Blood Pressure Measurement

PROCEDURE GOALS AND OBJECTIVES
Goal: To accurately measure the systemic arterial blood pressure
in any patient in any setting.
Objectives: The student will be able to …
• Describe the indications, contraindications, and rationale for
performing arterial blood pressure measurement.
• Describe the essential anatomy and physiology associated with
the performance of blood pressure measurement.
• Identify the necessary materials and their proper use for
performing blood pressure measurement.
• Perform the proper steps and techniques for obtaining blood
pressure measurement.
• Describe the indications for performing orthostatic blood
pressure assessment.
• Perform the proper steps and techniques for obtaining
orthostatic blood pressure measurement.

BACKGROUND AND HISTORY
Various theories about circulation and blood pressure (BP) emerged about
400 BC. Hippocrates knew about arteries and veins, but he believed veins
carried air. Six hundred years later, Galen demonstrated that both arteries
and veins carried blood; however, he also thought that the heart was a
warming machine for two separate types of blood. He was convinced that
veins and arteries were not connected and that blood flowed both backward
and forward from the heart. Subsequently Galen’s teachings remained
unchallenged for over 1000 years (Stevens, 1978).
It was William Harvey, in 1616, who disagreed with Galen by demonstrating
one-way circulation of blood and theorized the existence of capillaries. Thirty
years later, Marcello Malpighi was the first to view capillaries microscopically
(Stevens, 1978).
The first person to measure BP was Stephen Hales in 1733. An English
physiologist, clergyman, and amateur scientist, Hales inserted a brass pipe
into the carotid artery of a mare and then attached the pipe to a windpipe
taken from a goose. The flexible goose windpipe was then attached to a
12-foot glass tube. Although the experiment had little practical application at
the time, it did provide valuable information about BP (Wain, 1970).
Although Ritter von Basch experimented with a device that could measure
the BP of a human without breaking the skin, the prototype design of the
sphygmomanometer was devised in 1896 by Scipione Riva-Rocci (Lyons,
1987). He introduced a method for indirect measurement of BP based on
measuring the external pressure required to compress the brachial artery so
that arterial pulsations could no longer be transmitted through the artery.
The Riva-Rocci sphygmomanometer was described by Porter (1997) as “an
inflatable band that was wrapped around the upper arm; air was pumped in
until the pulse disappeared; it then was released from the band until the
pulse reappeared, and the reading was taken.”
In 1905, a Russian physician named Korotkoff first discovered the
auscultatory sounds that are heard while measuring BP. While the artery is
occluded during BP measurement, transmitted pulse waves can no longer be
heard distal to the point of occlusion. As the pressure in the bladder is reduced
by opening a valve on the inflation bulb, pulsatile blood flow reappears
through the generally compressed artery, producing repetitive sounds
generated by the pulsatile flow. The sounds, named after Korotkoff, change in
quality and intensity. The five phases of these changes are characterized in
Table 4-1. Around the turn of the 20th century, BP became an accepted clinical
measurement. As data increased, physicians and other clinicians were able
to establish normal BP ranges and identify abnormalities.
René Laënnec is credited with the invention of the stethoscope in 1816,
which became a convenience for physicians who preferred not to place their
ears directly on the chest wall of a patient. In 1905, Korotkoff tried using the
stethoscope to monitor the pulse while the sphygmomanometer was inflated.
He discovered a more accurate BP reading and that the pulse disappeared as
the cuff pressure decreased at a point in consonance with the expanding of

the heart. Subsequently, the term Korotkoff sounds came to be used (Lyons,
1987).
According to Grim and Grim (2000):
Indirect BP measurement is one of the most frequently performed health
care procedures. Because BP measurement is a simple procedure, it is
taken for granted that all graduates from medical training programs have
the ability to record accurate, precise, and reliable BP readings. However,
research since the 1960s has shown this assumption to be false. Most
health professionals do not measure BP in a manner known to be accurate
and reliable.
The authors describe two factors that contribute to inaccurate BP measurement:
(1) lack of depth in the instruction of basic skills in professional
education; and (2) relying on nonmercury devices. Subsequently, every
clinician who takes BP measurements should know and understand the
principles and steps needed to obtain accurate indirect auscultatory BP
measurement. The measurement taken is an important tool in screening and
diagnosis, which is why it is considered one of the patient’s “vital signs.”
For the accurate indirect measurement of BP, the American Heart
Association (AHA) recommends that the cuff size be based solely on the limb
circumference. Manning, Kuchirka, and Kaminski studied prevailing cuffing
habits, compared them with AHA guidelines, and reported their findings in
Circulation in 1983. They found that “miscuffing” occurred in 65 (32%) of 200
BP determinations in 167 unselected adult outpatients, including 61 (72%) of 85
readings taken on “nonstandard-size” arms. Undercuffing large arms was the
most frequent error, accounting for 84% of the miscuffings. They concluded
that undercuffing elevates the BP readings by an average of 8.5 mm Hg
systolic and 4.6 mm Hg diastolic. It is critical, therefore, that the clinician
choose the appropriate size cuff based on the circumference of a patient’s
bare upper arm. The bladder (inside the cuff) length should encircle 80% and
the width should cover 33% to 50% of an adult’s upper arm. For a child
younger than 13 years of age, the bladder should encircle 100% of the child’s upper arm. A cuff that is too narrow or too large for an arm may result in an
incorrect BP reading. Cuffs that are generally available usually have been
classified by the width of the bladder rather than by the length and are
labeled newborn, infant, child, small adult, adult, large adult, and thigh.
Over- and underestimation of BP by using an inappropriate cuff size has
been well documented in the literature. Health care settings should have
easy access to small, standard, and large cuffs (Graves, 2001).

INDICATIONS
As one of the vital signs, peripheral BP measurement is an indirect method
of determining cardiovascular function. Its use is indicated for evaluation of
both healthy and unhealthy patients to assess cardiac status. BP measurement
is a part of every complete physical or screening examination and is
performed to screen for hypertension or hypotension.

CONTRAINDICATIONS
There are no absolute contraindications to measuring BP. Relative contraindications
include physical defects and therapeutic interventions, such as
indwelling intravenous catheters and renal dialysis shunts.

POTENTIAL COMPLICATIONS
Complications from measurement of BP occur as a result of improper
training of the individual performing the assessment. Overinflation or prolonged
time of inflation may lead to tissue or vascular damage at the
measurement site. Lack of proper care of equipment or flawed equipment
may give an inaccurate reading.

REVIEW OF ESSENTIAL ANATOMY
AND PHYSIOLOGY
In most clinical settings, BP is measured by the indirect technique of using a
sphygmomanometer placed over the brachial artery of the upper extremity.
The brachial artery is a continuation of the axillary artery, which lies medial
to the humerus proximally and gradually moves anterior to the humerus as
it nears the antecubital crease (Fig. 4-1). Placement of the bladder and cuff of
the sphygmomanometer circumferentially over the brachial artery allows
inflation of the cuff to create adequate pressure so that the artery is fully
occluded when the pressure exceeds the systolic pressure within the
brachial artery.

Indirect measurement of the BP involves the auscultatory detection of the
initial presence and disappearance of changes and the disappearance of
Korotkoff sounds, which are audible with the aid of a stethoscope placed
over the brachial artery distal to the BP cuff near the antecubital crease.
Korotkoff sounds are low-pitched sounds (best heard with the stethoscope
bell) that originate from the turbulence created by the partial occlusion of
the artery with the inflated BP cuff.
As long as the pressure within the cuff is so little that it does not produce
even partial occlusion (or intermittent occlusion), no sound is produced
when auscultating over the brachial artery distal to the cuff. When the cuff
pressure becomes great enough to occlude the artery during at least some
portion of the arterial pressure cycle, a sound becomes audible over the
brachial artery distal to the cuff. This sound is audible with a stethoscope
and correlates with each arterial pulsation.
There are five phases of Korotkoff sounds used in determining systolic and
diastolic BP (see Table 4-1). Phase I occurs as the occluding pressure of the
cuff falls to a point that is the same as the peak systolic pressure within the
brachial artery (Fig. 4-2). The tapping sound that is produced is clear and
generally increases in intensity as the occluding pressure continues to
decrease. Phase II occurs at a point approximately 10 to 15 mm Hg lower than
at the onset of phase I, and the sounds become softer and longer with a
quality of intermittent murmur. Phase III occurs when the occluding pressure
of the cuff falls to a point that allows for large amounts of blood to cross the 

partially occluded brachial artery. The phase III sounds are again crisper and
louder than phase II sounds. Phase IV occurs when there is an abrupt
muffling and decrease in the intensity of the sounds. This occurs as the
pressure is close to that of the diastolic pressure of the brachial artery.
Phase V occurs when the blood vessel is no longer occluded by the pressure
in the cuff. At this point, the tapping sound disappears completely.

