Standard Precautions

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Standard Precautions

By Nancy B. Bjerke, BSN, RN, MPH, CIC

Objectives:

1. Describe the evolution of standard precautions.

2. Review the purpose of standard precautions.

3. Explain the basic requirements for standard precautions.

 The pandemic of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in the 1980s challenged healthcare personnel. The emotional response to a public health threat required a focus on the essential issue: how do healthcare personnel in all practice settings provide care and services to infected patients while protecting themselves from acquiring the disease? The steadfast and credible advice from Centers for Disease Control and Prevention (CDC) reflected a principle that has become routine for personnel in a diverse healthcare arena. This article describes the evolution of standard precautions, reviews the purpose of standard precautions and addresses the basic requirements for standard precautions.

The Evolution

In 1877, infected patients were quarantined with other sick patients in special houses known as infectious disease hospitals. However, patients acquired other infectious diseases from infected patients until those with the same diseases were grouped in the same room. This was isolation and the cohort concept.1 Observations by healthcare personnel noted that controlling the spread of disease would involve more prevention, thus nursing aseptic procedures were added to control disease transmission.2

By 1910, the cubicle system of placing infected patients in multiple-bed wards was introduced. Nurses wore gowns as barrier attire and antiseptic hand cleansing followed patient contact. Disinfection of patient-contaminated objects was accomplished.3 In 1950, when Staphylococcus outbreaks were occurring, infected patients were segregated in a single, specially designed isolation room or regular hospital patient room.4 By the 1960s, designated infectious disease and tuberculosis hospitals closed.

In 1970, CDC published its initial isolation techniques, "Isolation Techniques for Use in Hospitals," detailing the requirements and rationale for safe patient isolation practices in hospitals of varying size. A colored card system of isolation was developed designating five categories: strict isolation, respiratory isolation, protective isolation, enteric precautions and wound and skin precautions. Additionally, procedures for controlling cross infection from diseases were blood discharge precautions and discharge precautions, to include excretion and lesions or oral secretions.5 In naming blood discharge as a possible source for infectious disease transmission, the guidance focused on hepatitis, malaria, arthropodborne viral fevers and the septicemia stage of infectious disease. In the 1975 revision, specific safety requirements pertained to disposable needles and syringes with no recapping, reuse and purposely bending them before depositing them in a prominently labeled, impervious, puncture-resistant container for incineration or autoclaving before discarding. An appendix listed diseases alphabetically with type and duration of isolation or precaution, which referred to the cards for required protective attire, such as mask, gown and gloves.6 Updated isolation techniques came in 1978 as new syndromes were identified.7

By 1983, the title of "techniques" changed to guidance and involved a panel of outside infection control and prevention experts, who consulted with CDC personnel on the development of these guidelines. The momentum toward prudent practices was built on well-documented modes of transmission espoused in epidemiological studies and on theoretical rationale. This was the initial mention of a ranking system for isolation recommendations and facility implementation. The major change in the 1983 guidelines was designating seven isolation categories: strict isolation, respiratory isolation, contact isolation, tuberculosis isolation, enteric precautions, drainage/secretion precautions and blood/body fluid precautions. Healthcare workers (HCWs) employed their critical decision-making skills to protect themselves with barriers, to tailor the precautions based on the age and behavior of the patient in isolation and to establish a balance between the ideal and the practical precautions to isolate the disease, not the patient. These guidelines offered a choice of a familiar category specific or disease specific system, with each facility being given options to decide on a system and modify it as necessary to suit their facility's needs. While CDC guidance focused on the acute care practice setting, adaptation in other extended-care facilities was accomplished by modifying the requirements to the patient population and infectious diseases. The 1983 blood and body fluid precautions merited its own pink card, indicating that contact with these wet substances required barriers and immediate handwashing post-exposure and before caring for another patient. The reminder of safe sharp handling, bagging contaminated patient equipment before transferring for reprocessing and cleaning blood spills with a 5.25-percent sodium hypochlorite dilution (1 part bleach to 10 parts water) addressed known or suspected patients with a bloodborne pathogen infection. The listed diseases expanded to babesiosis, variant Creutzfeldt-Jakob disease (vCJD), leptospirosis, rat-bite and relapsing fevers and syphilis.7

