Standard Precautions

Standard Precautions

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

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) andacquired immunodeficiency syndrome (AIDS) in the 1980s challenged healthcarepersonnel. The emotional response to a public health threat required a focus onthe essential issue: how do healthcare personnel in all practice settingsprovide care and services to infected patients while protecting themselves fromacquiring the disease? The steadfast and credible advice from Centers forDisease Control and Prevention (CDC) reflected a principle that has becomeroutine for personnel in a diverse healthcare arena. This article describes theevolution of standard precautions, reviews the purpose of standard precautionsand addresses the basic requirements for standard precautions.

The Evolution

In1877, infected patients were quarantined with other sick patients in specialhouses known as infectious disease hospitals. However, patients acquired otherinfectious diseases from infected patients until those with the same diseaseswere grouped in the same room. This was isolation and the cohort concept.¹Observations by healthcare personnel noted that controlling the spread ofdisease would involve more prevention, thus nursing aseptic procedures wereadded to control disease transmission.²

By 1910, the cubicle system of placing infected patients in multiple-bedwards was introduced. Nurses wore gowns as barrier attire and antiseptic handcleansing followed patient contact. Disinfection of patient-contaminated objectswas accomplished.³ In 1950, when Staphylococcus outbreaks wereoccurring, infected patients were segregated in a single, specially designedisolation 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, "IsolationTechniques for Use in Hospitals," detailing the requirements and rationalefor safe patient isolation practices in hospitals of varying size. A coloredcard system of isolation was developed designating five categories: strictisolation, respiratory isolation, protective isolation, enteric precautions andwound and skin precautions. Additionally, procedures for controlling crossinfection from diseases were blood discharge precautions and dischargeprecautions, to include excretion and lesions or oral secretions.⁵ Innaming blood discharge as a possible source for infectious disease transmission,the guidance focused on hepatitis, malaria, arthropodborne viral fevers and thesepticemia stage of infectious disease. In the 1975 revision, specific safetyrequirements pertained to disposable needles and syringes with no recapping,reuse and purposely bending them before depositing them in a prominentlylabeled, impervious, puncture-resistant container for incineration orautoclaving before discarding. An appendix listed diseases alphabetically withtype and duration of isolation or precaution, which referred to the cards forrequired protective attire, such as mask, gown and gloves.⁶ Updatedisolation techniques came in 1978 as new syndromes were identified.⁷

By 1983, the title of "techniques" changed to guidance and involveda panel of outside infection control and prevention experts, who consulted withCDC personnel on the development of these guidelines. The momentum towardprudent practices was built on well-documented modes of transmission espoused inepidemiological studies and on theoretical rationale. This was the initialmention of a ranking system for isolation recommendations and facilityimplementation. The major change in the 1983 guidelines was designating sevenisolation categories: strict isolation, respiratory isolation, contactisolation, tuberculosis isolation, enteric precautions, drainage/secretionprecautions and blood/body fluid precautions. Healthcare workers (HCWs) employedtheir critical decision-making skills to protect themselves with barriers, totailor the precautions based on the age and behavior of the patient in isolationand to establish a balance between the ideal and the practical precautions toisolate the disease, not the patient. These guidelines offered a choice of afamiliar category specific or disease specific system, with each facility beinggiven options to decide on a system and modify it as necessary to suit theirfacility's needs. While CDC guidance focused on the acute care practice setting,adaptation in other extended-care facilities was accomplished by modifying therequirements to the patient population and infectious diseases. The 1983 bloodand body fluid precautions merited its own pink card, indicating that contactwith these wet substances required barriers and immediate handwashingpost-exposure and before caring for another patient. The reminder of safe sharphandling, bagging contaminated patient equipment before transferring forreprocessing and cleaning blood spills with a 5.25-percent sodium hypochloritedilution (1 part bleach to 10 parts water) addressed known or suspected patientswith a bloodborne pathogen infection. The listed diseases expanded to babesiosis,variant Creutzfeldt-Jakob disease (vCJD), leptospirosis, rat-bite and relapsingfevers 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 consideredpotentially infectious for HIV, hepatitis B virus (HBV) and other bloodbornepathogens, regardless of their bloodborne infection status.⁸ The UPrequirements espoused barrier techniques to block persons from bodily fluidexposure, reiterated the safe handling of sharp medical devices and supportedvaccination against HBV. A clarification on UP emphasized that visible blood inbody fluids required barrier protection when contact, handling and dispositionof these fluids occurred.⁹ In 1987, another approach, Body SubstanceIsolation (BSI), advocated all moist body substances were potentially infectiousand 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.¹¹The federal law adopted the 1987 CDC guidance of UP and added other requirementsto further protect HCWs. OSHA is focused on worker and worker-patientprotection, not patients exclusively.

As epidemiological debates continued, hospitals modified or created their ownisolation precautions and greater compliance with barrier protection becameroutine. The term "standard precautions" (SP) appeared in the 1996 CDCisolation revision. The preamble to these recommendations explains that SP are asynthesis of two other precautions (UP and BSI) and apply to all patientsreceiving healthcare, regardless of their diagnosis or presumed infectionstatus.¹² Thus, SP is the current isolation terminology and thefundamental premise employed by healthcare personnel when rendering care toevery patient. (Note: For the dental arena, UP equals SP; thus, these workersmay still use the term UP.)

