Use this SOP to isolate patients with potentially contagious conditions, protect patients and team members, and decontaminate the affected area safely.

DO NOT ENTER UNTIL

DATE: ____________________    TIME: ____________________

The posted time must be exactly two hours after the patient leaves. No routine reentry is permitted before that time.

📚 Resources Needed

  • A designated isolation examination room or the closest available examination room with a door that closes completely

  • Patient face masks and any other personal protective equipment needed to reduce transmission

  • A PPE Kit or Spill Kit containing a protective gown, gloves, mask, goggles, and hair cover

  • A reusable DO NOT ENTER UNTIL sign and a way to record the calculated date and time

  • EPA-approved disinfectant with a current status and effectiveness against HIV, HBV, and tuberculosis

  • Cleaning solution, disposable cleaning materials, and other required cleaning equipment

  • Red, leakproof biohazard bags that can be sealed

  • If used, a freshly prepared 10% bleach solution made from a product containing at least 5.25% sodium hypochlorite

  • The site-specific isolation procedure and current practitioner instructions

✅ Before You Start

  • All team members must be able to demonstrate or verbally explain the site-specific isolation procedure and must know where this written SOP is located.

  • Apply Standard Precautions to every patient, regardless of known infection status.

  • Treat blood, all body fluids, non-intact skin, and mucous membranes as potentially infectious for HIV, HBV, HCV, and other bloodborne pathogens.

  • Follow the OSHA-mandated Universal Precautions program, including work-practice controls, engineering controls, bloodborne-pathogen orientation and education, and required recordkeeping.

  • Confirm masks, PPE, disinfectant, cleaning supplies, biohazard bags, and the DO NOT ENTER UNTIL sign are available.

🚀 Tips & Tricks

  • Keep patient masks and the isolation sign where reception and clinical staff can reach them immediately.

  • Record the patient departure time first, then calculate the reopening time by adding exactly two hours.

  • Limit contact to the fewest team members necessary and keep the examination-room door fully closed.

  • Keep the door closed while cleaning and maintain required PPE until cleaning and waste disposal are complete.

📘 Instructions

Step 1: Recognize A Potentially Communicable Condition

  • If Patient came in without a mask, immediately provide them with one.

  • If a patient may have a communicable disease, begin the isolation procedure immediately.

  • If respiratory symptoms are present, provide the patient with a face mask. Provide any other PPE needed to reduce opportunities for microorganism transmission.

Step 2: Isolate The Patient Immediately

  • Take the patient immediately to the designated isolation examination room (Room 3) or the closest available examination room.

  • Place the patient in the room and close the door completely.

  • Immediately notify the physician or on-site practitioner and request that the patient be seen as quickly as possible.

  • Wipe the reception counter with an EPA-approved disinfectant cleaning solution, then continue seeing other patients.

  • If the patient must leave the examination room, including to use the restroom, the patient must wear a face mask covering the nose and mouth at all times and must return immediately to the designated isolation room.

  • Allow only the minimum number of team members necessary to have contact with the patient. Maintain Universal Precautions at all times.

Step 3: Follow The Practitioner’s Determination

  • If the practitioner determines the patient does not have a communicable disease, clean the room as usual between patients and return it to service.

  • If the practitioner determines the patient does have a communicable disease, follow the practitioner’s directions and orders without variation, then complete every remaining step in this SOP.

Step 4: Prepare The Patient And Team Member To Exit

  • When the practitioner indicates that the patient needs a mask, put on the protective gown, gloves, mask, and goggles from the PPE Kit or Spill Kit before assisting the patient.

  • Assist the patient with placing the mask on correctly.

  • Escort the patient out the front door. Ensure you and they do not touch anything on the way out.

Step 5: Close The Room For Two Full Hours

  • As soon as the patient leaves, record the departure date and time and calculate the reopening time by adding exactly two hours.

  • Post the DO NOT ENTER UNTIL sign on the examination-room door with the calculated date and time.

  • The room must remain closed for two full hours after the patient leaves, no matter what. Do not return the room to patient care early, even if cleaning is completed before the posted time.

  • Only authorized team members performing required cleaning may enter during the closure period, and they must use required PPE. Keep the door closed while the room is being cleaned.

Step 6: Clean And Decontaminate The Room

  • Return with the required cleaning solution, disposable materials, and equipment while wearing the required PPE.

  • Keep the room door closed throughout cleaning.