In August 1987, CDC initially introduced the concept of Universal Precautions (UP), stating blood and certain body fluids of all patients are considered potentially infectious for HIV, hepatitis B virus (HBV) and other bloodborne pathogens, regardless of their bloodborne infection status.8 The UP requirements espoused barrier techniques to block persons from bodily fluid exposure, reiterated the safe handling of sharp medical devices and supported vaccination against HBV. A clarification on UP emphasized that visible blood in body fluids required barrier protection when contact, handling and disposition of these fluids occurred.9 In 1987, another approach, Body Substance Isolation (BSI), advocated all moist body substances were potentially infectious and gloves should be worn for anticipated contact with these substances.10

On Dec. 6, 1991, Occupational Safety and Health Administration (OSHA) mandated UP as a protective approach against occupational exposure of HCWs.11 The federal law adopted the 1987 CDC guidance of UP and added other requirements to further protect HCWs. OSHA is focused on worker and worker-patient protection, not patients exclusively.

As epidemiological debates continued, hospitals modified or created their own isolation precautions and greater compliance with barrier protection became routine. The term "standard precautions" (SP) appeared in the 1996 CDC isolation revision. The preamble to these recommendations explains that SP are a synthesis of two other precautions (UP and BSI) and apply to all patients receiving healthcare, regardless of their diagnosis or presumed infection status.12 Thus, SP is the current isolation terminology and the fundamental premise employed by healthcare personnel when rendering care to every patient. (Note: For the dental arena, UP equals SP; thus, these workers may still use the term UP.)

The Purpose

The goal of isolation techniques is to prevent the spread of communicable diseases in hospitals and microorganisms among patients, personnel and visitors. These practical techniques evolved to control cross infection, namely patient to HCW and HCW to patient. Throughout the presentation of safe options to contain and confine disease transmission, the guidance states facilities are encouraged to modify the isolation recommendations to suit the practice setting and patient needs. This adaptation requires explicit written policies and procedures to ensure the proper application of the principles in the delivery of services and patient care. Prevention, control and reduction of infection remain the triad for safe practice. SP offers the safest standard of practice for patient care when healthcare personnel and providers adhere to its consistent application in each circumstance.

The Requirements

Isolation techniques evolved from the absence of any barriers to the current practice of fluid resistant, disposable and reusable barriers. Known as personal protective equipment (PPE) or personal protective attire (PPA), these barriers minimize the risk of bodily fluid exposures to healthcare personnel by protecting skin and mucous membranes from potentially infective materials. PPE/A are numerous in design, type, style, size, color and effectiveness in the multifaceted arena of patient care. The selection of appropriate protective attire is dependent on the procedure to be performed and the anticipated exposure that might occur. Employing the CDC recommendations, the federal mandate of 199111 delineated these same specific requirements for UP and PPE/A and added others to include education, post-exposure protocols, record keeping and a written exposure control plan. These essentials are applicable for SP despite the term change.

Gloves are manufactured in many styles using various base materials. They are available as disposable, reusable, sterile, nonsterile, mesh reinforced, powdered and nonpowdered, to name a few. Regardless of the many options in selecting glove type, quality and price range, user problems associated with continual wearing of gloves persist. The severity of latex allergies, for example, may pose inherent risks equal to the direct exposure of hands to contaminated bodily fluids. Despite the 1980s manufacturing challenges of greater demand than supply, gloves are routine attire for protection against bodily fluid contact, including blood, mucous membranes, secretions, excretions and nonintact skin. Gloves also reduce the risk of cross contamination from healthcare personnel to patients, and patient or fomite to healthcare personnel. Emphasis on the necessity to wash hands after glove removal remains a sound practice and federal mandate -- it's the law. Gloves are permitted to have small manufacturing-related defects, yet be cleared for market and healthcare-related use in the United States. Microorganisms are aggressive in their determination to press on, affix and invade new frontiers. Their maverick modes of behavior aim to cause host harm. Thus, glove use does not negate the hand cleansing practice, but reinforces the essential habit to wash bioburden away after glove removal, regardless if visible soilage is noted. Glove are required to be changed when personnel deliver care at one specific body site and then must move to another body site on the same patient for more care. For example, touching patient's genitals while assessing patency of the Foley catheter, then changing the surgical dressing. These care tasks require gloves be worn; however, the gloves are removed and hands cleansed after the Foley assessment and a fresh pair of gloves are donned before the dressing change occurs. The attending caregiver does not wear the same gloves for the whole episode of care on this single patient, as cross contamination of microbes from one body site can be transmitted to another body site on this same patient.