PATIENT PREPARATION
Ideally, the environment should be relaxed and peaceful. BP levels may be
affected by emotions, physical activity, or the environment. Subsequently,
the examiner should minimize any and all disturbances that may affect the
reading. The procedure should be explained to the patient.
The patient is asked to be seated or to lie down with the back supported,
making sure that the bare arm is supported horizontally at the level of the
heart. According to Mourad and Carney (2004):
Choosing the dependent arm is a behavior likely to lead to the overdiagnosis
of hypertension and inappropriate treatment of hypertension because the
dependent arm falsely elevates both systolic and diastolic blood pressure.
These results should encourage national and international organizations
to reaffirm the importance of the horizontal arm in the measurement of
blood pressure.
The clinician should avoid an arm that appears injured or has a fistula or an
IV or arterial line. If the patient has undergone breast or axilla surgery, avoid
the arm on the same side. It is important to note that rolling up the sleeves

has the potential of compressing the brachial artery and may have an even
greater effect on the BP than if the shirt is left under the manometer’s cuff
(Lieb, 2004) The patient should avoid smoking or ingesting caffeine for
30 minutes before the BP is recorded.

Materials Utilized for Blood Pressure
Measurement
■ Stethoscope
■ Calibrated sphygmomanometer (a mercury, aneroid, or hybrid
sphygmomanometer with a calibrated scale for measuring pressure;
inflatable rubber bladders; tubes; and valves). There continues to be
environmental concern over the use of mercury sphygmomanometers
because of the hazards of mercury spills and potential exposure (see
“Note”). As a result, more automated devices are being used
(Valler-Jones, 2005). One of the factors affecting the accuracy of BP
measurement is the equipment used. Defects or inaccuracy of aneroid
sphygmanometers may be a source of error in BP measurement.
■ Recording instruments (Fig. 4-3)

■ Appropriate size cuff: A cuff that has an antimicrobial agent to help
prevent bacterial growth is recommended. It has been reported that BP
cuffs can carry significant bacterial colonization and actually can be a
source of transmission of infection (Base-Smith, 1996).
Note: Modern sphygmomanometers are less likely to spill mercury if
dropped. If a spill occurs, however, mercury is fairly simple to clean up
unless it is spilled within heated devices or is trapped in upholstery,
carpeting, or other surfaces. Unfortunately, mercury in the organic form is
extremely toxic via skin contact, inhalation, and ingestion and may require
the calling of a hazardous materials team. If mercury manometers are used,
a mercury spill kit is recommended.

SPECIAL CONSIDERATIONS

THE APPREHENSIVE PATIENT OR “WHITE
COAT” HYPERTENSION

Ambulatory blood pressure measurement (ABPM) is increasingly being used
in clinical practice (O’Brien, 2003). ABPMs correlate better than clinical
measurements on patients with end-organ injury (Verdecchia, 2000). Twentyfour-
hour ABPM is the most efficient means for assessing white coat hypertension
(WCH), particularly in the absence of end-organ disease. WCH has
been defined as clinical BP greater than 140 mm Hg systolic and 90 mm Hg
diastolic (Al-Hermi, 2004). Ambulatory measurements are also valuable in
assessing patients with apparent drug resistance, low BP symptoms, and in
patients taking antihypertensive medications. There is now wider acceptance
of BP readings taken by patients in their homes. Patients should be encouraged
to monitor their BP at home with validated devices followed by appropriate
recording and reporting to their clinician.

THE OBESE OR LARGE ARM
It is well known that BP measurement with a standard 12- to 13-inch (27- to
34-cm) wide cuff is inappropriate for large or obese arms. If the arm circumference
of the patient exceeds 13 inches (34 cm), use a thigh cuff 17 to
20 inches (18 cm) wide on the patient’s upper arm. Table 4-2 gives acceptable
bladder dimensions for adult arms of different sizes. In patients with extremely
large arms, place the cuff on the patient’s forearm and listen over the radial
artery. Occasionally, it may be necessary to determine the BP in the leg; this
may be required to rule out coarctation of the aorta or if an upper extremity
BP determination is contraindicated. To do this, use a wide, long thigh cuff

with a bladder size of 45 to 52 cm and apply it to the mid-thigh. Center the
bladder over the posterior surface, wrap it securely, and listen over the
popliteal artery (Perloff, 1993).
According to Pickering and colleagues (2005), “wrist monitors may be useful
in very obese patients if the monitor is held at heart level. Finger monitors
are not recommended.” Block and Schulte (1996) discussed ankle BP measurements
and found that mean BP readings obtained at the arm and at the ankle
were statistically equivalent and concluded that ankle cuff placement provided
a reliable alternative to the placement of the cuff on the arm.

INFANTS AND CHILDREN
Measuring BP in infants and children presents special problems to the
clinician. The same measuring techniques are used as in adults. As mentioned
earlier, pediatric cuff sizes are available to ensure that the bladder
completely encircles the upper arm. Various techniques can enforce patient
compliance—using relaxation techniques for the child, having the mother
inflate the BP cuff, and/or demonstrating BP measurement on a stuffed animal.

ELDERLY PATIENTS
In elderly patients, who may have significant atherosclerosis, it is likely that
the systolic pressure is overestimated by the indirect method of BP measurement.
BP tends to be more labile in elderly patients, so it is important to
obtain several baseline measurements before making any diagnostic or
therapeutic decisions (Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure, 2003). ABPM is very
useful in this age group.

ASSESSMENT OF ORTHOSTATIC BLOOD
PRESSURE
The measurement of orthostatic BP is an essential clinical tool for the
assessment and management of patients suffering from many common
medical disorders. The most common causes are volume depletion and
autonomic dysfunction. According to Carlson (1999), orthostatic hypotension,
which is a decline in BP when standing erect, is the “result of an impaired
hemodynamic response to an upright posture or a depletion of intravascular
volume. The measurement of orthostatic blood pressure can be done at the
bedside and is therefore easily applied to several clinical disorders.”
Orthostatic hypotension is detected in 10% to 20% of community-dwelling
older individuals (Mader, 1987). This condition is frequently asymptomatic,
but disabling symptoms of light-headedness, weakness, unsteadiness,
blurred vision, and syncope may occur.

The American Academy of Neurology’s consensus statement (1996) defines
orthostatic hypotension as a “reduction of systolic blood pressure of at least
20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes
of standing.”
Many clinicians use a combination of a decrease in BP combined with an
increase in heart rate to determine the presence of orthostatic hypotension.
Performing these orthostatic measurements requires adequate techniques
in BP measurement, appropriate positioning of the patient, and proper timing
of the measurements.

Materials Utilized for Measuring Orthostatic Blood
Pressure
This technique requires the same equipment as previously mentioned for
measuring BP.

FOLLOW-UP CARE AND
INSTRUCTIONS
The results of the BP measurements dictate the follow-up actions and patient
instructions. Long-term observations have been made on the contributions
of high BP to illness and death. It is important to note that the classification
of BP has changed over the years. In 2003, the seventh report of the Joint
National Committee (JNC-VII) on prevention, detection, evaluation, and
treatment recommended the classification found in Table 4-3.

Clinicians should explain the meaning of their BP readings to patients and
advise them of the appropriate need for periodic follow-up care and remeasurement.
Table 4-4 demonstrates a suggested follow-up form to be given
to patients after their BP has been taken.
The measurement of orthostatic BP is a simple technique that requires the
same equipment as previously mentioned in this chapter for measuring BP.
Practical applications include the detection of intravascular volume
depletion and autonomic dysfunction and the treatment of hypertension,
congestive heart failure, and other clinical disorders.

REFERENCES
Al-Hermi B, Abbas B: The role of ambulatory blood pressure
measurements in adolescence and young adults. Transplant Proc
36:1818-1819, 2004.
American Academy of Neurology: Consensus statement on the
definition of orthostatic hypotension, pure autonomic failure, and
multiple system atrophy. Neurology 46:1470, 1996.

Base-Smith V: Nondisposable sphygmomanometer cuffs harbor
frequent bacterial colonization and significant contamination by
organic and inorganic matter. AANA 64:141-145, 1996.
Block FE, Schulte GT: Ankle blood pressure measurement: An
acceptable alternative to arm measurements. Int J Clin Monit Comput
13:167-171, 1996.
Carlson JE: Assessment of orthostatic blood pressure: Measurement,
technique, and clinical applications. South Med J 92:167-173, 1999.
Graves J: Prevalence of blood pressure cuff sizes in a referral practice
of 430 consecutive adult hypertensives. Blood Press Monit 6:17-20,
2001.
Grim CM, Grim C: Manual blood pressure measurement—Still the gold
standard: Why and how to measure blood pressure the old-fashioned
way. Hypertension Medicine October, 131-145, 2000.
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure: The seventh report of the Joint
National Committee (JNC-VII) on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure. JAMA 289:2560-2572, 2003.
Lieb M, Holzgreve H, Schultz M, et al: The effect of clothes on
sphygmomanometric and oscillometric blood pressure measurement.
Blood Press 13:279-282, 2004.
Lyons SA, Petrucelli RJ: Medicine: An Illustrated History. New York,
Abradale Press, 1987.
Mader SL, Josephson KR, Rubenstein LZ: Low prevalence of postural
hypotension among community-dwelling elderly. JAMA 258:1511-1514,
1987.
Manning DM, Kuchirka C, Kaminski J: Miscuffing: Inappropriate blood
pressure cuff application. Circulation 68:763-766, 1983.
Mourad A, Carney S: Brief communication: Arm position and blood
pressure: An audit. Intern Med J 34:290-291, 2004.
O’Brien E: Ambulatory blood pressure monitoring in the management of
hypertension. Heart 89:571-576, 2004.
Perloff D, Grim C, Flack J, et al: Human blood pressure by
sphygmomanometry. Circulation 88:2460-2470, 1993.
Pickering TG, Hall JE, Appel LJ, et al: Recommendations for blood
pressure measurement in humans: An AHA scientific statement from
the Council on High Blood Pressure Research Professional and Public
Education Subcommittee. J Clin Hypertens (Greenwich) 7:102-109,
2005.
Porter R: The Greatest Benefit to Mankind: A Medical History of
Humanity. New York, WW Norton, 1997.
Stevens G: Famous Names in Medicine. East Sussex, England, Wayland
Publishers, 1978.
Valler-Jones T, Wedgbury K: Measuring blood pressure using the
mercury sphygmomanometer. Br J Nurs 14;145-150, 2005.
Verdecchia P: Prognostic value of ambulatory blood pressure.
Hypertension 35:844-851, 2000.
Wain H: A History of Medicine. Springfield, Ill, Charles C Thomas, 1970.

