The key aspects of applying droplet precautions relate to: • standard precautions
• use of appropriate PPE • special handling of equipment • patient placement
• minimising patient transfer or transport. Hand hygiene and personal protective equipment
Droplet transmission is, technically, a form of contact transmission and some infectious agents transmitted by the droplet route may also be transmitted by contact (Siegel et al 2007). Hand hygiene is therefore an important aspect of droplet precautions and the 5 moments for hand hygiene outlined in Section B1.1.2 should be followed.
There is insufficient evidence to support the use of P2 respirators for reducing the risk of infections transmitted by the droplet route. Although surgical masks do not protect the wearer from infectious agents that are transmitted via the airborne route, surgical masks that meet Australian Standards are fluid resistant and protect the wearer from droplet contamination of the nasal or oral mucosa (DoHA 2006). The mask is generally put on upon room entry, with hand hygiene practiced before putting on the mask and after taking off the mask.
More studies are needed to improve understanding of droplet transmission under various
circumstances. The CDC isolation guidelines (Siegel et al 2007) specify that masks should be put on when the healthcare worker is ‘a short distance from a patient’, giving a distance of 1 metre around the patient as an example of what is meant by this, but also stating that it may be prudent to put on a mask upon entry into the patient’s room, especially when the patient has violent, frequent coughing and sneezing or when exposure to emerging or highly virulent pathogens is likely. There is insufficient evidence to recommend the routine use of protective eyewear with individuals on droplet precautions, unless there is a risk of splashes or spray to the mucosa (see Section B1.2). Goggles provide reliable eye protection from respiratory droplets from multiple angles.
Emerging evidence on droplet transmission will be monitored as a part of the ongoing review process.
recommendation
19 Personal protective equipment to prevent droplet transmission Grade
Placement of patients on droplet precautions
Placing patients on droplet precautions in a single-patient room reduces the risk of patient-to- patient transmission. When single-patient rooms are in short supply, the following principles apply in decision-making on patient placement:
• prioritise patients who have excessive cough and sputum production for single-patient room placement
• place together in the same room (cohort) patients who are infected with the same pathogen and are suitable roommates.
If it becomes necessary to place patients who require droplet precautions in a room with a patient who does not have the same infection:
• avoid placing patients on droplet precautions in the same room with patients who have conditions that may increase the risk of adverse outcomes from infection or that may facilitate transmission (e.g. those who are immunocompromised, have anticipated prolonged lengths of stay, have cystic fibrosis, cardiac conditions or muscular dystrophy)
• ensure that patients are physically separated (> 1 metre apart) from each other and draw the privacy curtain between beds to minimise opportunities for close contact.
In all cases, the importance of respiratory hygiene and cough etiquette should be explained to patients on droplet precautions (see Section B1.6).
In primary care and other office-based practice, examples of appropriate implementation of droplet precautions include segregation in waiting rooms for patients with violent or frequent coughing, and the availability of tissues, alcohol-based handrub and a waste bin so that patients can practice respiratory hygiene and cough etiquette.
recommendation
20 Placement of patients requiring droplet precautions Grade
Place patients who require droplet precautions in a single-patient room. GPP
transfer of patients on droplet precautions
When transfer of a patient on droplet precautions within or between facilities is necessary, there is the potential for other patients and healthcare workers to come in contact with infectious agents when the patient coughs or sneezes. This can be addressed by asking the patient to wear a mask while they are being transferred and to follow respiratory hygiene and cough etiquette. Children should wear a correctly fitting mask when they are outside an isolation room. The child’s oxygen saturation should be monitored.
risk-management case study Influenza in a long-term care facility
A cluster of cases of influenza occurred in a long-term care facility, which were observed after a group activity involving dancing was held in the dining room prior to the midday meal. It was observed that a number of residents who had been unwell had attended the group activity and had sat at the dining tables. Due to the lack of waste receptacles in the dining room, used tissues were placed on the dining room tables. It was also noticed that a number of residents remained in the vicinity of the dining room post activity as their rooms were a short distance from the dining room. The shared bathrooms were at the other end of the corridor so it was not known whether hand hygiene was performed prior to meals or the event. Residents reported signs and symptoms consistent
eliminating risks In this situation, it is not possible to eliminate the risk immediately, so it must be managed.
Identifying risks In this case, the risk has been identified as cross-transmission of influenza.
analysing risks One source of transmission is the assembling of large numbers of residents in a confined area
in which close contact droplet transmission occurred such as sneezing, coughing or talking. In addition the lack of waste receptacles available would have hindered immediate disposal of infectious waste material. Healthcare workers or other residents may have had indirect contact with influenza droplets from the dirty tissues lying on the table, particularly if any of the other people disposed of the tissues later. The lack of hand hygiene facilities in the immediate vicinity could have resulted in poor hand hygiene compliance, with staff or residents not decontaminating their hands prior to eating or after sneezing or coughing. Low levels of staff immunisation also contributed to the spread of the infection.
evaluating risks The balance of likelihood and consequences identify this as a ‘very high risk’ situation requiring
immediate response.
treating risks Immediate measures may include:
• waste receptacles being made available In a common area, so people can dispose of tissues immediately after use
• the provision of ABHR so residents (and staff) can decontaminate their hands prior to eating, handling food or coughing and sneezing.
Other measures may include:
• education of staff and residents on the importance of hand hygiene, respiratory hygiene and cough etiquette
• immunisation of residents and staff and asking sick staff members to stay at home;
• education of residents, that if they feel unwell, to avoid participating in group activities until they feel better
• displaying posters and signage on hand hygiene and respiratory hygiene around the facility on an ongoing basis.
monitoring Immunisation rates among staff and residents could be monitored, as well as monitoring
the difference in case numbers from previous influenza outbreaks and outbreaks after the measures have been put in place.