TWO

STANDARD PRECAUTIONS

BACKGROUND

In 1985, largely because of the emergence of HIV/AIDS, guidelines for

protecting healthcare workers from becoming infected with HIV and other

bloodborne infections (e.g., HCV) were quickly developed and became

known as Universal Precautions (UP). Almost from the moment they were

issued and hospitals and clinics began implementing them, it was

recognized that this new strategy, while protecting hospital personnel

(patient-to-personnel transmission), sacrificed some measures of

preventing patient-to-patient and personnel-to-patient transmission.

At nearly the same time that UP were being introduced, a new system of

health worker and patient precautions was proposed as an alternative to

the diagnosis-driven UP (Lynch et al 1987). This approach, called Body

Substance Isolation (BSI), focused on protecting patients and health

personnel from all moist and potentially infected body substances

(secretions and excretions), not just blood. BSI was based primarily on the

use of gloves. Personnel were instructed to put on clean gloves just before

touching mucous membranes or nonintact skin, and before anticipated

contact with moist body fluids (e.g., blood, semen, vaginal secretions,

wound drainage, sputum, saliva, amniotic fluid, etc.).

BSI quickly gained acceptance over UP because it was simple, easy to

learn and implement, and acknowledged that all patients, not just those

diagnosed or with symptoms, may be infected and therefore not free of

risk to other patients or staff. Disadvantages of BSI included the added

cost of protective barrier equipment, particularly gloves, difficulty in

maintaining routine use of the protocol for all patients, uncertainty about

precautions for patients in isolation rooms and the overuse of gloves to

protect staff at the expense of patients (Patterson et al 1991).

As a consequence, by the early 1990s healthcare facilities and staff were

totally confused regarding what to do about patient and staff precaution

guidelines. For example, some hospitals had implemented UP while others

had implemented BSI. Indeed, even hospitals and staff that thought they

were following UP were really using BSI, and vice versa. There was also

much local variation in interpretation and use of both UP and BSI, and a

variety of combinations was common. Moreover, there was continued lack

of agreement about the role of handwashing when gloves were used. This

confusion, coupled with the need to use additional precautions to prevent

diseases spread by airborne, droplet and contact routes, were major

limitations of BSI (Rudnick et al 1993).

In view of these problems and concerns, no simple merging together of

UP or BSI appeared likely to solve them. What has emerged since then is

a new system that provides a single set of isolation guidelines with

logistically feasible recommendations for preventing the many infections

that occur in healthcare facilities through all known modes of

transmission.

STANDARD PRECAUTIONS

The new guidelines issued by CDC in 1996 involve a two-level approach:

ü Standard Precautions, which apply to all clients and patients

attending healthcare facilities, and

ü Transmission-Based Precautions, which apply only to hospitalized

patients (Garner and HICPAC 1996).

As briefly presented, this new system retains features of

both UP and BSI. Moreover, it replaces the cumbersome disease-specific

isolation precautions with three sets of transmission-based precautions for

use in hospitalized patients.

Because most people with bloodborne viral infections such as HIV and

HBV do not have symptoms, nor can they be visibly recognized as being

infected, Standard Precautions are designed for the care of all persons—

patients, clients and staff—regardless of whether or not they are infected.

Standard Precautions apply to blood and all other body fluids, secretions

and excretions (except sweat), non-intact skin and mucous membranes.

Their implementation is meant to reduce the risk of transmitting

microorganisms from known or unknown sources of infection (e.g.,

patients, contaminated objects, used needles and syringes, etc.) within the

healthcare system. Applying Standard Precautions has become the primary

strategy to preventing nosocomial infections in hospitalized patients.

KEY COMPONENTS AND THEIR USE

The key components of the Standard Precautions and their use are outlined. Placing a physical, mechanical or chemical barrier between

microorganisms and an individual—whether a woman coming for

antenatal care, a hospitalized patient or healthcare worker—is a highly

effective means of preventing the spread of infections (i.e., the barrier

serves to break the disease transmission cycle). For example, the following

actions create protective barriers for preventing infections in clients,

patients and healthcare workers and provide the means for implementing

the new Standard Precautions:

ü Consider every person (patient or staff) as potentially infectious and

susceptible to infection.

ü Wash hands—the most important procedure for preventing crosscontamination (person to person or contaminated object to person).

ü Wear gloves (both hands) before touching anything wet—broken skin,

mucous membranes, blood or other body fluids, or soiled instruments

and contaminated waste materials—or before performing invasive

procedures.

• After touching blood, body fluids, secretions, excretions and contaminated items
• Immediately after removing gloves
• Between patient contact

Gloves

Ø For contact with blood, body fluids, secretions and contaminated items

Ø For contact with mucous membranes and nonintact skin

Masks, goggles, face masks

Ø Protect mucous membranes of eyes, nose and mouth when contact with blood and body fluids is likely

Gowns

Ø Protect skin from blood or body fluid contact

Ø Prevent soiling of clothing during procedures that may involve contact with blood

Ø or body fluids

Linen

Ø Handle soiled linen to prevent touching skin or mucous membranes

Patient care equipment

Ø Handle soiled equipment in a manner to prevent contact with skin or mucous

membranes and to prevent contamination of clothing or the environment

Environmental cleaning

Ø Routinely care, clean and disinfect equipment and furnishings in patient care areas

Sharps

Ø Avoid recapping used needles

Ø Avoid removing used needles from disposable syringes

Ø Avoid bending, breaking or manipulating used needles by hand

Ø Place used sharps in puncture-resistant containers

Patient resuscitation

Ø Use mouthpieces, resuscitation bags or other ventilation devices to avoid mouth-tomouth

resuscitation

Patient placement

Ø Place patients who contaminate the environment or cannot maintain appropriate

hygiene in private rooms

§ Use physical barriers (protective goggles, face masks and aprons) if

splashes and spills of any body fluids (secretions and excretions) are

likely (e.g., cleaning instruments and other items).

§ Use antiseptic agents for cleansing the skin or mucous membrane

prior to surgery, cleaning wounds, or doing handrubs or surgical

handscrubs with an alcohol-based antiseptic product.

§ Use safe work practices such as not recapping or bending needles,

safely passing sharp instruments and suturing, when appropriate, with

blunt needles.

§ Safely dispose of infectious waste materials to protect those who

handle them and prevent injury or spread of infection to the

community.

§ Process instruments, gloves and other items after use by first

decontaminating and thoroughly cleaning them, then either sterilizing

or high-level disinfecting them using the recommended procedures.