Sterile Technique

PROCEDURE GOALS AND OBJECTIVES
Goal: To provide clinicians with the knowledge and skills
necessary to perform clinical procedures using accepted sterile
technique.
Objectives: The student will be able to …
• Describe the indications and rationale for practicing sterile
technique.
• Identify and describe the history and development of the
concept of sterile technique.
• List the principles of sterile technique.
• Describe the essential steps performed in the surgical hand scrub.
• Describe the essential steps performed in preparing and
draping a sterile field.
• Describe the principles involved in the use of surgical caps,
masks, and gowns.
• Describe the principles involved in the use of standard
precautions.

BACKGROUND AND HISTORY
The teachings of Hippocrates (460 BC) were instrumental in turning the art of
healing away from mystical rites to an approach that everyone could
understand and practice. He stressed cleanliness to avoid infection by using
boiling water and fire to clean instruments and by irrigating dirty wounds
with wine or boiled water (Adams, 1929). Louis Pasteur (1822-1895) developed
what would come to be known as the germ theory of disease. His experiments
revealed that microbes could be found in the air and on the surface of every
object (Dubos, 1950). He discovered that the number of microbes could be
reduced on surfaces by using heat or appropriate cleansing but that they
would still remain in the air. Joseph Lister (1827-1912) is considered the
father of sterile technique (Godlee, 1917). When Lister learned of Pasteur’s
work, he began to experiment with various methods of sterile technique in
surgery. He noted a significant decrease in postoperative infections after
using carbolic acid to sterilize both surgical wounds and his own hands and
by spraying the operative field. His antiseptic methods of performing surgery
were refined over the years and eventually incorporated into hospitals
worldwide.

PRINCIPLES OF STERILE TECHNIQUE
Sterile technique is the method by which contamination with microorganisms
is minimized. Adherence to protocol and strict techniques is required at all
times when caring for open wounds and performing invasive procedures. To
avoid infection, procedures should be performed within a sterile field from
which all living microbes have been excluded. Items entering the sterile field,
including instruments, sutures, and fluids, must be sterile. Although it is not
possible to sterilize the skin, it is possible to reduce significantly the number
of bacteria that is normally present on the skin. Before a procedure, personnel
must first perform a surgical hand scrub and then don sterile gloves, sterile
gown, and mask. The primary goal is to provide an environment for the
patient that promotes healing, prevents infections, and minimizes the length
of recovery time. Using the principles of sterile technique will help accomplish
that goal. The principles are as follows:
■ All items used within a sterile field must be sterile.
■ A sterile barrier that has been permeated must be considered
contaminated.
■ The edges of a sterile container are considered contaminated once the
package is opened.
■ Gowns are considered sterile in front from shoulder to waist level, and
the sleeves are considered sterile to 2 inches above the elbow.
■ Tables are sterile at table level only.

■ Sterile persons and items touch only sterile areas; unsterile persons and
items touch only unsterile areas.
■ Movement within or around a sterile field must not contaminate the field.
■ All items and areas of doubtful sterility are considered contaminated.

SURGICAL HAND SCRUB
The surgical hand scrub has its own traditions and rituals dating back to the
use of chlorinated lime by Semmelweis, who in 1846 recognized the role of
contagions on doctors’ hands in the spread of puerperal fever, and the use of
carbolic acid by Lister to soak his instruments and hands (Lister, 1867). The
goal of the surgical hand scrub is to remove dirt and debris and to reduce
bacterial flora. An ideal surgical hand scrub should provide the following
antimicrobial effects:
■ Immediate reduction in the resident bacterial flora
■ Sustained effect to maintain a reduced bacterial count under surgical
gloves
■ Cumulative effect with each additional application of the antiseptic
■ Persistent effect providing progressive reduction of bacteria with
additional applications
The traditional 10-minute surgical scrub, using a stiff brush and harsh
chemicals, does not meet the criteria for satisfactory antimicrobial action
(an immediate reduction in microbial count that is sustained, cumulative,
and persistent) and is associated with a number of difficulties and problems,
chiefly a high incidence of irritation and dermatitis that can paradoxically
result in an increased microbial population on the hands (Larson, 1986).
Modifications have been made to the traditional surgical hand scrub to
increase its beneficial effects and to decrease its harmful effects.
The duration of the recommended scrub time has been decreased so that
a 2-minute scrub time is now considered by some to be optimal (Wheelock,
1997). Some authors have recommended eliminating the scrub brush, to
decrease abrasion of the hands (Gruendemann, 2001). New antiseptics,
emollients, and humectants have been developed to minimize skin dryness
and dermatitis resulting from the surgical hand scrub. New procedures and
products for hand hygiene and the surgical hand scrub have been
consolidated into a publication that was issued by the Centers for Disease
Control and Prevention (CDC) in 2002. These guidelines are comprehensive,
providing an analysis of the science of hand hygiene and specific recommendations
for surgical hand antisepsis (CDC, 2002):

SURGICAL HAND ANTISEPSIS

1. Remove rings, watches, and bracelets before beginning the “surgical
hand scrub” (i.e., a process to remove or destroy transient microorganisms
and reduce resident flora).
2. Remove debris from underneath fingernails using a nail cleaner under
running water.
3. “Surgical hand antisepsis” (i.e., a process for removal or destruction of
transient microorganisms) using either an antimicrobial soap or an
alcohol-based hand rub with persistent activity is recommended before
donning sterile gloves when performing surgical procedures.
4. When performing surgical hand antisepsis using an antimicrobial soap,
scrub hands and forearms for the length of time recommended by the
manufacturer, usually 2 to 6 minutes. Long scrub times (e.g., 10 minutes)
are not necessary.
5. When using an alcohol-based surgical hand scrub product with
persistent activity, follow the manufacturer’s instructions. Before
applying the alcohol solution, prewash hands and forearms with a
nonantimicrobial soap and dry hands and forearms completely. After
application of the alcohol-based product as recommended, allow hands
and forearms to dry thoroughly before donning sterile gloves.


Materials Utilized for Hand Scrub

■ Chlorhexidine gluconate or povidone-iodine solutions are rapid-acting,
broad-spectrum antimicrobials that are effective against gram-positive
and gram-negative microorganisms. Each is prepared in combination
with a detergent to give a cleansing action along with the antimicrobial
effect.
■ Sterile disposable scrub brushes impregnated with chlorhexidine
gluconate, povidone-iodine, or other CDC-approved products (CDC,
2002).

REFERENCES

Adams F: The Genuine Works of Hippocrates. New York, W. Wood, 1929.
Centers for Disease Control and Prevention: Guideline for hand hygiene
in health-care settings. MMWR Recomm Rep 51(RR-16):1-45, 2002.
Centers for Disease Control and Prevention: Recommendations for
prevention of HIV transmission in health-care settings. MMWR Morb
Mortal Wkly Rep 36(suppl 2):1S-18S, 1987.
Dubos R: Louis Pasteur: Free Lance of Science. Boston, Little, Brown,
1950.
Godlee RJ: Lord Lister. London, Macmillan, 1917.
Gruendemann BJ: Is it time for brushless scrubbing with an alcoholbased
agent? AORN J 74:859-873, 2001.
Larson E: Physiologic and microbiologic changes in skin related to
frequent handwashing. Infect Control Hosp Epidemiol 7:59-63, 1986.
Lister J: On a new method of treating compound fractures, abscess, etc.
with observations on the conditions of suppuration. Lancet 1:326,
357, 507, 1867.
Wheelock SM: Effect of surgical hand scrub time on subsequent
bacterial growth. AORN J 65:1087-1098, 1997.

