By Elizabeth Srejic
Healthcare-associated infections (HAIs) are a major health concern, despite being largely preventable.(1) Standard precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered.(2-3) These basic but effective practices are designed to both protect healthcare workers (HCW) and prevent HCWs from spreading infections among patients.(4)
“Standard precautions largely have their roots in the beginning of the HIV epidemic,” says Betsy Todd, MPH, RN, CIC, clinical editor for the American Journal of Nursing, a registered nurse with more than 40 years of experience and a nurse epidemiologist. “They were originally called ‘universal precautions’ and their emphasis was on using practices that would prevent the spread of bloodborne pathogens like HIV, hepatitis B or hepatitis C. And then the Centers for Disease Prevention and Control (CDC) changed the name from ‘universal precautions’ to ‘standard precautions.’”
That name change, which occurred in 1996, reflected the evolution of the guidelines over the years into recommendations with a broader focus than universal precautions including bloodborne, airborne and epidemiologically important pathogens.(5)
“The emphasis went from concern over spreading only bloodborne pathogens to concern over transmitting any type of pathogen,” Todd says. “In other words, we’re not supposed to give anybody anything that they didn’t walk in here with.”
Another principle embodied in the changing of the term is standardization of practices, Todd says.
“One of the things I like about the change in terminology is the subtle difference between the terms and what it signifies,” Todd adds. “Universal precautions means that these practices should be used for all encounters but standard precautions for me better emphasizes that they are the absolute basis for practice: this is the standard and we always use it for everything that we’re doing.”
According to Todd, one of the most significant breaches in standard precautions is hand hygiene.
“I think hospitals have been forced to get really good at the big things in infection prevention but the basics like hand hygiene and surface disinfection still need attention,” she says. “With hand hygiene we know that we don’t practice it as often as we should and technique is really important -- not only with washing your hands in soap and water but also in alcohol rubs or gels. I’m surprised at the number of clinicians who think that if you just slap some alcohol rub on your hands and move on then your hands are in wonderful shape to touch another patient. Like using soap and water, using alcohol gel takes technique. You do need to rub it all over your hands, run your fingernails across your palms to try to get the alcohol rub up there and rub it up past your wrists. Those are all important in really keeping your hands as clean as you can. And alcohol-based products that are used prior to aseptic technique or in surgical settings need to be used differently because the different brands are all different, the instructions are all different, and we have to do what the manufacturer has tested and set forth.”
Todd proposes that HCW monitoring might be a solution to ensuring hand hygiene compliance. “Maybe the use of special ID cards so that we can monitor how often individual staff members are cleaning their hands could help to enforce hand hygiene practices,” she says. “But an-other significant factor in compliance is organizational factors. You can’t clean your hands properly if you’re extremely short staffed. You won’t know how to clean your hands prior to a surgical procedure if there isn’t enough education staff and all staff haven’t been trained in proper usage. So the whole idea of having enough staff, proper training, and a code that says that these things are important are really key to solving the hand hygiene problem.”
Another significant breach in standard precautions is following isolation protocols, according to Todd.
“Following isolation protocols and the proper donning and doffing of isolation gear has been a big breach,” she says. “Fortunately I think that due to tragedies related to the current Ebola epidemic we’re getting a little better at isolation protocols. It was so interesting to me that during the Ebola scare all of a sudden HCW were saying, ‘Oh my goodness, we have to put gowns on a certain way to protect ourselves or we could die!’ Well, yes. But the whole area of donning and doffing isolation gear -- that’s not new. We are doing some new things in the Ebola epidemic but specific donning and doffing procedures are not new. You have HCW in hospitals who have patients on contact isolation and they kind of throw on their gown and they don’t bother to tie it at the neck because they’re just too busy and it’s hanging down their chest and such, and so they contaminate their uniform and theoretically four days later the patient down the hall has a MRSA pneumonia. Nobody can connect that to an individual staff transmission but we haven’t even been thinking about the fact that if we’re sloppy with our protocols it’s possible for us to carry those nasty organisms to another patient. But we’ve finally woken up because the person who could be contaminated and die is us. So I hope that the importance of these protocols to protect our patients as well as ourselves turns out to be a really enlightening moment for everyone in healthcare.”
