What to Know About Standard Precautions
This report examines "standard precautions," including the definition, what they include, recent changes and more.
What Are Standard Precautions?
As the Centers for Disease Control and Prevention (CDC) notes, "Standard precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered."
What Do Standard Precautions Include?
Standard precautions include a set of prevention practices that apply to all patients across the continuum of care, regardless of the infection status of the patient. Standard precautions apply to:
Blood
All body fluids, secretions and excretions (except sweat), regardless of whether they contain visible blood
Non-intact skin
Mucous membrane
Background on Standard Precautions
Standard precautions were first recommended in the 1996 CDC isolation guideline. Their success reinforced the value of this approach to preventing transmission of infectious agents and formed the foundation for healthcare professionals in their efforts to keep patients, staff and visitors as safe as possible during encounters in healthcare settings.
This success led to the CDC developing a 2007 update to the guideline, which included the addition of several new components, addressed further below. The "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007" updates and expands the 1996 "Guideline for Isolation Precautions in Hospitals." In addition to standard precautions, the CDC added transmission-based precautions.
Several facts contributed to the revision of the original guideline. These included, but are not limited to:
The emergence of non-acute care settings, including ambulatory care, home care, long-term care and other sites, created a need for standardizing principles of infection prevention and control across the continuum of care with modification for different settings.
The emergence of new pathogens (e.g., SARS-CoV associated with the severe acute respiratory syndrome (SARS), Avian influenza in humans)
Ongoing concern for evolving known pathogens (e.g., Clostridium difficile (C. diff), norovirus, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA).
Components of Standard Precautions
HAND HYGIENE
Hand hygiene is generally considered the most important practice for preventing healthcare-associated infections by reducing the transmission of infectious agents. Hand hygiene includes washing with soap and water and use of alcohol-based products that do not require water. The use of alcohol-based products for the purpose of disinfection is preferred over handwashing unless the hands are visibly soiled. If hands are visibly soiled, they must be washed under running water and dried as alcohol will not disinfect soiled hands. Data has shown that hand hygiene is effective in reducing the incidence of multi-drug resistant (MDRO) infections in various settings, including acute-care hospital intensive-care unit (ICU) patients.
The guideline also addresses the type and length of fingernails and wearing of artificial nails as these have been shown to increase the risk of infection, especially by transmission of gram-negative bacteria and fungus. It is recommended that artificial nails that include extenders (plastic tips with gel or acrylic overlays) be prohibited in areas where patients are at greater risk for infection (ICU and operating room). In addition, while data has not been provided regarding artificial nails and high-risk populations such as oncology and cystic fibrosis patients, some experts have recommended these nails be prohibited, but at the discretion of the facility.
CDC does not have recommendations about the wearing of rings, but organizations such as the Association of periOperative Registered Nurses (AORN) recommend rings be removed before performing a surgical scrub.
PERSONAL PROTECTIVE EQUIPMENT (PPE)
PPE is recommended to protect healthcare workers' mucous membranes, skin, airways and clothing from contact with potentially infectious agents. PPE use is dependent on specific patient care as well as contact with the environment. Hand hygiene is always the final step after removing and disposing of PPE.
PPE includes the following:
Gloves. Gloves are used to prevent contamination of healthcare personnel's hands when handling blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material or other potentially infectious materials (OPIM). Gloves are worn when having direct contact with patients colonized or infected with MDROs (e.g., vancomycin-resistant Enterococcus (VRE), MRSA, C. diff.). Gloves are worn when handling potentially contaminated patient care equipment and environmental surfaces.
Gloves used in healthcare require FDA clearance. The gloves used for standard precautions are nonsterile and made of a variety of materials. Gloves must be removed, and hand hygiene performed between patients. Disposable gloves should not be washed or reused. If additional PPE is worn, such as gowns, gloves are donned last. When gloves are finally removed, hand hygiene must follow.
Isolation gowns. Isolation gowns protect healthcare workers' arms and other exposed areas from potential contamination. Gowns also prevent contamination of clothing with blood, body fluids and OPIM. The type of isolation gown is selected by considering the nature of interaction with patients, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier.
The Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard mandates the wearing of isolation gowns and other protective apparel when exposure to blood or body fluids and OPIM is anticipated. Gowns are usually the first piece of PPE to be donned. Isolation gowns should be removed before leaving the patient care area to prevent possible contamination of the environment outside the patient's room. Isolation gowns should be removed in a manner that prevents contamination of clothing or skin.
Face protection: masks, goggles and face shields. These items are used for protection of healthcare personnel from patients' respiratory secretions and potential aerosolization of blood or body fluids. Selection of face protection is dependent upon individual patient procedures and specific circumstances. Procedures that generate splashes or sprays of blood, body fluids, secretions or excretions (e.g., endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a face shield (disposable or reusable) or mask and goggles. The wearing of masks, eye protection and face shields in specified circumstances when blood or body fluid exposures are likely to occur is mandated by the OSHA bloodborne pathogens standard. Appropriate PPE should be selected based on the anticipated level of exposure. Personal eyeglasses and contact lenses are not considered adequate eye protection by National Institute for Occupational Safety and Health (NIOSH).
Updated Standard Precautions
Additions in the 2007 guideline update included the following:
Respiratory hygiene/cough etiquette. This came about after the SARS outbreaks where it was recognized after the fact that a very likely source of transmission of the coronavirus (SARS-CoV) was attributable to failure on the part of responsible parties to implement control measures at a critical time during the outbreak. This includes lack of proper hygiene practices among patients, visitors and healthcare personnel experiencing respiratory symptoms.
The elements of respiratory hygiene/cough etiquette include the following:
healthcare worker, patient and visitor education;
posted CDC generated "cover your cough" or similar signs with instructions at the point of entry and additional strategic locations;
instituting control measures, including providing the supplies needed to cover the mouth/nose with a tissue, dispose of used tissues in a trash can and covering the mouth and nose with a surgical mask;
performing hand hygiene after contact with respiratory secretions; and
spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible.
It is proven that "covering your cough" and mask placement on patients prevents respiratory secretions from contaminating the air.
Safe injection practices. These were introduced in the guideline due to emerging outbreaks of hepatitis B and hepatitis C viruses mainly in ambulatory settings. Practice breaches included 1) reuse of needles into a multiple-dose vial or solution container (e.g., saline bag) and 2) use of a single needle/syringe to administer intravenous medication to multiple patients.
In one of these outbreaks, a possible contributing factor was preparation of medications in the same workspace where used needle/syringes were dismantled. Basic practices using aseptic technique during preparation and administration of parenteral medications is imperative. These include the use of a single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication. There are several additional components to safe injection practices detailed in a position paper developed in 2016 by the Association for Professionals in Infection Control (APIC). Access it here.
Practice for special lumbar puncture procedures. This was added after identification of eight cases of bacterial meningitis attributed to respiratory flora. CDC added the use of a mask when placing a catheter or injecting material into the spinal canal or subdural space (e.g., during myelograms, lumbar puncture and spinal or epidural anesthesia) to its guideline.
Implementing Standard Precautions Best Practices
If your facility requires assistance complying with standard precautions and implementing best practices, schedule a consultation with the infection prevention and infection control consulting experts at ICCS.
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