STANDARD PRECAUTIONS

Although universal precautions were designed to address the transmission
of blood-borne infections through blood and certain body fluids, they do not
address other routes of disease transmission, which were addressed at the
time by body substance isolation guidelines. Additionally, confusion developed
as to whether one should use universal precautions and body substance
isolation guidelines, because both guidelines dealt with similar circumstances
but offered conflicting recommendations. The guideline for isolation precautions
in hospitals was revised in 1996 by the CDC and the Hospital
Infection Control Practices Advisory Committee (HICPAC), which had been
established in 1991 to serve in a guiding and advisory capacity to the Secretary
of the Department of Health and Human Services (DHHS), the Assistant
Secretary of Health of the DHHS, the Director of the CDC, and the Director of
the National Center for Infectious Diseases with respect to hospital infection control practices and U.S. hospital surveillance, prevention, and control
strategies for nosocomial infections. The CDC guideline revision was designed
to include the following objectives:

(1) to be epidemiologically sound; (2) to recognize the importance of all
body fluids, secretions, and excretions in the transmission of nosocomial
pathogens; (3) to contain adequate precautions for infections transmitted
by the airborne, droplet, and contact routes of transmission; (4) to be as
simple and user friendly as possible; and (5) to use new terms to avoid
confusion with existing infection control and isolation systems.
(Garner, 1996)

The new guidelines were designed to supersede universal precautions and
body substance isolation guidelines and in essence combined parts of both
these previous guidelines. This synthesis of guidelines allows patients who
were previously covered under disease-specific guidelines to now fall under
standard precautions, a single set of recommendations. For patients who
require additional precautions (defined as transmission-based precautions, for
use when additional transmission risk exists [e.g., from airborne or droplet
contamination]), additional guidelines have been developed to go above and
beyond those of standard precautions (Garner, 1996) (see Table 2-1).

GLOVES, GOWNS, MASKS, AND
OTHER PROTECTIVE BARRIERS AS
PART OF UNIVERSAL PRECAUTIONS

 

All health care workers should routinely use appropriate barrier precautions
to prevent skin and mucous membrane exposure during contact with any
patient’s blood or body fluids that require universal precautions.
Gloves should be worn as follows:
■ For touching blood and body fluids requiring universal precautions,
mucous membranes, or nonintact skin of all patients
■ For handling items or surfaces soiled with blood or body fluids to which
universal precautions apply
Gloves should be changed after contact with each patient. Hands and other
skin surfaces should be washed immediately or as soon as patient safety
permits if contaminated with blood or body fluids requiring universal
precautions. Hands should be washed immediately after gloves are removed.
Gloves should reduce the incidence of blood contamination of hands during
phlebotomy, but they cannot prevent penetrating injuries caused by needles
or other sharp instruments. Institutions that judge routine gloving for all
phlebotomies as not necessary should periodically re-evaluate their policy.
Gloves should always be available to health care workers who wish to use
them for phlebotomy. In addition, the following general guidelines apply:
■ Use gloves for performing phlebotomy when the health care worker has
cuts, scratches, or other breaks in the skin.

 ■ Use gloves in situations in which the health care worker judges that
hand contamination with blood may occur; for example, when
performing phlebotomy in an uncooperative patient.
■ Use gloves for performing finger or heel sticks, or both, in infants and
children.
■ Use gloves when persons are receiving training in phlebotomy.
Masks and protective eyewear or face shields should be worn by health care
workers to prevent exposure of mucous membranes of the mouth, nose, and
eyes during procedures that are likely to generate droplets of blood or body
fluids requiring universal precautions. Gowns or aprons should be worn
during procedures that are likely to generate splashes of blood or body fluids
requiring universal precautions.
All health care workers should take precautions to prevent injuries caused
by needles, scalpels, and other sharp instruments or devices during
procedures; when cleaning used instruments; during disposal of used
needles; and when handling sharp instruments after procedures. To prevent
needlestick injuries, needles should not be recapped by hand, purposely
bent or broken by hand, removed from disposable syringes, or otherwise
manipulated by hand. After they are used, disposable syringes and needles,
scalpel blades, and other sharp items should be placed in puncture-resistant
containers for disposal. The puncture-resistant containers should be located
as close as is practical to the area of use. All reusable needles should be
placed in puncture-resistant containers for transport to the reprocessing area.
General infection control practices should further minimize the already
minute risk for salivary transmission of human immunodeficiency virus. These
infection control practices include the use of gloves for digital examination
of mucous membranes and endotracheal suctioning, hand washing after
exposure to saliva, and minimizing the need for emergency mouth-to-mouth
resuscitation by making mouthpieces and other ventilation devices available
for use in areas where the need for resuscitation is predictable.

 

THE APPLICATION OF STANDARD
PRECAUTIONS IN CLINICAL
PROCEDURES
Standard precautions should be followed when performing any procedure in
which exposure to, or transmission of, infectious agents is possible. These
guidelines attempt to minimize exposure to infectious body fluids. Because it
is not always possible to determine in advance whether a specific patient is
infectious, these precautions should be followed routinely for all patients.
The nature of performing clinical procedures often results in exposure to
body fluids. Consequently, as practitioners involved in performing clinical
procedures, it is imperative that we attempt to anticipate potential exposures
and implement preventive guidelines to reduce exposure risks. 

 Additionally, it is important that the practitioner assess the health status
of each patient to determine if additional precautions are warranted and, if
so, apply the necessary transmission-based precautions as described in
Table 2-1. Standard precautions are the current recommended behaviors
designed to prevent the transmission of pathogens from patient to practitioner
or practitioner to patient. It is imperative that all providers be knowledgable
about standard precautions and transmission-based precautions and how to
practice them competently and consistently.

 

REFERENCES
Centers for Disease Control and Prevention: Interim recommendations
for infection control in health-care facillities caring for patients with
known or suspected avian influenza. May 21, 2004. Available at
http://www.cdc.gov/flu/avian/professional/infect-control.htm, accessed
7/3/06.
Centers for Disease Control and Prevention: Public health guidance for
community-level preparedness and response to severe acute
respiratory syndrome (SARS) version 2. Supplement I: Infection control
in healthcare, home, and community setting. May 3, 2005. Available at
http://www.cdc.gov/ncidod/sars/guidance/i/, accessed 7/3/06.
Centers for Disease Control and Prevention: Updated U.S. Public Health
Service guidelines for the management of occupational exposures to
HBV, HCV, and HIV and recommendations for postexposure
prophylaxis. MMWR Morb Mortal Wkly Rep 50:1-42, 2001.
Centers for Disease Control and Prevention: Recommendations for
prevention and control of hepatitis C virus (HCV) infection and
HCV-related chronic disease. MMWR Morb Mortal Wkly Rep 47:1-39,
1998.
Centers for Disease Control and Prevention: Laboratory management of
agents associated with hantavirus pulmonary syndrome: Interim
biosafety guidelines. MMWR Morb Mortal Wkly Rep 43:1-7, 1994.
Centers for Disease Control: Guidelines for preventing the transmission
of tuberculosis in health-care settings, with special focus on
HIV-related issues. MMWR Morb Mortal Wkly Rep 39:1-29, 1990.
Centers for Disease Control: Risks associated with human parvovirus
B19 infection. MMWR Morb Mortal Wkly Rep 38:81-88, 93-97, 1989.
Centers for Disease Control: Management of patients with suspected
viral hemorrhagic fever. MMWR Morb Mortal Wkly Rep 37:1-16, 1988.
Centers for Disease Control: Update: Universal precautions for
prevention of transmission of human immunodeficiency virus,
hepatitis B virus, and other blood borne pathogens in health-care
settings. MMWR Morb Mortal Wkly Rep 37:377-388, 1988.
Garner JS: Guideline for isolation precautions in hospitals. Part I.
Evolution of isolation practices, Hospital Infection Control Practices
Advisory Committee. Am J Infect Control 24:24-31, 1996.
Garner JS: Comments on CDC guideline for isolation precautions in
hospitals, 1984. Am J Infect Control 12:163-164, 1984.
Haley RW, Garner JS, Simmons BP: A new approach to the isolation of
patients with infectious diseases: Alternative systems. J Hosp Infect
6:128-139, 1985.

Lynch P, Cummings MJ, Roberts PL: Implementing and evaluating a
system of generic infection precautions: Body substance isolation.
Am J Infect Control 18:1-12, 1990.
Lynch P, Jackson MM: Rethinking the role of isolation precautions in the
prevention of nosocomial infections. Ann Intern Med 107:243-246, 1987.
Lynch T: Communicable Disease Nursing. St. Louis, CV Mosby, 1949.

