care worker gets sick with a communicable disease, the possible spread may occur to other health care workers or susceptible patients within the health care facility. This can include patients with a weakened immune system and may be at risk for serious complications. [33]

Health care workers who become infected with certain contagious agents may not be permitted to work with patients for a period of time. The Occupational Safety and Health Administration (OSHA) has implemented several standards and directives applicable to protecting health care workers from the spread of infectious agents. These include bloodborne pathogens, personal protective equipment, and respiratory protections. The CDC has also released resource for health care facilities to assist in assessing and reducing risk for occupational exposure to infectious diseases. The purpose of these standards and guidelines is to prevent the spread of disease to others in a health care facility. [34]

Consequences

Disease isolation is rarely disputed for its importance in protecting others from disease. However, it is important to consider the consequences disease isolation may have on an individual. For instance, patients may not be able to receive visitors, and in turn, become lonely. Patients may experience depression, anxiety, and anger. [35] Small children may feel their isolation is a punishment. [36] Staff may need to spend more time with patients. Patients may not be able to receive certain types of care due to the risk that other patients may become contaminated. This includes forms of care that involve use of equipment common to all patients at the facility, or that involve transporting the patient to an area of the facility common to all patients. Given the impact of isolation on patients, social and emotional support may be needed. [37]

Although a majority of health care professionals advocate for disease isolation as an effective means of reducing disease transmission, some health care professionals are concerned with implementing such control protocols given the possible negative consequences on patients. Patients isolated with Methicillin Resistant Staphylococcus Aureus (MRSA) can also be negatively impacted by having less documented care/bedside visits from attending and residents. [38]

Ethics

The new Ebola isolation ward in Lagos, Nigeria provides more space and better treatment. New isolation ward.jpg
The new Ebola isolation ward in Lagos, Nigeria provides more space and better treatment.

Disease isolation serves as an important method to protect the general community from disease, especially in a hospital or community-wide outbreak. However, this intervention poses an ethical question on rights of the individual versus rights of the general community. [39]

In cases of disease outbreaks, isolation can be argued as an ethical and necessary precaution for protecting the community from further disease transmission. This can be seen during the 2014 Disneyland measles outbreak and 2014 Ebola outbreak. This can be justified using felicific calculus to predict the outcomes (consequences) of moral action between the individual rights versus the rights of the general public during disease isolation. This justifies that disease isolation is most likely to result in the greatest amount of positive outcomes for the largest number of people. [40]

Disease isolation can also be justified as a morally legitimate ethical practice in public health based on the reciprocal relationship between the individual and the state. The individual is obligated to protect others by preventing further spread of disease, respect the instructions from public health authorities and sequester themselves in their homes and not attend public gatherings, and act as a first responder (if a healthcare professional) by providing services to protect and restore public health. The state, on the other hand, is obligated to provide support to individuals burdened as a result of restrictive measures (e.g. compensation for missed work, providing access to food and other necessities for those medically isolated, assistance for first responders to balance personal/professional obligations), ensure several legal protections are in place for those subjected to restrictive measures and communicate all relevant information regarding the necessity of restriction. [41]

The United Nations and the Siracusa Principles

Guidance on when and how human rights can be restricted to prevent the spread of infectious disease is found in the Siracusa Principles, [42] a non-binding document developed by the Siracusa International Institute for Criminal Justice and Human Rights and adopted by the United Nations Economic and Social Council in 1984. [43] The Siracusa Principles state that restrictions on human rights under the International Covenant on Civil and Political Rights must meet standards of legality, evidence-based necessity, proportionality, and gradualism, noting that public health can be used as grounds for limiting certain rights if the state needs to take measures "aimed at preventing disease or injury or providing care for the sick and injured." Limitations on rights (such as medical isolation) must be "strictly necessary," meaning that they must:

In addition, when medical isolation is imposed, public health ethics specify that:

Finally, the state is ethically obligated to guarantee that:

See also

Related Research Articles

<span class="mw-page-title-main">Quarantine</span> Epidemiological intervention to prevent disease transmission

A quarantine is a restriction on the movement of people, animals, and goods which is intended to prevent the spread of disease or pests. It is often used in connection to disease and illness, preventing the movement of those who may have been exposed to a communicable disease, yet do not have a confirmed medical diagnosis. It is distinct from medical isolation, in which those confirmed to be infected with a communicable disease are isolated from the healthy population.

