Universal precautions were introduced by the Centers for Disease Control (CDC) in 1985, mostly in response to the human immunodeficiency virus (HIV) epidemic. [1][2][3]Universal precautions are a standard set of guidelines aimed at preventing the transmission of bloodborne pathogens from exposure to blood and other potentially infectious materials (OPIM). OPIM is defined by the Occupational Safety and Health Administration (OSHA) as:
Universal precautions do not apply to sputum, feces, sweat, vomit, tears, urine, or nasal secretions unless they are visibly contaminated with blood because their transmission of Hepatitis B or HIV is extremely low or non-existent.
In 1987, the CDC introduced another set of guidelines termed Body Substance Isolation. These guidelines advocated the avoidance of direct physical contact with “all moist and potentially infectious body substances,” even if blood is not visible. A limitation of this guideline was that it emphasized handwashing after removal of gloves only if the hands were visibly soiled.
In 1996, the CDC Guideline for Isolation Precautions in Hospitals, prepared by the Healthcare Infection Control Practices Advisory Committee (HICPAC), combined the major features for Universal Precaution and Body Substance Isolation into what is now referred to as Standard Precautions. These guidelines also introduced three transmission-based precautions: airborne, droplet, and contact. All transmission-based precautions are to be used in conjunction with standard precautions.[4][5][6]
Standard Precautions
Standard precautions apply to the care of all patients, irrespective of their disease state. These precautions apply when there is a risk of potential exposure to (1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous membranes. This includes the use of hand hygiene and personal protective equipment (PPE), with hand hygiene being the single most important means to prevent transmission of disease.[7][8][9][10]
Personal protective equipment is used as a barrier to protect skin, mucous membranes, airway, and clothing, and includes gowns, gloves, masks, and face shields or goggles.
The following list of standard precautions is not all-inclusive, and contains some of the most commonly used recommendations for healthcare workers.
Hand Hygiene
Hand washing with soap and water for at least 40 to 60 seconds, making sure not to use clean hands to turn off the faucet, must be performed if hands are visibly soiled, after using the restroom, or if potential exposure to spore-forming organisms.
Hand rubbing with alcohol applied generously to cover hands completely should be performed and hands rubbed until dry.
Hand Hygiene Indications
Gloves
Must be worn when touching blood, body fluids, secretions, excretions, mucous membranes, or non-intact skin. Change when there is contact with potentially infected material in the same patient to avoid cross-contamination. Remove before touching surfaces and clean items. Wearing gloves does not mitigate the need for proper hand hygiene.
Mask, Goggles/Eye Visor, and/or Face Shield
Wear a mask and eye protection or face shield during procedures that may spray or splash blood, body fluids, secretions, or excretions.
Gown
Wear to protect skin or clothing during procedures that may spray or splash blood, body fluids, secretions, or excretions.
Needles and Other Sharps
Do not break, bow, or directly manipulate used needles. Recapping is not recommended, but if necessary, “use a one-handed scoop technique only.” Discard all used sharps in appropriate puncture-resistant containers.
Transmission-based Precautions
Airborne Precautions
These precautions are used in patients with known or suspected infection with pathogens that are spread by airborne transmission, i.e., “airborne droplet nuclei (small-particle residue {5 um or smaller in size} of evaporated droplets that may remain suspended in the air for long periods of time) or dust particles containing the infectious agent.”
Patient Placement
Patients should be placed in a negative pressure isolation room that allows a minimum of 6 to 12 air changes per hour. Patients with the active infection with the same pathogen, and no other infection, may be roomed together (cohorting). Doors to the room must remain closed at all times. “When a private room is not available, and cohorting is not desirable, consultation with infection control professionals is advised before patient placement.”
PPE
Respirators that filter at least 95% of airborne particles must be worn over the nose and mouth, i.e., N95 respirator or powered air-purifying respirator (PAPR) with a high-efficiency particular air (HEPA) filter.
Transport
When necessary, patients being transported out of their rooms should wear a surgical mask.