 

BIBLIOGRAPHY
American College of Physicians Task Force on Adult Immunization and
Infectious Diseases Society of America: Guide for Adult Immunization,
3rd ed. Philadelphia, American College of Physicians, 1994.
Bell DM, Shapiro CN, Ciesielski CA, Chamberland ME: Preventing blood
borne pathogen transmission from health care workers to patients:
The CDC perspective. Surg Clin North Am 75:1189-1203, 1995.
Cardo DM, Culver DH, Ciesielski CA, et al: A case-control study of HIV
seroconversion in health care workers after percutaneous exposure:
Centers for Disease Control and Prevention Needlestick Surveillance
Group. N Engl J Med 337:1485-1490, 1997.
Centers for Disease Control and Prevention: Public Health Service
(PHS) guidelines for the management of health care worker
exposures to HIV and recommendations for postexposure
prophylaxis. MMWR Morb Mortal Wkly Rep 47:1-33, 1998.
Centers for Disease Control and Prevention: Immunization of
health-care workers: Recommendations of the Advisory Committee
on Immunization Practices (ACIP) and the Hospital Infection Control
Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly
Rep 46:1-42, 1997.
Centers for Disease Control and Prevention: Recommendations for
follow-up of health-care workers after occupational exposure to
hepatitis C virus. MMWR Morb Mortal Wkly Rep 46:603-606, 1997.
Centers for Disease Control and Prevention: Case-control study of HIV
seroconversion in health-care workers after percutaneous exposure
to HIV infected blood—France, United Kingdom, and United States,
January 1988-August 1994. MMWR Morb Mortal Wkly Rep 44:929-933,
1995.
Centers for Disease Control and Prevention: Hospital Infection Control
Practices Advisory Committee: Guideline for prevention of
nosocomial pneumonia. Infect Control Hosp Epidemiol 15:587-627,
1994.
Centers for Disease Control and Prevention: Guidelines for preventing
the transmission of Mycobacterium tuberculosis in health-care
facilities, 1994. MMWR Morb Mortal Wkly Rep 43:1-132, 1994.
Centers for Disease Control and Prevention: National Institutes for
Health: Biosafety in Microbiological and Biomedical Laboratories, 3rd
ed. Atlanta, U.S. Department of Health and Human Services, Public
Health Service, 1993.
Centers for Disease Control and Prevention: Update on adult
immunization: Recommendations of the Immunization Practices
Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep 40:1-94,
1991.
Centers for Disease Control and Prevention: Protection against viral
hepatitis: Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep
39:1-27, 1990.

Chin J (ed): Control of Communicable Diseases Manual, 17th ed.
Washington, DC, American Public Health Association, 1999.
Diekema DJ, Alabanese MA, Schuldt SS, Doebbeling BN: Blood and body
fluid exposures during clinical training: Relation to knowledge of
universal precautions. J Gen Intern Med 11:109-111, 1996.
Garner JS: Hospital Infection Control Practices Advisory Committee:
Guidelines for Isolation Precautions in Hospitals. Infect Control Hosp
Epidemiol 17:53-80, 1996.
Gerberding JL, Lewis FR Jr, Schecter WP: Are universal precautions
realistic? Surg Clin North Am 75:1091-1104, 1995.
Moran G: Emergency department management of blood and fluid
exposures. Ann Emerg Med 35:47-62, 2000.
National Committee for Clinical Laboratory Standards: Protection of
laboratory workers from infectious disease transmitted by blood,
body fluids, and tissue: Tentative guideline. NCCLS Document M29-
T2, vol 11. Villanova, Pa, National Committee for Clinical Laboratory
Standards, 1991, pp 1-214.
Orenstein R, Reynolds L, Karabaic M, et al: Do protective devices
prevent needlestick injuries among health care workers? Am J Infect
Control 23:344-351, 1995.
Osborn EH, Papadakis MA, Gerberding JL: Occupational exposures to
body fluids among medical students: A seven-year longitudinal study.
Ann Intern Med 130:45-51, 1999.
Peter G (ed): Report of the Committee on Infectious Diseases Red Book,
25th ed. Elk Grove Village, Ill, American Academy of Pediatrics, 2000.
U.S. Department of Labor, Occupational Health and Safety
Administration: Criteria for recording on OSHA Form 200. OSHA
instruction 1993, standard 1904. Washington, DC, U.S. Department of
Labor, 1993.
U.S. Department of Labor, Occupational Safety and Health
Administration: Occupational exposure to blood borne pathogens,
final rule. CFR Part 1910.1030. Fed Reg 56:64004-64182, 1991.
U.S. Department of Labor, Occupational Health and Safety
Administration: Record keeping guidelines for occupational injuries
and illnesses: The Occupational Safety and Health Act of 1970 and 29
CFR 1904. OMB No. 120-0029. Washington, DC, U.S. Department of
Labor, 1986.

 

 

Standard Precautions

BACKGROUND AND HISTORY

The concept of isolating patients with infectious diseases in separate facilities,
which became known as infectious disease hospitals, was introduced in a
published hospital handbook as early as 1877. Although infected and noninfected
patients were separated, nosocomial transmission continued, largely
because of the lack of minimal aseptic procedures, coupled with the fact that
infected patients were not separated from each other by disease. By 1890 to
1900, nursing textbooks discussed recommendations for practicing aseptic
procedures and designating separate floors or wards for patients with similar
diseases, thereby beginning to solve the problems of nosocomial transmission
(Lynch, 1949).
Shortly thereafter, the cubicle system of isolation changed U.S. hospital
isolation procedures as patients were placed in multiple-bed wards. “Barrier
nursing” practices, consisting of the use of aseptic solutions, hand washing
between patient contacts, disinfecting patient-contaminated objects, and
separate gown use, were developed to decrease pathogenic organism transmission
to other patients and personnel. These practices were used in U.S.
infectious disease hospitals. By the 1960s, the designation of specifically
designed single- or multiple-patient isolation rooms in general hospitals and
outpatient treatment for tuberculosis caused these specialized hospitals
(which since the 1950s had housed tuberculosis patients almost exclusively)
to close (Garner, 1996).
The lack of consistent infectious patient isolation policies and procedures
noted by the Centers for Disease Control (CDC) investigators in the 1960s led
to the CDC publication in 1970 of a detailed isolation precautions manual
entitled Isolation Techniques for Use in Hospitals, designed to assist large
metropolitan medical centers as well as small hospitals with limited budgets.
After revision in 1983, the manual was renamed the CDC Guidelines for
Isolation Precautions in Hospitals. These new guidelines encouraged hospital
infection control decision making with respect to developing isolation systems
specific to the hospital environment and circumstances or choosing to select
between category-specific or disease-specific isolation precautions. Decisions
regarding individual patient precautions were to be based on factors such as
patient age, mental status, or possible need to prevent sharing of contaminated
articles and were to be determined by the individual who placed the patient
on isolation status. Decisions regarding the need for decreasing exposure to
infected material by wearing masks, gloves, or gown were to be left to the
patient caregiver (Garner, 1984; Haley, 1985).
Issues of overisolation of some patients surfaced using the 1983 categories
of isolation, which included strict isolation, contact isolation, respiratory
isolation, tuberculosis (acid-fast bacilli) isolation, enteric precautions,
drainage-secretion precautions, and blood and body fluid precautions. In
using the disease-specific isolation precautions, the issue of mistakes in
applying the precautions arose if the patient carried a disease not often seen
or treated in the hospital (Garner, 1984; Haley, 1985), if the diagnosis was
delayed, or if a misdiagnosis occurred. This happened even if additional  training of personnel was encouraged. These factors, coupled with increased
knowledge of epidemiologic patterns of disease, led to subsequent updates
of portions of the CDC reports:

■ Recommendations for the management of patients with suspected
hemorrhagic fever published in 1988 (CDC, 1988)
■ Recommendations for respiratory isolation for human parvovirus B19
infection specific to patients who were immunodeficient and had chronic
human parvovirus B19 infection or were in transient aplastic crisis (CDC,
1989)
■ Recommendations for the management of tuberculosis, which stemmed
from increasing concern for multidrug-resistant tuberculosis, especially
in human immunodeficiency virus (HIV)–infected patients in care
facilities (CDC, 1990)
■ Recommendations for hantavirus infection risk reduction (CDC, 1994)
■ Expansion of recommendations for the prevention and control of
hepatitis C virus (HCV) infection and hepatitis C virus–related chronic
disease (CDC, 1998)
■ Occupational exposure recommendations and postexposure management
for hepatitis B virus (HBV), HCV, and HIV (CDC, 2001)
■ Recommendations for infection control of avian influenza and management
of exposure to severe acute respiratory syndrome–associated coronavirus
(SARS-CoV) in the healthcare setting (CDC, 2004; CDC, 2005)

BODY SUBSTANCE ISOLATION
An entirely different approach to isolation, called body substance isolation
(BSI), was developed in 1984 by Lynch and colleagues (1987, 1990) and
required personnel, regardless of patient infection status, to apply clean
gloves immediately before all patient contact with mucous membranes or
nonintact skin, and to wear gloves if a likelihood existed of contact with any
moist body substances. An apron or other barrier was also to be worn to
keep the provider’s own clothing and skin clean. It was recommended also
that personnel be immunized if proof of immunity could not be documented
when barriers, such as masks, could not prevent transmission by airborne
routes (e.g., rubella, chickenpox). Additionally, when immunity was not
possible, as with pulmonary tuberculosis, masks were to be worn during all
patient contact. Goggles or glasses, hair covers, and shoe covers were also
used as barriers. Careful handling of all used sharps, recapping of needles
without using the hands, and the disposal of used items in rigid punctureresistant
containers were stressed. Trash and soiled linen from all patients
were bagged and handled in the same manner. This approach sought to
protect the patient from contracting nosocomial infections and the provider
from bacterial or viral pathogens that might originate with the patient.

UNIVERSAL PRECAUTIONS
In response to increasing concerns by health care workers and others about
occupational exposure and the risk of transmission of human immunodeficiency
virus, HBV, and other blood-borne pathogens during provision of
health care and first aid, the CDC, in 1987, defined a set of precautions that
considered blood and certain body fluids from all patients to be potential
sources of infection for human immunodeficiency virus, HBV, and other
blood-borne pathogens. These recommendations became known as
universal precautions (UP) and have subsequently been integrated into the
Recommendations for Isolation Precautions in Hospitals, 1996, which includes
the current standard precautions (SP) (Table 2-1).

Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996

  

STANDARD PRECAUTIONS
Use Standard Precautions, or the equivalent, for the care of all patients.

HAND WASHING
Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items,
whether or not gloves are worn. Wash hands immediately after gloves are removed, between
patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other
patients or environments. It may be necessary to wash hands between tasks and procedures
on the same patient to prevent cross-contamination of different body sites.
Use a plain (nonantimicrobial) soap for routine hand washing.
Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (e.g.,
control of outbreaks or hyperendemic infections), as defined by the infection control program.
(See “Contact Precautions” for additional recommendations on using antimicrobial and
antiseptic agents.)

GLOVES
Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids,
secretions, excretions, and contaminated items. Put on clean gloves just before touching
mucous membranes and nonintact skin. Change gloves between tasks and procedures on the
same patient after contact with material that may contain a high concentration of
microorganisms. Remove gloves promptly after use, before touching noncontaminated items
and environmental surfaces, and before going to another patient, and wash hands immediately
to avoid transfer of microorganisms to other patients or environments.

MASK, EYE PROTECTION, FACE SHIELD
Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes,
nose, and mouth during procedures and patient care activities that are likely to generate
splashes or sprays of blood, body fluids, secretions, and excretions.

GOWN
Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling of
clothing during procedures and patient care activities that are likely to generate splashes or
sprays of blood, body fluids, secretions, or excretions. Select a gown that is appropriate for
the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly
as possible, and wash hands to avoid transfer of microorganisms to other patients or
environments.

PATIENT CARE EQUIPMENT
Handle used patient care equipment soiled with blood, body fluids, secretions, and excretions
in a manner that prevents skin and mucous membrane exposures, contamination of clothing,

Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996—cont’d

and transfer of microorganisms to other patients and environments. Ensure that reusable
equipment is not used for the care of another patient until it has been cleaned and
reprocessed appropriately. Ensure that single-use items are discarded properly.

ENVIRONMENTAL CONTROL
Ensure that the hospital has adequate procedures for the routine care, cleaning, and
disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other
frequently touched surfaces, and ensure that these procedures are being followed.

LINEN
Handle, transport, and process used linen soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures and contamination
of clothing, and that avoids transfer of microorganisms to other patients and environments.

OCCUPATIONAL HEALTH AND BLOOD-BORNE PATHOGENS
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or
devices; when handling sharp instruments after procedures; when cleaning used instruments;
and when disposing of used needles. Never recap used needles, or otherwise manipulate them
using both hands, or use any other technique that involves directing the point of a needle
toward any part of the body; rather, use either a one-handed “scoop” technique or a
mechanical device designed for holding the needle sheath. Do not remove used needles from
disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles
by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in
appropriate puncture-resistant containers, which are located as close as is practical to the
area in which the items were used, and place reusable syringes and needles in a punctureresistant
container for transport to the reprocessing area.
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to
mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.

PATIENT PLACEMENT
Place a patient who contaminates the environment or who does not (or cannot be expected
to) assist in maintaining appropriate hygiene or environmental control in a private room. If a
private room is not available, consult with infection control professionals regarding patient
placement or other alternatives.

AIRBORNE PRECAUTIONS
In addition to standard precautions, use airborne precautions, or the equivalent, for patients
known or suspected to be infected with microorganisms transmitted by airborne droplet
nuclei (small-particle residue [5 μm or smaller in size] of evaporated droplets containing
microorganisms that remain suspended in the air and that can be dispersed widely by air
currents within a room or over a long distance).

PATIENT PLACEMENT
Place the patient in a private room that has (1) monitored negative air pressure in relation to
the surrounding area, (2) six to twelve air changes per hour, and (3) appropriate discharge of
air outdoors or monitored high-efficiency filtration of room air before the air is circulated to
other areas in the hospital. Keep the room door closed and the patient in the room. When a
private room is not available, place the patient in a room with a patient who has active
infection with the same microorganism, unless otherwise recommended, but with no other
infection. When a private room is not available and cohorting is not desirable, consultation
with infection control professionals is advised before patient placement.

RESPIRATORY PROTECTION
Wear respiratory protection when entering the room of a patient with known or suspected
infectious pulmonary tuberculosis. Susceptible persons should not enter the room of patients
known or suspected to have measles (rubeola) or varicella (chickenpox) if other, immune
caregivers are available. If susceptible persons must enter the room of a patient known or

Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996—cont’d

suspected to have measles (rubeola) or varicella, they should wear respiratory protection.
Persons immune to measles (rubeola) or varicella need not wear respiratory protection.

PATIENT TRANSPORT
Limit the movement and transport of the patient from the room to essential purposes only. If
transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a
surgical mask on the patient, if possible.

ADDITIONAL PRECAUTIONS FOR PREVENTING TRANSMISSION OF TUBERCULOSIS
Consult CDC Guidelines for Preventing the Transmission of Tuberculosis in Health Care Facilities
for additional prevention strategies.

DROPLET PRECAUTIONS
In addition to standard precautions, use droplet precautions, or the equivalent, for a patient
known or suspected to be infected with microorganisms transmitted by droplets (large-particle
droplets [larger than 5 μm in size] that can be generated by the patient during coughing,
sneezing, talking, or the performance of procedures).

PATIENT PLACEMENT
Place the patient in a private room. When a private room is not available, place the patient in a
room with a patient(s) who has active infection with the same microorganism but with no
other infection (cohorting). When a private room is not available and cohorting is not
achievable, maintain spatial separation of at least 3 feet between the infected patient and
other patients and visitors. Special air handling and ventilation are not necessary, and the
door may remain open.

MASK
In addition to standard precautions, wear a mask when working within 3 feet of the patient.
(Logistically, some hospitals may want to implement the wearing of a mask to enter the room.)

PATIENT TRANSPORT
Limit the movement and transport of the patient from the room to essential purposes only. If
transport or movement is necessary, minimize patient dispersal of droplets by masking the
patient, if possible.

CONTACT PRECAUTIONS
In addition to standard precautions, use contact precautions, or the equivalent, for specified
patients known or suspected to be infected or colonized with epidemiologically important
microorganisms that can be transmitted by direct contact with the patient (hand or skin-toskin
contact that occurs when performing patient care activities that require touching the
patient’s dry skin) or indirect contact (touching) with environmental surfaces or patient care
items in the patient’s environment.

PATIENT PLACEMENT
Place the patient in a private room. When a private room is not available, place the patient in a
room with a patient(s) who has active infection with the same microorganism but with no
other infection (cohorting). When a private room is not available and cohorting is not
achievable, consider the epidemiology of the microorganism and the patient population when
determining patient placement. Consultation with infection control professionals is advised
before patient placement.

GLOVES AND HAND WASHING
In addition to wearing gloves as outlined under “Standard Precautions,” wear gloves (clean,
nonsterile gloves are adequate) when entering the room. During the course of providing care
for a patient, change gloves after having contact with infective material that may contain high
concentrations of microorganisms (fecal material and wound drainage). Remove gloves before
leaving the patient’s environment and wash hands immediately with an antimicrobial agent or

Table 2.1 Recommendations for Isolation Precautions in
Hospitals, Hospital Infection Control Practices Advisory
Committee, 1996—cont’d

a waterless antiseptic agent. After glove removal and hand washing, ensure that hands do not
touch potentially contaminated environmental surfaces or items in the patient’s room to avoid
transfer of microorganisms to other patients or environments.

GOWN
In addition to wearing a gown as outlined under “Standard Precautions,” wear a gown (a clean,
nonsterile gown is adequate) when entering the room if you anticipate that your clothing will
have substantial contact with the patient, environmental surfaces, or items in the patient’s
room, or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound
drainage not contained by a dressing. Remove the gown before leaving the patient’s environment.
After gown removal, ensure that clothing does not contact potentially contaminated
environmental surfaces to avoid transfer of microorganisms to other patients or environments.

PATIENT TRANSPORT
Limit the movement and transport of the patient from the room to essential purposes only. If
the patient is transported out of the room, ensure that precautions are maintained to minimize
the risk of transmission of microorganisms to other patients and contamination of environmental
surfaces or equipment.

PATIENT CARE EQUIPMENT
When possible, dedicate the use of noncritical patient care equipment to a single patient (or
cohort of patients infected or colonized with the pathogen requiring precautions) to avoid
sharing between patients. If use of common equipment or items is unavoidable, adequately
clean and disinfect them before use for another patient.

ADDITIONAL PRECAUTIONS FOR PREVENTING THE SPREAD OF
VANCOMYCIN RESISTANCE
Consult the HICPAC report on preventing the spread of vancomycin resistance for additional
prevention strategies.