<span class="mw-page-title-main">Universal precautions</span> Medical standard for contact avoidance

Universal precautions refers to the practice, in medicine, of avoiding contact with patients' bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields. The infection control techniques were essentially good hygiene habits, such as hand washing and the use of gloves and other barriers, the correct handling of hypodermic needles, scalpels, and aseptic techniques.

<span class="mw-page-title-main">Blood-borne disease</span> Medical condition

A blood-borne disease is a disease that can be spread through contamination by blood and other body fluids. Blood can contain pathogens of various types, chief among which are microorganisms, like bacteria and parasites, and non-living infectious agents such as viruses. Three blood-borne pathogens in particular, all viruses, are cited as of primary concern to health workers by the CDC-NIOSH: HIV, hepatitis B (HVB), & hepatitis C (HVC).

In medicine, public health, and biology, transmission is the passing of a pathogen causing communicable disease from an infected host individual or group to a particular individual or group, regardless of whether the other individual was previously infected. The term strictly refers to the transmission of microorganisms directly from one individual to another by one or more of the following means:

<span class="mw-page-title-main">Hospital-acquired infection</span> Infection that is acquired in a hospital or other health care facility

A hospital-acquired infection, also known as a nosocomial infection, is an infection that is acquired in a hospital or other healthcare facility. To emphasize both hospital and nonhospital settings, it is sometimes instead called a healthcare-associated infection. Such an infection can be acquired in a hospital, nursing home, rehabilitation facility, outpatient clinic, diagnostic laboratory or other clinical settings. A number of dynamic processes can bring contamination into operating rooms and other areas within nosocomial settings. Infection is spread to the susceptible patient in the clinical setting by various means. Healthcare staff also spread infection, in addition to contaminated equipment, bed linens, or air droplets. The infection can originate from the outside environment, another infected patient, staff that may be infected, or in some cases, the source of the infection cannot be determined. In some cases the microorganism originates from the patient's own skin microbiota, becoming opportunistic after surgery or other procedures that compromise the protective skin barrier. Though the patient may have contracted the infection from their own skin, the infection is still considered nosocomial since it develops in the health care setting. The term nosocomial infection is used when there is a lack of evidence that the infection was present when the patient entered the healthcare setting, thus meaning it was acquired or became problematic post-admission.

<i>Cordon sanitaire</i> (medicine) Quarantine of a geographic area

A cordon sanitaire is the restriction of movement of people into or out of a defined geographic area, such as a community, region, or country. The term originally denoted a barrier used to stop the spread of infectious diseases. The term is also often used metaphorically, in English, to refer to attempts to prevent the spread of an ideology deemed unwanted or dangerous, such as the containment policy adopted by George F. Kennan against the Soviet Union.

A contagious disease is an infectious disease that can be spread rapidly in several ways, including direct contact, indirect contact, and Droplet contact.

<span class="mw-page-title-main">Contact tracing</span> Finding and identifying people in contact with someone with an infectious disease

In public health, contact tracing is the process of identifying people who may have been exposed to an infected person ("contacts") and subsequent collection of further data to assess transmission. By tracing the contacts of infected individuals, testing them for infection, and isolating or treating the infected, this public health tool aims to reduce infections in the population. In addition to infection control, contact tracing serves as a means to identify high-risk and medically vulnerable populations who might be exposed to infection and facilitate appropriate medical care. In doing so, public health officials utilize contact tracing to conduct disease surveillance and prevent outbreaks. In cases of diseases of uncertain infectious potential, contact tracing is also sometimes performed to learn about disease characteristics, including infectiousness. Contact tracing is not always the most efficient method of addressing infectious disease. In areas of high disease prevalence, screening or focused testing may be more cost-effective.

