Standard Precautions

August 1, 2002

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