Contact precautions policy updated

The Infection Control Contact Precautions Policy was updated April 5. The updated policy will require gloves to be worn at all times (donned prior to entering a room) and a yellow isolation gown worn whenever the health care worker, student, or visitor anticipates that their clothing will have direct contact with the patient, potentially contaminated environmental surfaces or equipment in close proximity to the patient.

This policy modification is consistent with recommendations from the CDC and with a recently published Joint Commission Frequently Asked Question (FAQ) response regarding their expectations of when a health care worker must wear an isolation gown.  A link to The Joint Commission FAQ is available here.

The following situations are provided as examples to help clarify when a yellow isolation gown is indicated.

Gown Required

  • A nurse providing a bath, or performing vital signs, or repositioning the patient
  • A physician checking a surgical wound or performing a physical exam
  • A housekeeper cleaning the bed or pulling the trash
  • A visitor, social worker, or dietitian who sits in a chair in the room while talking with the patient
  • A respiratory therapist changing ventilator tubing or adjusting an oxygen mask
  • Health care worker, visitor/parent, volunteer holding a pediatric patient


Gown Not Required*

  • Rounding physicians (e.g., students) who enter the room but do not touch the patient or items in the immediate environment (e.g., bedrails) of the patient
  • Nurse who enters only to check an alarm or to hang a bag of IV fluids and their clothing has no direct contact with the patient or items in the immediate environment of the patient
  • A Dietary worker dropping off or picking up a meal tray or taking a patient’s meal order and the employee’s clothing and electronic dietary pad has no direct contact with the patient or items in the immediate environment of the patient
  • A Maintenance worker performing routine maintenance on a wall fixture


*If you anticipate a gown will not be needed but after entering the room unanticipated contact is indicated that may result in contamination of your clothing, you must leave the room and put on an isolation gown. Before putting on the gown, remove contaminated gloves, perform hand hygiene, and then don the gown and a clean pair of gloves.

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