<span class="mw-page-title-main">Asepsis</span> Absence of disease-causing microorganisms

Asepsis is the state of being free from disease-causing micro-organisms. There are two categories of asepsis: medical and surgical. The modern day notion of asepsis is derived from the older antiseptic techniques, a shift initiated by different individuals in the 19th century who introduced practices such as the sterilizing of surgical tools and the wearing of surgical gloves during operations. The goal of asepsis is to eliminate infection, not to achieve sterility. Ideally, a surgical field is sterile, meaning it is free of all biological contaminants, not just those that can cause disease, putrefaction, or fermentation. Even in an aseptic state, a condition of sterile inflammation may develop. The term often refers to those practices used to promote or induce asepsis in an operative field of surgery or medicine to prevent infection.

Infection prevention and control is the discipline concerned with preventing healthcare-associated infections; a practical rather than academic sub-discipline of epidemiology. In Northern Europe, infection prevention and control is expanded from healthcare into a component in public health, known as "infection protection". It is an essential part of the infrastructure of health care. Infection control and hospital epidemiology are akin to public health practice, practiced within the confines of a particular health-care delivery system rather than directed at society as a whole.

<span class="mw-page-title-main">Airborne transmission</span> Disease transmission by airborne particles

Airborne transmission or aerosol transmission is transmission of an infectious disease through small particles suspended in the air. Infectious diseases capable of airborne transmission include many of considerable importance both in human and veterinary medicine. The relevant infectious agent may be viruses, bacteria, or fungi, and they may be spread through breathing, talking, coughing, sneezing, raising of dust, spraying of liquids, flushing toilets, or any activities which generate aerosol particles or droplets.

Transmission-based precautions are infection-control precautions in health care, in addition to the so-called "standard precautions". They are the latest routine infection prevention and control practices applied for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. Universal precautions are also important to address as far as transmission-based precautions. Universal precautions is the practice of treating all bodily fluids as if it is infected with HIV, HBV, or other blood borne pathogens.

<span class="mw-page-title-main">Prevention of viral hemorrhagic fever</span>

Prevention of viral hemorrhagic fever is similar for the different viruses. There are a number of different viral hemorrhagic fevers including Ebola virus disease, Lassa fever, Rift valley fever, Marburg virus disease, Crimean-Congo haemorrhagic fever (CCHF) and yellow fever. Lassa, Ebola, Marburg and CCHF can be spread by direct contact with the body fluids of those infected. Thus the content here covers the prevention of Ebola.

<span class="mw-page-title-main">2002–2004 SARS outbreak among healthcare workers</span>

The rapid spread of severe acute respiratory syndrome (SARS) in healthcare workers (HCW)—most notably in Toronto, Ontario hospitals—during the global outbreak of SARS in 2002–2003 contributed to dozens of identified cases, some of them fatal.

<span class="mw-page-title-main">N95 respirator</span> Particulate respirator meeting the N95 standard

An N95 respirator is a disposable filtering facepiece respirator or reusable elastomeric respirator filter that meets the U.S. National Institute for Occupational Safety and Health (NIOSH) N95 standard of air filtration, filtering at least 95% of airborne particles that have a mass median aerodynamic diameter of 0.3 micrometers under 42 CFR 84, effective July 10, 1995. A surgical N95 is also rated against fluids, and is regulated by the US Food and Drug Administration under 21 CFR 878.4040, in addition to NIOSH 42 CFR 84. 42 CFR 84, the federal standard which the N95 is part of, was created to address shortcomings in the prior United States Bureau of Mines respirator testing standards, as well as tuberculosis outbreaks, caused by the HIV/AIDS epidemic in the United States. Since then, N95 respirator has continued to be used as a source control measure in various pandemics that have been experienced in the United States and Canada, including the 2009 swine flu and the COVID-19 pandemic.

