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By Phenelle Segal, RN, CIC, FAPIC
The practice of standard precautions has evolved from infection control practices that began as far back as the Middle Ages. Isolation of potentially infectious patients began strictly for inpatients in acute care hospitals and eventually became common practice in non-acute care facilities including long-term care, behavioral health and outpatient settings.
This article discusses the history of isolation precautions, how standard precautions evolved, components and finally, the contrast between inpatient and outpatient practices.
History of Isolation Precautions
As far back as the 14th century, the practice known as quarantine began in Italy, when ships coming into Venice from areas known to be infected, had to anchor for 40 days before docking to protect people from the plague.
By the early 1900s rudimentary precautions were being practices including wearing of barrier gowns and the beginning of antisepsis especially with respect to hand hygiene and disinfection. These practices were known as “barrier nursing.”
In 1970, a manual titled “Isolation Techniques for Use in Hospitals” was developed and published by the Centers for Disease Control and Prevention (CDC) primarily as a guide for general hospitals. In 1975, the manual was revised and introduced precaution categories. In 1983, the CDC Guideline for Isolation Precautions in Hospitals replaced the isolation manual from 1975 and was a more robust manual, giving staff the ability to make decisions.
The concept and practice of universal precautions (UP) was introduced as a new strategy for isolation following the epidemic of HIV, after needlestick injuries were documented as a source for healthcare workers being infected from the blood of positive patients. This approach began the era of recognizing that all patients should be placed on blood and body fluid precautions as many undiagnosed patients are potentially a source of infection.
Body Substance Isolation
After a few years of study, a new form of isolation known as body substance isolation (BSI), was proposed in 1897. BSI focused on the isolation of all moist and potentially infectious body substances from all patients, regardless of their presumed infection status, primarily through the use of gloves. The airborne route of transmission was introduced and nurses would determine use of masks.
Standard Precautions: Evolution
By the early 1990s, as a result of confusion related to UP and BSI, isolation practices were overhauled and an “enhanced” set of precautions called standard precautions, were designed to reduce the risk of transmission of bloodborne and other pathogens in hospitals. In conjunction with standard precautions, transmission-based precautions were introduced to reduce the risk of airborne, droplet, and contact transmission in hospitals.
Standard Precautions: Components
Standard precautions is well documented in the 2007 CDC “Guideline for Isolation Precautions" and applicable to most settings with variations for individual facilities. Standard precautions includes hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield. Also, patient-care equipment or items must be handled in a manner to prevent transmission of infectious agents, (e.g., wear gloves for handling, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment). Eventually, the CDC introduced safe injection practices, infection control practices for special lumbar puncture procedures, respiratory hygiene and cough etiquette into the guide.
Hand hygiene includes handwashing with either plain or antiseptic-containing soap and water, and/or use of waterless alcohol-based products (gels, rinses, foams). In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience.
Personal Protective Equipment (PPE): Gloves are worn when staff is anticipating contact with blood, body fluids, secretions, excretions, contaminated items and when touching mucous membranes and nonintact skin. Gowns are worn when procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated. Mask, eye and face protection are worn during procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation. During aerosol-generating procedures on questionable patients a fit-tested N95 or higher respirator in addition to gloves, gown and face/eye protection is indicated.
Patient-care equipment should be handled in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene.
Environmental controls for routine care, cleaning, and disinfection of environmental surfaces should be used, especially frequently touched surfaces in patient-care areas.
Textiles and laundry are to be handled in a manner that prevents transfer of microorganisms to others and to the environment.
Safe injection practice includes an extensive list of practices that enhance safety for patients and employees. The Association for Professionals in Infection Control and Epidemiology (APIC) released a position statement with an update in 2016, detailing practices which can be accessed online at: https://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/2016APICSIPPositionPaper.pdf
Infection control practices for special lumbar puncture procedures include wearing of a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia.
Respiratory hygiene and cough etiquette includes signage in waiting rooms and public areas that are accessed by patients, providing tissues, masks, hand-sanitizer and trash cans, identifying patients who may have a respiratory infection, placing them if possible in a separate area and requesting that they wear a facemask until they are in a location that lessens the risk of transmission, or discharged from the facility. In addition, educating patients and staff about “covering your cough.”