The Purpose

The goal of isolation techniques is to prevent the spread of communicablediseases in hospitals and microorganisms among patients, personnel and visitors.These practical techniques evolved to control cross infection, namely patient toHCW and HCW to patient. Throughout the presentation of safe options to containand confine disease transmission, the guidance states facilities are encouragedto modify the isolation recommendations to suit the practice setting and patientneeds. This adaptation requires explicit written policies and procedures toensure the proper application of the principles in the delivery of services andpatient care. Prevention, control and reduction of infection remain the triadfor safe practice. SP offers the safest standard of practice for patient carewhen healthcare personnel and providers adhere to its consistent application ineach circumstance.

The Requirements

Isolation techniques evolved from the absence of any barriers to the currentpractice of fluid resistant, disposable and reusable barriers. Known as personalprotective equipment (PPE) or personal protective attire (PPA), these barriersminimize the risk of bodily fluid exposures to healthcare personnel byprotecting skin and mucous membranes from potentially infective materials. PPE/Aare numerous in design, type, style, size, color and effectiveness in themultifaceted arena of patient care. The selection of appropriate protectiveattire is dependent on the procedure to be performed and the anticipatedexposure that might occur. Employing the CDC recommendations, the federalmandate of 1991¹¹ delineated these same specific requirements for UPand PPE/A and added others to include education, post-exposure protocols, recordkeeping and a written exposure control plan. These essentials are applicable forSP despite the term change.

Gloves are manufactured in many styles using various base materials. They areavailable as disposable, reusable, sterile, nonsterile, mesh reinforced,powdered and nonpowdered, to name a few. Regardless of the many options inselecting glove type, quality and price range, user problems associated withcontinual wearing of gloves persist. The severity of latex allergies, forexample, may pose inherent risks equal to the direct exposure of hands tocontaminated bodily fluids. Despite the 1980s manufacturing challenges ofgreater demand than supply, gloves are routine attire for protection againstbodily fluid contact, including blood, mucous membranes, secretions, excretionsand nonintact skin. Gloves also reduce the risk of cross contamination fromhealthcare personnel to patients, and patient or fomite to healthcare personnel.Emphasis on the necessity to wash hands after glove removal remains a soundpractice and federal mandate -- it's the law. Gloves are permitted to have smallmanufacturing-related defects, yet be cleared for market and healthcare-relateduse in the United States. Microorganisms are aggressive in their determinationto press on, affix and invade new frontiers. Their maverick modes of behavioraim to cause host harm. Thus, glove use does not negate the hand cleansingpractice, but reinforces the essential habit to wash bioburden away after gloveremoval, regardless if visible soilage is noted. Glove are required to bechanged when personnel deliver care at one specific body site and then must moveto another body site on the same patient for more care. For example, touchingpatient's genitals while assessing patency of the Foley catheter, then changingthe surgical dressing. These care tasks require gloves be worn; however, thegloves are removed and hands cleansed after the Foley assessment and a freshpair of gloves are donned before the dressing change occurs. The attendingcaregiver does not wear the same gloves for the whole episode of care on thissingle patient, as cross contamination of microbes from one body site can betransmitted to another body site on this same patient.

Mask choices include disposable or reusable types; individual or withattached eye protection; efficacy in protection against fluids, microbes andvapors; different colors; and various sizes and attributes. Coveragerequirements for the nose and mouth and fluid resistance apply with this PPA.Protection is focused on unanticipated splashes from potentially infectivebodily fluids. A new mask per episode of patient care is the norm with morefrequent changing if the mask is moist and no longer provides an effectivebarrier from exposure. Disposal is immediate after care; the mask should not beworn around the neck for later use.

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

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

The work practices, engineering controls, immunizations and otherrequirements of UP are applicable for isolation containment and personalprotection against blood and bodily fluid exposure. While the focus has been onisolation evolution, UP and SP are similar in that blood is a source ofpathogens and provides a vehicle of infectious and communicable diseasetransmission to others. Although an intraoperative cleaning concept, thecontain-and-confine principle applies to isolation. Every patient and everyoperation should be considered a possible source of cross contamination ... thearea of contamination should be confined to as small an area as possible ... toan area close to the patient ... items that become contaminated must becontained to prevent cross contamination.¹³ This principle hasapplications in many healthcare activities, including isolation.

Summary

The original quarantine of infected patients to infectious disease hospitalsoccurred in the late 1800s, but evolved to isolation rooms by the early 1900sdue to increasing knowledge about microorganisms, infectious diseases andepidemiology of infection. With differential modes of disease transmission,specific categories of isolation became disease-specific precautions, as a meansto a more tailored approach to patient uniqueness. These precautions werefurther diversified into a federally mandated UP approach focused on minimizingexposures and disease acquisition. The current tiered system of isolationadvocates SP for each patient and transmission-based precautions for specialpatient 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 andexpand our knowledge, strategies to prevent, control and reduce widespreadinfections are built on the foundation of contain and confine with the goal ofprotecting others from acquiring these adverse conditions.

Answers

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