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HICPAC, Hospital Infection Control Practices Advisory Committee.
From Centers for Disease Control and Prevention: Recommendations for Isolation Precautions in
Hospitals, 1996. Available at: http://www.cdc.gov/ncidod/hip/isolat/isopart1.htm and
www.cdc.gov./ncidod/hip/isolat/isopart2.htm

BACKGROUND AND HISTORY OF THE PATIENT-PROVIDER RELATIONSHIP

Over the last four decades, there has been a dramatic shift in the character
of the physician-patient relationship, from one traditionally paternalistic or
physician-focused in nature, to one that recognizes patient autonomy and
is predominantly patient-centered. This struggle between paternalism and
autonomy has been central to the discussions of ethically acceptable medical
practice and has formed the basis for the doctrine of informed consent.
Paternalism is based on the principle of beneficence, the desire to do good
for the patient. The concept of informed consent asserts that the desire to do
good is not a justification for overriding a competent patient’s right to
personal autonomy and self-determination. Although there is some question
about whether consent to medical procedures can ever be truly informed,
the process of obtaining informed consent from a patient has been incorporated
into American society’s expectation of good medical practice.

PURPOSE OF INFORMED CONSENT
In May 2000 (amended May 2004), the House of Delegates of the American
Academy of Physician Assistants adopted a policy of comprehensive “Guidelines
for Ethical Conduct for the Physician Assistant Profession.” The guidelines
address the profession’s responsibility in protecting a patient’s autonomy.

Physician assistants have a duty to protect and foster an individual
patient’s free and informed choices. The doctrine of informed consent
means that a PA provides adequate information that is comprehendible to
a competent patient or patient surrogate. At a minimum, this should
include the nature of the medical condition, the objectives of the proposed
treatment, treatment options, possible outcomes, and the risks involved.
PAs should be committed to the concept of shared decision making, which
involves assisting patients in making decisions that account for medical,
situational, and personal factors.
(American Academy of Physician Assistants, 2004)

Informed consent should be obtained from a patient before all medical
interventions that have the potential for harm, including diagnostic and
therapeutic procedures. A patient, through the exercise of personal autonomy,
may either agree to or refuse a proposed procedure or treatment, but it is the
responsibility of the practitioner to make sure that the decision is based on
complete and appropriate information.
At the present time, the United States has no federal statute that comprehensively
sets national standards of practice regarding patient consent for
medical procedures. There is an implied moral obligation on professionals to
disclose the necessary information to the patient, but the nature and extent of the legal obligation varies from one jurisdiction to another (Beauchamp,
2001). In most states, health care providers have an “affirmative duty” to
disclose information regarding medical treatments, which means that information
must be volunteered and not just provided in response to questions
posed by the patient. Once the information has been disclosed, the provider’s
obligation has been met. Weighing the risks and deciding on a course of action
then becomes the responsibility of the patient or the patient’s surrogate.
Legal actions against health care professionals for failure to obtain informed
consent to treatment have been pursued under two separate theories of
liability—one based on the concept of battery and the other on the concept
of negligence (Applebaum, 1987).
Most early litigation involving informed consent argued that the provision
of treatment without consent constituted battery—an intentional, nonconsensual
touching of the patient. The concept of battery protects a person’s
physical integrity against unwanted invasion.
After 1957, most suits alleging lack of informed consent were brought
under the legal theory of negligence. Under this theory, an injured patient
argues that he or she was harmed by the provider’s unintentional failure to
satisfy a professional standard of care. When applied in an informed consent
case, the alleged negligence results from a failure to disclose sufficient
information about the risks or complications of a treatment.

ESSENTIAL COMPONENTS OF
INFORMED CONSENT
There are three essential conditions that must be met to ensure effective
informed consent. First, the patient must have the capacity, or competence,
to make an informed decision. A distinction is sometimes made between the
medical judgment of a patient’s capacity to consent and the legal judgment
of his competence; however, in clinical practice the two are closely linked
(Beauchamp, 2001). Second, the patient must be given sufficient information
about the procedure or treatment and the alternatives available, to allow him
or her to make an informed choice. Third, the patient must give consent to
treatment voluntarily, without coercion, manipulation, or duress.

PATIENT CAPACITY
There is no universally accepted test of a patient’s capacity to consent to
treatment. In general, an adult is presumed to be legally competent unless he
or she has been formally and legally declared incompetent. Conversely, a
minor is generally presumed to be legally incompetent to make medical
decisions, although a number of exceptions to this rule exist and are often
state-specific (e.g., emancipation). Additionally, specific legislation sometimes
grants minors legal status to make some medical decisions for themselves
(e.g., testing for sexually transmitted diseases, reproductive decisions).

Competency is usually established by assessing whether the patient has
the capacity to understand the nature of his or her condition and the various
options available and whether he or she is capable of making a rational
decision. To make a rational choice, patients must be able to understand the
treatments available and the likely outcomes in each case. They must also be
able to deliberate and consider their options and weigh them against one
another to choose the best alternative. To do so effectively, they must assess
the options available in relation to a set of values and goals, without which
they would have no basis for preferring one outcome to any other (Moskop,
1999). They must also be able to communicate their understanding and their
decision in some intelligible way.

ADEQUATE INFORMATION
The second requirement of informed consent is that the patient must be
provided with adequate information with which to make a decision. The right
to informed consent is embedded in the nature of fiduciary relationships,
wherein one party has differential power, and thus that party has the
inherent responsibility to share necessary information with the other.
General categories of information that must be provided are the diagnosis;
the nature of the proposed procedure; the risks, consequences, and benefits
of the procedure; an assessment of the likelihood that the procedure(s) will
accomplish the desired outcomes; and any reasonable and feasible alternatives
to treatment (including the alternative of not having the procedure)
and the risks and benefits of each. In clinical practice, the information
required to be disclosed is frequently summarized by using the abbreviation
PARQ: P (the recommended medical procedure), A (the reasonable alternatives
to the recommended procedure), and R (the risks of the procedure);
Q represents the additional step of asking the patient if he or she has any
questions about the proposed procedure not adequately disclosed in the
discussion.
States are far from uniform in their views of how much information should
be disclosed for meaningful informed consent. Various criteria have been
proposed as both legal and moral standards for adequate disclosure. The
“reasonable physician” standard bases disclosure of information on the
prevailing practice within the profession. What would a typical health
care provider in the same specialty and “community” disclose about this
procedure? This legal standard, the only judicial standard by which courts
judged physicians prior to 1972, allows the practitioner to determine what
information is appropriate to disclose. It is often argued that this more
paternalistic approach, although still dominant in the courts, is inconsistent
with the goals of informed consent and true patient autonomy.
The second standard of disclosure, introduced in 1972, is the “reasonable
person” standard. The reasonable person standard requires a health care
provider to disclose to a patient any material information that the practi-tioner recognizes that a reasonable person in the patient’s position would
consider to be significant to his or her decision making about the recommended
medical intervention. Risks that are not serious, or are unlikely, are
not considered material. Under this standard, the critical requirement shifts
from whether the disclosure met the profession’s standard to whether the
undisclosed information would have been material to a reasonable patient’s
decision making.
The great advantage of the reasonable person standard is the focus on the
preferences of the patient. A requirement for this standard is that the type
and amount of information provided must be at the patient’s level of understanding
if he or she is truly to be an autonomous decision maker. The
disadvantages of this standard include its failure to articulate the nature of
the “hypothetical” reasonable person. In addition, the retrospective
application of this standard presents a significant problem in that any
complication of a procedure is likely to seem material after it has occurred
(Nora, 1998).
Although the reasonable person standard does focus more on the patient,
it does not require that the disclosure be tailored to each patient’s specific
informational needs or desires. Instead, it bases the requirements on what a
hypothetical reasonable person would want to know. The third standard of
disclosure, the “subjective” standard, addresses this limitation by asking the
question, What would this particular patient need to know and understand in
order to make an informed decision? This patient-centered approach allows
greater differentiation based on patient preference, relying on the unique
nature and abilities of the individual patient to determine the degree of
disclosure needed to satisfy the requirements of informed consent. This
standard is the most challenging to implement in practice due to its requirement
to tailor information specifically to each patient.
In addition to providing information, the clinician has the ethical
obligation to make reasonable efforts to ensure comprehension. Communicating
highly technical and specialized knowledge to someone who is not
conversant in the subject presents a formidable challenge. Patient-centered
barriers to informed consent—such as anxiety, language differences, and
physical or emotional impairments—can impede the process. Lack of
familiarity or sensitivity to the patient’s cultural and health care beliefs
on the part of the provider can act as a significant barrier to providing
effective informed consent. Process-centered barriers, including readability
of consent forms, timing of the consent discussion, and amount of time
devoted to the process, also may reflect disrespect for the autonomy of the
patient.
To optimize information sharing, explanations should be given clearly and
simply, and questions should be asked frequently to assess understanding.
Whenever possible, a variety of communication techniques should be used,
including written forms of educational materials, videotapes, CDs, DVDs,
and additional media sources. Computers have taken on a new and everexpanding
role as an effective tool in patient education when integrated into
the clinical setting.

VOLUNTARY CHOICE
In a clinical setting, voluntariness may be influenced by the vulnerability of
the patient and the inherent imbalance in knowledge and power between the
health care professional and the patient. Care needs to be exercised in
advising patients carefully so that what professionals construe in good faith
as rational persuasion does not unintentionally exert undue influence on a
patient’s decision making (Messer, 2004). Consent to treatment obtained using
manipulation or coercion, or both, is the antithesis of informed consent.
Although a health care provider’s recommendation regarding treatment
typically can have a strong influence on a patient’s decision making, a recommendation
offered as part of the clinician’s responsibility to inform and guide
a patient in his or her decision making is not considered coercion.