Mask choices include disposable or reusable types; individual or with attached eye protection; efficacy in protection against fluids, microbes and vapors; different colors; and various sizes and attributes. Coverage requirements for the nose and mouth and fluid resistance apply with this PPA. Protection is focused on unanticipated splashes from potentially infective bodily fluids. A new mask per episode of patient care is the norm with more frequent changing if the mask is moist and no longer provides an effective barrier from exposure. Disposal is immediate after care; the mask should not be worn around the neck for later use.

Gowns and protective apparel are options HCWs have to protect their clothing and skin from contamination during patient care or indirect services rendered in support of patient care. Some of these items include aprons, body suits, jackets and coats. Protective head covering and footwear are more common in surgery, mortuary, processing or trauma situations. The fluid-resistant characteristic applies to these choices. Like the previous requirements, the selection choices are numerous; yet efficacy in protection is fundamental. Disposable and reusable items are worn once per patient contact. If an apparel piece like an apron is shared, it is cleaned after use and definitely before the next person wears the item.

Eye protection requires preplanning. Donning eye equipment only works before the splash or spatter occurs, not after the exposure. The fluid resistance aspect is fundamental. Whether the item is reusable as in a face shield, community shared goggles, or personal athletic eye wear, immediate cleaning of the reusable item is essential to prevent cross contamination, namely conjunctivitis, among wearers. For disposables, the options are frequently attached to disposable masks. The clear plastic normally protects the entire eye region (front and sides), fits over corrective vision glasses and does not hamper visual acuity.

The work practices, engineering controls, immunizations and other requirements of UP are applicable for isolation containment and personal protection against blood and bodily fluid exposure. While the focus has been on isolation evolution, UP and SP are similar in that blood is a source of pathogens and provides a vehicle of infectious and communicable disease transmission to others. Although an intraoperative cleaning concept, the contain-and-confine principle applies to isolation. Every patient and every operation should be considered a possible source of cross contamination ... the area of contamination should be confined to as small an area as possible ... to an area close to the patient ... items that become contaminated must be contained to prevent cross contamination.13 This principle has applications in many healthcare activities, including isolation.

Summary

The original quarantine of infected patients to infectious disease hospitals occurred in the late 1800s, but evolved to isolation rooms by the early 1900s due to increasing knowledge about microorganisms, infectious diseases and epidemiology of infection. With differential modes of disease transmission, specific categories of isolation became disease-specific precautions, as a means to a more tailored approach to patient uniqueness. These precautions were further diversified into a federally mandated UP approach focused on minimizing exposures and disease acquisition. The current tiered system of isolation advocates SP for each patient and transmission-based precautions for special patient needs. Standard precautions are universally applicable to all patients, are fundamental to patient care and are the standards of practice by every HCW. As the epidemiology of microbes, disease processes and host responses unfold and expand our knowledge, strategies to prevent, control and reduce widespread infections are built on the foundation of contain and confine with the goal of protecting others from acquiring these adverse conditions.

Test Questions: True or False T F
1. Standard Precautions only apply to visible blood in bodily fluids.
2. Isolation techniques were designed primarily to protect healthcare workers.
3. Infectious disease hospitals preceded the cubicle concept of quarantine.
4. Eye protection is a requirement for both universal and standard precautions.
5. Negative pressure rooms are essential to standard precautions.
6. The danger of disease transmission by blood is a significant threat to HCWs.
7. Hands are cleansed of bioburden with soap and water.
8. The contain-and-confine approach minimizes communicable disease transmission.
9. Handling of sharp medical devices was advocated before federal mandate.
10. Isolation practices are designed to isolate the patient, not the disease.

Answers

1. F

2. F

3. T

4. T

5. F

6. T

7. T

8. T

9. T

10. F

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