Droplet Precautions
These precautions are used in patients with known or suspected infection with pathogens that are spread by droplet transmission. “Droplets are particles of respiratory secretions +/- 5 microns. Droplets remain suspended in the air for limited periods. Transmission is associated with exposure within three to six feet (one to two meters) of the source.”
Patient Placement
Private rooms are preferred; however, they may be placed in a semi-private room with another patient having the same active infection, and no other infection (cohorting). When a private room or cohorting is not available, the infected patient should be placed at least 3 feet away from other patients and visitors. The doors to the room may be left open, and no special air handling is required
PPE
Surgical masks should be worn while within 6 feet of the patient.
Transport
When necessary, patients being transported out of their rooms should wear a surgical mask.
Contact Precautions
These precautions are used in patients with known or suspected infection or colonization with pathogens that are spread by direct and indirect patient contact. Indirect patient contact occurs when physical contact is made with items or surfaces in the patient’s environment.
Patient Placement
Private rooms are preferred; however, they may be placed in a semi-private room with another patient having the same active infection, and 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.”
PPE
Gloves and gowns should be donned prior to entering the patient's room, and removed before leaving. Hand hygiene should be performed immediately afterward. Care should be taken not to touch any potentially contaminated surface upon leaving the room.[11][12]
Transport
Maintain contact precautions at all times.
Patient Equipment
When possible, patients should have dedicated equipment that remains in the room with them, e.g., single-patient-use blood pressure cuff. If single-patient-use items are not available, then they should be cleaned and disinfected before use on another patient.
Airborne precautions should be used for the following infections and conditions for the minimum duration listed:
Droplet precautions should be used for the following infections and conditions for the duration listed:[13]
Contact precautions should be used for the following infections and conditions for the duration listed:
Occupational exposure to blood and other potentially infectious materials (OPIM) is of such great concern that multiple government agencies have instituted guidelines and regulations regarding universal precautions. Knowledge and implementation of standard precautions are vital to limiting the spread of infectious disease.[14][15] Their use requires the healthcare provider to be proactive in anticipating the types of exposure they may encounter with each patient, e.g., a trauma patient with arterial bleeding would require donning gloves, mask with face shield, and gown. In regards to transmission-based precautions, the healthcare provider should be aware that some diseases require more than one type of transmission-based precautions, e.g., disseminated herpes zoster requires contact, airborne, and standard precautions.
Proper Donning and Removal of PPE
Donning of PPE
The CDC recommends that PPE be donned in following sequence: (1) gown, (2) mask or respirator, (3) goggles or face shield, and (4) gloves.
Removal of PPE
The safe removal of PPE also follows a specific sequence that requires special attention to areas that are now considered contaminated: (1) gloves should be removed by first grasping the palm of the other hand and peeling off the first glove, keep hold of the removed glove in the gloved hand, slide the fingers of the ungloved hand under the remaining glove and peel it off over the first glove, (2) goggles or face shield should be removed by lifting from behind the head, (3) gowns should untied and removed by pulling away from the neck and shoulders, turning the gown inside out and only touching the inside, (4) mask or respirator should be removed by reaching behind the head and grasping the bottom ties then the top ties, and removing without touching the front. Alternatively, the gloves and gown may be removed at the same time by grasping the gown from the front and pulling away from the body, rolling the gown into a bundle, and removing the gloves at the same time using the inside of the gown. Hand hygiene should be performed after removal of all PPE, and anytime during removal if they become contaminated.
All healthcare workers including nurse practitioners are responsible for prevention of infectious disorders. In 1996, the CDC Guideline for Isolation Precautions in Hospitals, prepared by the Healthcare Infection Control Practices Advisory Committee (HICPAC), combined the major features for Universal Precaution and Body Substance Isolation into what is now referred to as Standard Precautions. These guidelines also introduced three transmission-based precautions: airborne, droplet, and contact. All transmission-based precautions are to be used in conjunction with standard precautions. Every hospital has an interprofessional team that ensures proper adoption of the universal guidelines. Audits should randomly be performed and healthcare workers who do not follow the guidelines should be reprimanded and sent for remedial education on infection prevention.[16][17]
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