<span class="mw-page-title-main">Workplace hazard controls for COVID-19</span> Prevention measures for COVID-19

Hazard controls for COVID-19 in workplaces are the application of occupational safety and health methodologies for hazard controls to the prevention of COVID-19. Multiple layers of controls are recommended, including measures such as remote work and flextime, personal protective equipment (PPE) and face coverings, social distancing, and enhanced cleaning programs. Recently, engineering controls have been emphasized, particularly stressing the importance of HVAC systems meeting a minimum of 5 air changes per hour with ventilation or MERV-13 filters, as well as the installation of UVGI systems in public areas.

A patient under investigation refers to a person who had been in close contact with a person with confirmed infection or/and may have been to place where there is an outbreak or superspreading event. This person exhibits the symptoms of the disease and is required to be tested, and undergo a quarantine or isolation while waiting for the laboratory results. It is a term used by health care workers in classifying patients during evaluation and testing in contact tracing in times of infectious disease outbreaks.

In epidemiology, a non-pharmaceutical intervention (NPI) is any method used to reduce the spread of an epidemic disease without requiring pharmaceutical drug treatments. Examples of non-pharmaceutical interventions that reduce the spread of infectious diseases include wearing a face mask and staying away from sick people.

<span class="mw-page-title-main">Source control (respiratory disease)</span> Strategy for reducing disease transmission

Source control is a strategy for reducing disease transmission by blocking respiratory secretions produced through breathing, speaking, coughing, sneezing or singing. Multiple source control techniques can be used in hospitals, but for the general public wearing personal protective equipment during epidemics or pandemics, respirators provide the greatest source control, followed by surgical masks, with cloth face masks recommended for use by the public only when there are shortages of both respirators and surgical masks.

An occupational infectious disease is an infectious disease that is contracted at the workplace. Biological hazards (biohazards) include infectious microorganisms such as viruses, bacteria and toxins produced by those organisms such as anthrax.

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  40. ↑ Aita MD, Mark C, Ragland MA, Takeem T (2015). "Ebola Scare and Measles Resurgence: Mandatory Isolation/quarantine and Vaccination". Online Journal of Health Ethics. 11 (2): 2. doi: 10.18785/ojhe.1102.02 .
  41. ↑ Viens AM, Bensimon CM, Upshur RE (1 June 2009). "Your Liberty or Your Life: Reciprocity in the Use of Restrictive Measures in Contexts of Contagion". Journal of Bioethical Inquiry. 6 (2): 207–17. doi: 10.1007/s11673-009-9149-2 . S2CID   62889751.
  42. ↑ https://www.icj.org/wp-content/uploads/1984/07/Siracusa-principles-ICCPR-legal-submission-1985-eng.pdf
  43. ↑ United Nations Economic and Social Council UN Sub-Commission on Prevention of Discrimination and Protection of Minorities, "The Siracusa Principles on the limitation and derogation provisions in the International Covenant on Civil and Political Rights," Section I.A.12 UN Doc. E/CN.4/1985/4, Annex. Geneva, Switzerland: UNHCR; 1985. unhcr.org, accessed 5 February 2020
  44. ↑ Todrys, K. W.; Howe, E.; Amon, J. J. (2013). "Failing Siracusa: Governments' obligations to find the least restrictive options for tuberculosis control". Public Health Action. 3 (1): 7–10. doi:10.5588/pha.12.0094. PMC   4463097 . PMID   26392987.
  45. ↑ M. Pabst Battin, Leslie P. Francis, Jay A. Jacobson, The Patient as Victim and Vector: Ethics and Infectious Disease, Oxford University Press, 2009. ISBN   019533583X

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