Surface disinfection protocols are another routinely violated precaution, Todd says.
“Disinfection of all of the things we use with patients is important,” she says. “But those routine disinfections in an outpatient setting -- like wiping down the chairs between patients or how rooms are cleaned in between patients after discharge and so forth -- are really important and don’t happen magically. With some products you have to let them sit wet on surfaces for a certain amount of time to kill all the germs as they can kill for you. And that whole idea of contact time is still not that ingrained in a lot of people’s minds in hospitals. It applies to disinfecting your stethoscope between patients and making sure that you’re getting the area wet and rubbing thoroughly, and it applies to putting antiseptics like alcohol or chlorhexadine on a patient’s skin before drawing blood. You have to disinfect the area; you don’t just give it a quick wipe and assume that all the germs are magically gone. “
Todd also cites sharps handling as another area of concern within practicing standard precautions.
“We know how to protect ourselves -- with safety-engineered sharps, proper sharps handling protocols, safe disposal and so on -- although still some organizations are behind even in the basics, but I think in most organizations the really big area for improvement for workers is the efficiency of response to a sharps-related injury,” she says. “Some hospitals and healthcare organizations still have not streamlined their processes to be sure that when a staff member is cut with a sharp or splashed in the face with fluids, that they get evaluated immediately and receive proper prophylaxis and support if needed. Because even if statistically the device that caused the injury or circumstances or source pa-tient might be low risk, it might still be perceived as a scary experience for the person who has been injured.”
The sharps issue, like every element of standard precautions, is inextricably one of protecting both HCW and patients, Todd adds.
“Part of sharp safety for workers is that any organization should have absolutely zero tolerance for sharps injuries to non-clinical staff,” she says. “When non-clinical staff gets injured it almost always means one of us clinicians -- who are the only people who are supposed to be the only people handling sharps -- did something wrong. Maybe someone left a needle where they shouldn’t have -- put it on a dietary tray, left it on a seat, threw it away in a wastebasket, etc. Even with the best protocols, even with safety-engineered sharps, there are going to be circumstances, unfortunately, in which clinicians get stuck. But it shouldn’t happen to housekeepers, dietary workers, and maintenance crew and so on. And the other half of the sharps issue is protecting patients. In my opinion, a lot of organizations are not following best injection practices. I’ve been involved in investigating some highly publicized incidents where hundreds of patients have to be followed up and evaluated for bloodborne pathogens because there was a safety breach at a doctor’s clinic or even a hospital. And there are practices that were routine early in my career that have since been shown to transmit infection. Even if you change needles you cannot use the same syringe to re-enter a vial. Single dose vials are always single-dose vials -- even if there’s enough left over for another dose, you don’t re-enter the vial and use that drug for another patient. You never use the same syringe for multiple patients even if you have a new needle. Glucometers and insulin pens are only intended for use by one individual patient and you don’t share them even if you change the needle in between or clean off the device. There’s a wonderful website -- oneandonlycampaign.org -- that really emphasizes the concept of one needle, one syringe, one patient, one time only.”
In conclusion, Todd opined that organizational commitment is essential in ensuring that standard precautions are successfully practiced.
“All of these issues are going to remain hard problems until organizations really commit to commit to having the staff and the education in place to make sure that the people really understand the impact of these basic procedures and how we can do them properly,” she says. “We all really need to fine-tune our infection prevention skills. We need to always be thinking what is the risk to me in the situation I’m working in and what is the risk to my patients? We need to really think through what we’re doing and really apply what we know.”
Elizabeth Srejic is a freelance writer.
1. Carter EJ, Pouch SM, Larson EL. Common infection control practices in the emergency department: a literature review. Am J Infect Con-trol. 2014 Sep;42(9):957-62.
2. Huang GK, Stewardson AJ, Grayson ML. Back to basics: hand hygiene and isolation. Curr Opin Infect Dis. 2014 Aug;27(4):379-89.
3. Centers for Disease Control and Prevention Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. September 9, 2014. Accessed Feb. 15, 2015. http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-precautions.html.
5. West KH, Cohen ML. Standard precautions--a new approach to reducing infection transmission in the hospital setting. J Intraven Nurs. 1997 Nov-Dec;20(6 Suppl):S7-10.