Standard precautions

Introduction

Standard precautions synthesize the major features of UP (Blood and Body Fluid Precautions) [1,2] (designed to reduce the risk of transmission of bloodborne pathogens) and BSI [3,4] (designed to reduce the risk of transmission of pathogens from moist body substances) and applies them to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. Standard precautions apply to [5] blood; [6] all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; [7] non-intact skin; and, [8] mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

Recommendations

The recommendations presented below are categorized as follows:

• Category IA. Strongly recommended for all hospitals and strongly supported by well-designed experimental or epidemiologic studies.
• Category IB. Strongly recommended for all hospitals and reviewed as effective by experts in the field and a consensus of HICPAC based on strong rationale and suggestive evidence, even though definitive scientific studies have not been done.
• Category II. Suggested for implementation in many hospitals. Recommendations may be supported by suggestive clinical or epidemiologic studies, a strong theoretical rationale, or definitive studies applicable to some, but not all, hospitals.
• No recommendation; unresolved issue. Practices for which insufficient evidence or consensus regarding efficacy exists.

The recommendations are limited to the topic of isolation precautions. Therefore, they must be supplemented by hospital policies and procedures for other aspects of infection and environmental control, occupational health, administrative and legal issues, and other issues beyond the scope of this guideline.

Use standard precautions, or the equivalent, for the care of all patients. Category IB.

Hand hygiene: use an alcohol-based hand rub agent. WHO recommends alcohol-based hand rubs based on the following factors:

• evidence-based, intrinsic advantages of fast-acting and broad-spectrum microbicidal activity with minimal risk of generating resistance to antimicrobial agents;
• suitability for use in resource-limited or remote areas with a lack of accessibility to sinks or other facilities for hand hygiene (including clean water, towels, etc.);
• capacity to promote improved compliance with hand hygiene by making the process faster and more convenient.

The 5 Moments for Hand Hygiene approach defines the key moments when healthcare workers should perform hand hygiene. This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in various settings. This approach recommends that healthcare workers to clean their hands:

1. before touching a patient;
2. before clean/aseptic procedures;
3. after body fluid exposure/risk;
4. after touching a patient;
5. after touching the patient's surroundings.

Gloves: wear gloves (clean, non-sterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and non-intact skin. Change gloves between tasks and procedures on the same patient after contact with a material containing a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid the transfer of microorganisms to other patients or environments. Category IB.

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. Category IB.

Gown: wear a gown (a clean, non-sterile 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 the amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible, and wash hands to avoid the transfer of microorganisms to other patients or environments. Category IB.

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, 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. Category IB.

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. Category IB.

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. Category IB.

Occupational health and bloodborne pathogens [5]: 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 practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area. Category IB [6] 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. Category IB.

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. Category IB.

References

• Center for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(2S):1S-18S.
• Centers for Disease Control. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-382,387-388.
• Lynch P, Jackson MM, Cummings MJ, Stamm WE. Rethinking the role of isolation practices in the prevention of nosocomial infections. Ann Intern Med 1987;107:245-246.
• Lynch P, Cummings MJ, Roberts PL, Herriott MJ, Yates B, Stamm WE. Implementing and evaluating a system of generic infection precautions: body substance isolation. Am J Infect Control 1990;18:1-12.
• Garner JS. The CDC Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1993;21:160-162.
• National Communicable Disease Center. Isolation Techniques for Use in Hospitals. 1st ed. Washington, DC: US Government Printing Office; 1970. PHS publication no. 2054.
• Centers for Disease Control. Isolation Techniques for Use in Hospitals. 2nd ed. Washington. DC: US Government Printing Office; 1975. HHS publication no. (CDC) 80-8314.
• Garner JS, Simmons BP. CDC Guideline for Isolation Precautions in Hospitals. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control; 1983. HHS publication no. (CDC) 83-8314; Infect Control 1983;4:245-325, and Am J Infect Control 1984;12:103-163.

Original contribution from:

• Leo Ummels, Infection Prevention & Health Care Photography, Nijmegen, Netherland.