  • Use Caviwipes or a decontamination product with a current EPA-approved status that effectively kills HIV, HBV, and tuberculosis. A manufacturer claim that the product kills tuberculosis is understood to mean the product also effectively kills HIV and HBV.

  • Reconstitute and apply every decontamination product according to the manufacturer’s decontamination instructions.

  • Pre-clean visibly soiled surfaces before disinfecting because organic matter such as dirt, blood, or excrement can inactivate sodium hypochlorite and reduce disinfectant effectiveness.

  • Allow surfaces to air dry or remain wet for the full contact time stated on the product label before drying them.

Step 7: Use Bleach Correctly When Selected

  • If a 10% bleach solution is used, prepare it from a bleach product with a minimum sodium hypochlorite concentration of 5.25%.

  • Change or reconstitute the solution every 24 hours because bleach becomes unstable after it is mixed with water.

  • Clean the surface before applying bleach, then allow the surface to air dry or remain wet for the label-specified contact time.

  • Follow the manufacturer’s directions for the specific bleach product carefully.

Step 8: Dispose Of Contaminated Materials

  • Place all trash and exposed disposable items in a red, leakproof biohazard bag.

  • Include the protective gown, mask, gloves, hair cover, and other disposable PPE worn while cleaning.

  • Seal the biohazard bag and handle it according to Besa Health’s hazardous and medical-waste procedures.

Step 9: Reopen The Room Only After The Posted Time

  • Do not remove the sign or return the room to patient care before the posted DO NOT ENTER UNTIL date and time.

  • At or after the posted time, confirm decontamination is complete, contaminated materials are removed, the biohazard bag is sealed, surfaces are dry, and required supplies have been restocked.

  • Remove the sign and return the room to service only after every completion-check item is satisfied.

🦠 Examples Of Communicable Diseases

  • Droplet Precautions: influenza, pertussis, COVID-19, meningitis, and mumps

  • Contact Precautions: MRSA, VRE, C. difficile, and norovirus

  • Airborne Precautions: tuberculosis, measles, rubella, and chickenpox

🛠 Troubleshooting

No Examination Room Is Immediately Available

Provide the appropriate mask or PPE, separate the patient from others as much as possible, notify the practitioner immediately, and make the closest available examination room ready without delay. If there is a chance we won't have a room in the immediate, please send the Patient to UCI Medical Center on Main Street

The Patient Must Leave The Room Before Discharge

Make sure the patient wears a face mask over the nose and mouth at all times, minimize the route and contact with others, and return the patient immediately to the isolation room.

The Sign Has No Reopening Time

Do not leave the sign incomplete. Record the patient’s departure date and time, add exactly two hours, and write the resulting date and time on the sign before leaving the doorway.

Cleaning Is Completed Before Two Hours Have Passed

Keep the room closed and keep the sign posted. Cleaning does not shorten the required two-hour closure.

Disinfectant Status Or Instructions Cannot Be Confirmed

Do not use the product. Obtain an EPA-approved product with current status and follow its manufacturer instructions for dilution, application, and contact time.

The Practitioner Determines The Condition Is Not Communicable

Clean the room as usual between patients and continue using the room. The two-hour closure applies when the practitioner determines the patient has a communicable disease.

✅ Completion Check

Confirm every item before removing the sign and returning the room to patient care:

  • Team members can demonstrate or verbally explain the site-specific isolation procedure and locate this written SOP.

  • The patient received a face mask for respiratory symptoms and any other needed PPE.

  • The patient was placed immediately in a closed examination room, and the physician or on-site practitioner was notified without delay.

  • The reception counter was disinfected, patient movement was minimized, and Universal Precautions were maintained.

  • The practitioner’s directions and orders were followed without variation.

  • The patient was assisted with the mask and escorted to the closest exit, preferably without passing through the waiting room.

  • The DO NOT ENTER UNTIL sign shows a reopening date and time exactly two hours after the patient left.

  • The room remained closed for the full two hours and was not returned to patient care early.

  • The room was cleaned with the door closed, required PPE was used, and an appropriate EPA-approved disinfectant was applied according to its manufacturer instructions.

  • Any bleach solution used met the concentration requirement, was no more than 24 hours old, and was applied after pre-cleaning for the required contact time.

  • All trash, exposed disposable items, and disposable cleaning PPE were placed in a sealed red, leakproof biohazard bag.

  • The room was reopened only after the posted time and after decontamination, drying, waste removal, and restocking were complete.