Patient-Specific Scenarios
Used alongside standard precautions when dealing with patients who have known or suspected infectious diseases. Do not delay standard precautions while deciding the transmission route — apply both simultaneously.
These precautions are usually applied empirically based on the patient's clinical syndrome — for example, severe acute diarrhoea or a suspicious respiratory cough — and modified once a diagnosis is confirmed.
Decision Overview
Triage Decision Tree
The first staff member who sees the patient (registration clerk, triage nurse, or MA) initiates this filter. The MO confirms and escalates as needed.
3-Question Filter
| Question | If Yes | Action |
|---|---|---|
| 1. Fever + cough + shortness of breath? | Suspect airborne / droplet | Surgical mask on patient → isolate → notify MO |
| 2. Chronic cough >2 weeks + weight loss + night sweats? | Suspect TB (airborne) | N95 for staff + isolate in ventilated area |
| 3. Diarrhoea + incontinence + known MRO? | Suspect contact | Gloves + apron + limit patient movement |
If you cannot confidently classify the risk, apply the higher precaution level while waiting for the MO's assessment. It is safer to over-protect than under-protect.
1. Airborne Precautions
Diseases
- Tuberculosis (TB)
- Measles
- Chickenpox (varicella)
- COVID-19 (SARS-CoV-2) [?]
Staff PPE
- N95 respirator (fit-tested, seal-checked every single time) [?]
- Gloves and gown if contact with patient or environment is anticipated
Patient Placement
- Isolate the patient in a separate room with the door closed.
- Prefer natural ventilation (open windows, cross-ventilation).
- If available, use a negative pressure room.
- Minimise time in shared waiting areas.
Environmental Controls
- Do not recirculate air from the isolation room into general clinic spaces.
- Room should have ≥12 air changes per hour (natural or mechanical). [1]
2. Droplet Precautions
Diseases
- Influenza
- MERS-CoV
- N. meningitidis (meningococcal disease)
- Pertussis (whooping cough)
- Mumps
Staff PPE
- Surgical mask
- Eye protection if splash risk exists
- Gloves and apron for patient contact
Patient Placement
- Maintain 1–2 metre distance between the patient and other patients/staff when not examining.
- The patient must wear a surgical mask when outside the examination room.
- Seat in a designated corner or last row of the waiting area to reduce exposure. [1]
A patient with suspected influenza sitting in the main waiting area for 2 hours defeats the purpose of PPE in the consultation room. Provide a mask at registration and reduce waiting time if possible.
3. Contact Precautions
Diseases / Conditions
- MRSA (methicillin-resistant Staphylococcus aureus)
- Other multidrug-resistant organisms (MROs)
- C. difficile
- Herpes simplex (disseminated or severe)
- Norovirus
- Scabies
- Extensive skin infections
Staff PPE
- Gloves
- Plastic apron or gown
- Hand hygiene before and after patient contact
Patient Movement
- Limit patient movement to essential clinical areas only.
- Do not send the patient to pharmacy, x-ray, or lab without first notifying those units.
- Use dedicated equipment (stethoscope, BP cuff) where possible, or disinfect thoroughly after use.
Terminal Cleaning
After the patient leaves:
- Do not perform a quick wipe-down.
- Initiate terminal cleaning — deep clean from top to bottom:
- Start with highest surfaces (light fittings, shelves).
- Work down to beds, chairs, and floors.
- Use appropriate disinfectant for the surface.
- Clean and disinfect all reusable equipment used on the patient. [1]
Quick Reference Table
| Precaution | Diseases | Patient Mask | Staff Mask | Distance | Room |
|---|---|---|---|---|---|
| Airborne | TB, measles, varicella | Surgical (if tolerated) | N95 | N/A | Isolate + ventilation |
| Droplet | Influenza, MERS-CoV | Surgical | Surgical | 1–2m | Single room preferred |
| Contact | MRSA, MRO, norovirus | Not required | Surgical if indicated | N/A | Single room if available |
Emerging Framework: CDC 2024 Draft
The CDC's Draft 2024 Guideline to Prevent Transmission of Pathogens in Healthcare Settings is restructuring how transmission-based precautions are categorized. The traditional "Droplet vs. Airborne" dichotomy does not accurately capture the true continuum of how respiratory pathogens spread through the air. [?]
The updated framework divides transmission into two broad pathways: Touch and Air.
Preventing Transmission by Touch
| Precaution | Setting | Action |
|---|---|---|
| Contact Precautions | All settings | Gown and gloves on room entry; dedicated or thoroughly disinfected equipment between uses. [1] |
| Enhanced Barrier Precautions | Skilled nursing facilities | Gowns and gloves during high-contact care (bathing, wound care, linen changes) for residents colonized with MDROs. Residents are not room-restricted. [?] |
Preventing Transmission through the Air
The old Airborne and Droplet categories are replaced with three tiers based on transmission efficiency and distance:
| Tier | Pathogen Profile | Staff PPE | Room Requirements |
|---|---|---|---|
| Routine Air Precautions | Endemic, common respiratory pathogens (e.g., seasonal colds) spread predominantly over short distances | Standard surgical mask on entry | Private room preferred; AIIR not routinely needed |
| Special Air Precautions | New or emerging pathogens causing more than mild illness; not expected to spread through facility ventilation | Fit-tested N95 respirator (or higher) | Private room indicated; AIIR generally not required |
| Extended Air Precautions | Highly contagious pathogens observed to spread efficiently over long distances and extended times (e.g., TB, measles) | N95 respirator (or higher) | AIIR with negative pressure mandatory [?] |
This CDC 2024 framework is still in draft status and has not been adopted by the Malaysia Ministry of Health. Continue to use the traditional Contact / Droplet / Airborne model for daily clinical operations until official national guidance is updated.
Special Populations
| Population | Identification Challenge | Solution |
|---|---|---|
| Unconscious / altered | Cannot state name or symptoms | Verify identity via companion + wristband + IC. Use full PPE until risk is known. |
| Paediatric patients | Child may not describe symptoms | Verify child's name + parent's IC. Assess based on parent report and visual cues (rash, cough). |
| Cognitive impairment | Patient may wander or resist isolation | Assign a staff member to observe. Use gentle redirection. Notify caregiver. |
| Non-Malay speaking patients | May not understand isolation instructions | Use multilingual staff, pictograms, or family interpreters. Document the method used. |