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.

 

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