TYPES OF INFORMED CONSENT
Consent may take many forms, including implied, general, and special.
Implied consent is often used when immediate action is required. In the
emergency room, consent is presumed when inaction may cause greater
injury or would be contrary to good medical practice. General consent is
often obtained on hospital admission to provide consent for routine services
and routine touching by health care staff. Such “blanket” forms generally do
not list specific procedures, risks, benefits, or alternatives that might be
encountered by a patient during a hospitalization. Additionally, the risk
associated with a procedure may be variable depending upon a patient’s
condition. Therefore, a consent to “general treatment” upon hospital
admission may not be adequate to meet the requirements of informed
consent (Manthous, 2003). Finally, special consent is required for specific
high-risk procedures and medical treatments.
State laws vary as to which interventions require a signed consent form.
Some states require a written consent only for surgical interventions,
anesthesia, or other more invasive procedures. Other states require informed
consent be documented for a broader range of procedures.
In order to ensure that informed consent is properly obtained, the health
care provider should actually discuss with the patient each of the procedures
to be performed, including the nature, risks, and alternatives. Consent
obtained verbally is as binding as written consent because there is no legal
requirement that consent be in written form; however, when disagreements
arise, oral consent becomes difficult to prove. The health care provider
should always document verbal consent explicitly in the medical record.
Written consent is the preferred form of consent. The consent form
provides legal, visible proof of a patient’s intentions. A well-drafted informed
consent document can provide concrete evidence that some exchange of
information was communicated to, and some assent obtained from, the
patient. Such a document, supported by an entry in the patient’s medical
record, is often the key to a successful malpractice defense when the issue
of consent to treatment arises.

Some states have laws that specify certain language on consent forms for
certain procedures. In cases that do not require specific forms, a general
consent form that identifies the patient, the date, and precise time of
signature and documents the procedure, the risks associated with it, the
indications, and the alternatives can be used. Most states require a consent
form to be witnessed. Because of the potential conflict of interest, office
personnel (nursing or other staff) should not act as the sole witness to a
consent document.
A written informed consent document should be prepared with the patient’s
needs in mind and should verify that the patient was given the opportunity
to ask questions and discuss concerns. Consent forms are often written in
great detail and use medical and legal terminology that is far beyond the
capacity of many patients. For true autonomy to exist in informed consent,
consent forms should be understandable and should include the patient’s
primary language or languages whenever possible. When appropriate, an
interpreter should be made available during the informed consent conference.
The issue of comprehension is vital to the process. Health care
providers should not make the mistake of equating the written and signed
document with informed consent. The provider should always take care to
make sure that information-transferring communication did occur.

PATIENT’S RIGHT TO REFUSE
TREATMENT
Patients have the right to refuse treatment. In such circumstances, it is
essential to document carefully such refusals and, most importantly, the
patient’s understanding of the potential consequences of refusing treatment.
The signature of a witness is helpful in these circumstances.

EXCEPTIONS TO INFORMED
CONSENT REQUIREMENTS
Several types of legitimate exceptions to the right of informed consent have
been described. In rare instances, courts have recognized limited privileges
that potentially can protect health care providers from claims alleging a lack
of informed consent. Such exceptions include emergencies, patients unable
to consent, a patient waiver of consent, public health requirements, and
therapeutic privilege. In all these instances, the provider has the burden of
proving that the claimed exception was invoked appropriately.
According to the emergency exception, if treatment is required to prevent
death or other serious harm to a patient, that treatment may be provided
without informed consent. Courts have upheld that the emergent nature of
the situation and the impracticality of conferring with the patient preclude
the need for informed consent. This exception is based on the presumption
that the patient would consent to treatment to preserve life or health if he orshe were able to do so and if there were sufficient time to obtain consent.
Despite this exception, a competent patient may refuse interventions even if
they are life-saving. For example, courts have repeatedly recognized the
rights of Jehovah’s Witnesses to refuse blood products.
Care of patients who lack decision-making capacity can be provided
without the patient’s informed consent. This exception, however, does not
imply that no consent is necessary; instead, informed consent is required
from a surrogate acting on behalf of the patient. Some surrogate decision
makers are clearly identifiable (e.g., the legal guardians assigned to protect
the best interests of persons judged to be incompetent and the parents of
minor children). In other cases, surrogates are more difficult to determine.
The decision-making authority of surrogates is directed by defined
standards. These standards require surrogates to rely first on any treatment
preferences specifically indicated by the patient, either written or oral,
before he or she lost decision-making capacity. Lacking such direction,
surrogates are then empowered to exercise “substituted judgment,”—that is,
to use their knowledge of the patient’s preferences and values to choose the
alternative they believe the patient would choose if he or she were able to do
so. In some instances, prior knowledge of a patient’s preferences or values is
lacking. In such situations, surrogates are directed to rely on their assessment
of the patient’s best interests and are encouraged to pursue the course
of action they deem most likely to foster the patient’s overall well-being
(Buchanan, 1989).
When a surrogate’s treatment choice appears clearly contrary to a patient’s
previously expressed wishes or best interests, the patient’s provider is dutybound
to question that choice. The health care provider does not have the
authority to unilaterally override the surrogate’s decision but must bring the
issue to the attention of an appropriate legal authority for review and
adjudication.
In the “Guidelines for Ethical Conduct for the Physician Assistant Profession,”
the clinician’s role with regard to surrogates is clearly delineated.
When the person giving consent is a patient’s surrogate, a family member,
or other legally authorized representative, the PA should take reasonable
care to assure that the decisions made are consistent with the patient’s
best interests and personal preferences, if known. If the PA believes the
surrogate’s choices do not reflect the patient’s wishes or best interests, the
PA should work to resolve the conflict. This may require the use of
additional resources, such as an ethics committee.
(American Academy of Physician Assistants, 2004)
Informed consent, although clearly recognized as a patient’s right, is not a
patient’s duty. Patients can choose to waive their right to receive the relevant
information and give informed consent to treatment. The provider may honor
the patient’s right to choose someone else to make treatment decisions on
his or her behalf as long as the request is made competently, voluntarily, and
with some understanding that the patient recognizes that he or she is
relinquishing a right. Health care providers should not feel obligated to accept the responsibility for making treatment decisions for the patient if
they are asked to do so. Instead, they can request that the patient make his
or her own choice or designate another person to serve as surrogate.
Sometimes medical interventions have a potential benefit not only to the
patient but also to others in the community. In such rare instances, public
health statutes may authorize patient detention or treatment without the
patient’s consent. This exception overrides individual patient autonomy in
specific circumstances to protect important public health interests.
The final exception to informed consent is the concept of therapeutic
privilege, which allows the health care provider to let considerations about
the physical, mental, and emotional state of the patient affect what information
is disclosed to the patient. The practitioner should believe that the risk of
giving information would pose a serious detriment to the patient. The anticipated
harm must result from the disclosure itself and not from the potential
influence that the information might have on the patient’s choice. The sole
justification of concern that the patient might refuse needed therapy is not
considered adequate to justify invoking this exception. The therapeutic
privilege is extremely controversial and not universally recognized. Thus,
the value of therapeutic privilege as an independent exception to informed
consent is limited.

CONCLUSIONS
The moral and legal doctrine of informed consent and its counterpart, the
refusal of treatment, are products of the last half of the 20th century. During
this time, judges sought to protect patient autonomy—that is, the patient’s
right to self-determination. Informed consent requires the health care practitioner
to provide the patient with an adequate disclosure and explanation of
the treatment and the various options and consequences.
Informed consent, however, is more than a legal necessity. When conducted
properly, the process of communicating appropriate information to patients
about treatment alternatives can help establish a reciprocal relationship
between health care provider and patient that is based on good and
appropriate communication, considered advice, mutual respect, and rational
choices. The therapeutic objective of informed consent should be to replace
some of the patient’s anxiety and unease with a sense of participation as a
partner in decision making. Such a sense of participation strengthens the
therapeutic alliance between provider and patient. After initial consent to
treatment has occurred, a continuing dialogue between patient and practitioner,
based on the patient’s continuing medical needs, reinforces the original
consent. In the event of an unfavorable outcome, the enhanced relationship
will prove crucial to maintaining the patient’s trust.
In the area of informed consent, as in every other area of risk management,
the best recommendation is to practice good medicine. Informed consent is
an essential part of good medical practice today and is an ethical and moral
responsibility of all health care providers.

REFERENCES
American Academy of Physician Assistants: Guidelines for Ethical
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Clinical Practice. New York, Oxford University Press, 1987.
Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 5th ed.
New York, Oxford University Press, 2001.
Buchanan AE, Brock DW: Deciding for Others: The Ethics of Surrogate
Decision Making. Cambridge, England, Cambridge University Press,
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Manthous CA, DeFirolamo A, Haddad C, Amoateng-Adjepong Y: Informed
consent for medical procedures: local and national practices. Chest
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