Cleaning of point-of-care devices (e.g., blood glucose and hemoglobin monitoring) includes following manufacturer’s instructions for use (IFUs) ensuring that devices used for more than one patient are appropriately disinfected to eliminate the risk of transmitting blood borne pathogens.
Standard Precautions in the Outpatient Setting
Outpatient services are provided in clinics (hospital and nonhospital based), physician offices, ambulatory surgical centers, free-standing dialysis centers, urgent care centers and more. The risk of patients incubating or presenting with active infections is not unusual for these settings and places others at risk. Infections include childhood diseases, bloodborne pathogens and respiratory illnesses.
The CDC isolation guidelines of 2007 addresses outpatient care in a “global sense” and is still used as a general reference. However, the CDC, recognizing the growing risk of infection transmission in the outpatient setting, released a specific document in 2012 and updated in 2016 that transformed the practice of Standard Precautions for this population of patients. The “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations For Safe Care” is accompanied by a companion checklist and facilities are encouraged to refer to it as the “gold standard” when developing, implementing and sustaining an infection prevention program for outpatient settings. It includes a comprehensive list of practices including hand hygiene, PPE, injection safety (if applicable), respiratory hygiene/cough etiquette, point-of-care testing (if applicable) and environmental cleaning. In addition, device reprocessing is also addressed as many outpatient facilities including surgery centers, are providing services that include the need to reprocess reusable patient care items.
Contrast Between In-Patient and Outpatient Care
Inpatient facilities have been mandated by the federal government through the Centers for Medicaid and Medicare Services (CMS) and accreditation agencies including the Joint Commission and others to strictly adhere to the principles of infection prevention for decades. Every hospital is required to have one or more designated infection prevention professionals with most individuals dedicated solely to the program. Besides ambulatory surgery centers (ASCs) and dialysis centers, most outpatient facilities are not as regulated as hospitals and most non-surgery settings are not accredited. Lack of regulation puts the responsibility on the individual outpatient facilities to designate personnel to direct a program.
ASCs have been under close federal and accreditation scrutiny since 2009 when CMS developed a strict set of measures for use during unannounced surveys after a serious breach in practices occurred in a GI center in Nevada. The CMS surveyor’s worksheet prompted significant change in the way standard precautions and other infection prevention practices are conducted.
Inconsistency in how standard precautions is practiced between acute and outpatient care is also influenced by significant differences in the following:
• Patient placement: In the event of a suspected or documented transmissible infection, acute-care hospitals have private rooms and the Emergency Department will triage patients based on their signs, symptoms and history. An outpatient center lacks the space and resources to separate patients if discharge of the patient is delayed or the patient needs urgent care that must be provided at that location.
• Fiscal resources: Hospitals and other inpatient facilities, largely due to their CMS and accreditation requirements usually allocate more funds for supplies (gloves, masks, gowns, eyewear, respiratory protection devices and more). Outpatient facilities including surgery centers have had to restructure funding for infection prevention programs to ensure that they have the necessary supplies for compliance. This includes the extremely costly safe-injection practice of eliminating the use of multi-dose vials for more than one patient use, due to the liability and labor intensive requirements.
• Human resources: For decades, infection prevention staff has been dedicated in a primary role to the department in acute care hospitals (depending on the nature and size of the hospital). Infection Prevention programs run more efficiently when there is a dedicated infection preventionist for the most part. In the outpatient setting, ASCs for example, are required to have a “designated person,” but that person most often has additional responsibilities and that is a huge challenge for the facility to maintain precautions and practices. Non-surgical settings are even more challenged with respect to human resources as these are often large clinics and facilities with many services offered and staff resources are lacking.
• Education: Is required in the inpatient setting which poses less of a challenge than in the outpatient sector as very often, hospitals have specific education staff to develop and maintain programs. Outpatient settings have a tremendous need for staff and patients to be educated in basic principles of infection prevention including the components of standard precautions. In addition, the infection prevention designee may be required to receive formal training.
Standard precautions form the basis of prevention of transmission of infections in the healthcare settings. These precautions have evolved over time and are practiced across the continuum of care. Each setting has different challenges and practices which is evidenced in the outpatient settings as services offered are diverse and place facilities at risk for transmission of a variety of infections. Education relating to the fundamental principles of transmission prevention and practices that mitigate risk are key elements in infection prevention.
Phenelle Segal, RN, CIC, FAPIC, is president of Infection Control Consulting Services, LLC. (ICCS).