July 12th, 2012
By Jennifer Olin, BSN, RN
The release of the new guidelines for managing the hepatitis B virus in infected healthcare workers got me thinking about all the precautions we take when caring for our patients. All nurses have heard it a hundred times: our number one job is patient safety. Included in that is personal safety because you can’t provide quality care if you aren’t healthy yourself.
In a previous article I started to use the phrase “universal precautions” then I thought, “no, those are standard precautions.” Then I started thinking why two names, what’s the difference, why does this seem confusing? It was all rolled up in my mind like a ball of yarn after a kitten has passed by.
I think I practice safe care when I am with my patients. I wear gloves, I wash my hands a lot, and I even glance at the safety posters occasionally. But, after some consideration I realized, if put on the spot, I couldn’t tell you what universal or standard precautions are by definition and if there was even a difference. Time for a little research.
In the mid-80s with the emergence of HIV/AIDS and the overwhelming prevalence of hepatitis B virus infections in healthcare workers, guidelines were established in a joint effort between OSHA (Occupational Safety and Health Administration) and the CDC (Centers for Disease Control and Prevention) to protect more people from exposure to blood borne infections. The guidelines were quickly adopted and became known as “Universal Precautions (UP).”
These were working great for protecting hospital personnel in patient-to-personnel transmissions but these guidelines didn’t completely address preventing patient-to-patient and personnel-to-patient infection transmissions. These guidelines were primarily diagnosis driven, meaning healthcare workers would implement the measures when they knew a patient was sick with a blood borne illness. But what if you couldn’t tell?
At about the same time as the UP were being introduced, another team of researchers developed an alternative approach to patient and healthcare worker precautions, known as BSI (Body Substance Isolation), which focused on protecting patients and health personnel from all moist and potentially infected body substances (secretions and excretions), not just blood.
The basic premise was that all people have an increased risk for infection in their mucous membranes and at non-intact skin and that an unknown portion of clients and healthcare workers will always be colonized or infected with potentially infectious microorganisms in their blood, and other moist body sites and substances.
BSI was based primarily on the use of gloves. Personnel were instructed to put on clean gloves just before touching mucous membranes or non-intact skin, and before anticipated contact with moist body fluids. This led to a popular nursing school teaching, “If it's wet, and it's not yours, don't touch it.”
Now both sets of guidelines shared what we now consider common sense basics such as:
BSI quickly gained acceptance over UP because it was simple, easy to learn and implement, and acknowledged that all patients, not just those diagnosed or with symptoms, may be infected and therefore not free of risk to other patients or staff.
There were disadvantages in adopting BSI including the added cost of protective barrier equipment, particularly gloves, difficulty in maintaining routine use of the protocol for all patients, uncertainty about precautions for patients in isolation rooms and the overuse of gloves to protect staff at the expense of patients.
By the early 1990s healthcare facilities and staff were totally confused regarding what to do about patient and staff precaution guidelines. Some hospitals implemented UP while others used BSI. Some hospitals and staff that thought they were following UP were really using BSI, and vice versa. There was also a lot of local variation in the interpretation and use of both UP and BSI; meaning every place had their own version of what should have been standard.
Standard Precautions Emerge
Finally, in 1996, the CDC issued a new set of guidelines and called them “Standard Precautions.” They were the best of both worlds and involved a two tier approach.
The key component in Standard Precautions involves placing a physical, mechanical, or chemical barrier between microorganisms and an individual. This is a highly effective means of preventing the spread of infections (i.e., the barrier serves to break the disease transmission cycle).
Simply stated, the Standard Precautions are:
Pretty simple seven steps to safety. They are not even that hard to remember. So, in this day and age, Standard Precautions are it. While someone may use the term “Universal Precautions” take it that they are just using the terms interchangeably.
Tier Two or transmission based precautions are more specified as “Airborne,” “Droplet,” and “Contact” precautions and we will look at them in a future post, along with isolation precautions.