Nurses and Standard Precautions

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.

Background

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:

• UP said wear masks, protective eyewear or face shields, even gowns if it is likely that droplets of blood or body fluids will be sprayed. BSI expanded that to include plastic aprons, hair covers, and shoe covers to keep all moist body substances off clothing, skin, hair, and mucous membranes.
• UP called for discarding needles in puncture-resistant containers. BSI expanded that to discarding all needles and sharp instruments in puncture-proof containers.
• UP guidelines were for gloves to be worn when in contact with body fluids and to wash hands after removing gloves. BSI called for a thorough hand washing before and after client care and wearing gloves before any contact with fluids or moist body areas (in other words put gloves on as soon as you wash your hands).

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.

1. Standard Precautions apply to all clients and patients attending healthcare facilities.
2. Transmission-Based Precautions which apply only to hospitalized patients.

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:

1. Wash hands after contact with blood, body fluids, secretions, excretions, and contaminated objects whether or not gloves are worn.
2. Wear clean gloves when touching blood, body fluids, secretions, excretions, and contaminated items (i.e. soiled gowns).
3. Wear a mask, eye protection, or a face shield if splashes or sprays of blood, body fluids, secretions, excretions can be expected.
4. Wear a clean, non-sterile gown if client case is likely to result in splashes or sprays of blood, body fluids, secretions, or excretions. The gown is intended to protect clothing.
5. Handle client care equipment that is soiled with blood, body fluids, secretions, or excretions carefully to prevent the transfer of microorganisms to others and to the environment.
6. Handle, transport, and process linen that is soiled with blood, body fluids, secretions, or excretions in a manner to prevent contamination of clothing and the transfer of microorganisms to others and to the environment.
7. Prevent injuries from used equipment, i.e. scalpels or needles, and place in puncture-resistant containers.

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

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.