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Introduction
The pandemic of human immunodeficiency virus (HIV) and acquired immunodeficiency
syndrome (AIDS) in the 1980s challenged health care personnel. The emotional
response to a public health threat required a focus on the essential issue: How do
health care personnel in all practice settings provide care and services to infected
patients while protecting themselves from acquiring the disease? The steadfast and
credible advice from the Centers for Disease Control and Prevention (CDC) reflected a
principle that has become routine for personnel in a diverse health care arena. This
article describes the evolution of standard precautions, reviews the purpose of standard
precautions, and addresses the basic requirements for standard precautions.
The Evolution
In 1877, infected patients were quarantined with other sick patients in special houses
known as infectious disease hospitals. However, patients acquired other infectious
diseases from infected patients until those with the same diseases were grouped in the
same room. This was isolation and the cohort concept. Observations by health care
personnel noted that controlling the spread of disease would involve more prevention,
thus nursing aseptic procedures were added to control disease transmission.
By 1910, the cubicle system of placing infected patients in multiple-bed wards was
introduced. Nurses wore gowns as barrier attire and antiseptic hand cleansing followed
patient contact. Disinfection of patient-contaminated objects was accomplished. In
1950, when Staphylococcus outbreaks were occurring, infected patients were
segregated in a single, specially designed isolation room or regular hospital patient
room. By the 1960s, designated infectious disease and tuberculosis hospitals closed.
In 1970, CDC published its initial isolation techniques, “Isolation Techniques for Use in
Hospitals,” detailing the requirements and rationale for safe patient isolation practices in
hospitals of varying size. A colored-card system of isolation was developed designating
five categories: strict isolation, respiratory isolation, protective isolation, enteric
precautions, and wound and skin precautions.
Additionally, procedures for controlling cross-infection from diseases were blooddischarge precautions and discharge precautions, to include excretion and lesions or
oral secretions. In naming blood discharge as a possible source for infectious disease
transmission, the guidance focused on hepatitis, malaria, arthropodborne viral fevers,
and the septicemia stage of infectious disease. In the 1975 revision, specific safety
requirements pertained to disposable needles and syringes with no recapping, reuse,
and purposely bending them before depositing them in a prominently labeled,
impervious, puncture-resistant container for incineration or autoclaving before
discarding. An appendix listed diseases alphabetically with type and duration of isolation
or precaution, which referred to the cards for required protective attire, such as mask,
gown, and gloves. Updated isolation techniques came in 1978 as new syndromes were
identified. By 1983, the title of “techniques” changed to “guidance” and involved a panel
of outside infection control and prevention experts, who consulted with CDC personnel
on the development of these guidelines. The momentum toward prudent practices was
built on well-documented modes of transmission espoused in epidemiological studies
and on theoretical rationale. This was the initial mention of a ranking system for isolation
recommendations and facility implementation. The major change in the 1983 guidelines
was designating seven isolation categories: strict isolation, respiratory isolation, contact
isolation, tuberculosis isolation, enteric precautions, drainage/secretion, precautions,
and blood/body fluid precautions. Health care workers (HCWs) employed their critical
decision-making skills to protect themselves with barriers, to tailor the precautions
based on the age and behavior of the patient in isolation, and to establish a balance
between the ideal and the practical precautions to isolate the disease, not the patient.
These guidelines offered a choice of a familiar category-specific or disease-specific
system, with each facility being given options to decide on a system and modify it as
necessary to suit the facility’s needs. While CDC guidance focused on the acute care
practice setting, adaptation in other extended-care facilities was accomplished by
modifying the requirements to the patient population and infectious diseases. The 1983
blood and body fluid precautions merited its own pink card, indicating that contact with
these wet substances required barriers and immediate hand-washing post-exposure
and before caring for another patient.
The reminder of safe sharp handling, bagging contaminated patient equipment before
transferring for reprocessing, and cleaning blood spills with a 5.25-percent sodium
hypochlorite dilution (1 part bleach to 10 parts water) addressed known or suspected
patients with a bloodborne pathogen infection. The listed diseases expanded to
babesiosis, variant Creutzfeldt-Jakob disease (vCJD), leptospirosis, rat-bite and
relapsing fevers, and syphilis. In August 1987, CDC initially introduced the concept of
universal precautions (UP), stating blood and certain body fluids of all patients are
considered potentially infectious for HIV, hepatitis B virus (HBV), and other bloodborne
pathogens, regardless of their bloodborne infection status. The UP requirements
espoused barrier techniques to block persons from bodily fluid exposure, reiterated
the safe handling of sharp medical devices, and supported vaccination against HBV. A
clarification on UP emphasized that visible blood in body fluids required barrier
protection when contact, handling, and disposition of these fluids occurred. In 1987,
another approach, body substance isolation (BSI), advocated all moist body substances
were potentially infectious and gloves should be worn for anticipated contact with these
substances.
On Dec. 6, 1991, the Occupational Safety and Health Administration (OSHA) mandated
UP as a protective approach against occupational exposure of HCWs. Federal law
adopted the 1987 CDC guidance of UP and added other requirements to further protect
HCWs. OSHA is focused on worker and worker-patient protection, not patients
exclusively. As epidemiological debates continued, hospitals modified or created their
own isolation precautions and greater compliance with barrier protection became
routine. The term “standard precautions” (SP) appeared in the 1996 CDC isolation
revision. The preamble to these recommendations explains that SP is a synthesis of two
other precautions (UP and BSI) and applies to all patients receiving health care,
regardless of their diagnosis or presumed infection status. Thus, SP is the current
isolation terminology and the fundamental premise employed by health care personnel
when rendering care to every patient. (Note: For the dental arena, UP equals SP; thus,
these workers may still use the term UP.)
The Purpose
The goal of isolation techniques is to prevent the spread of communicable diseases in
hospitals and microorganisms among patients, personnel, and visitors. These practical
techniques evolved to control cross-infection, namely patient to HCW and HCW to
patient. Throughout the presentation of safe options to contain and confine disease
transmission, the guidance states facilities are encouraged to modify the isolation
recommendations to suit the practice setting and patient needs. This adaptation
requires explicit written policies and procedures to ensure the proper application of the
principles in the delivery of services and patient care. Prevention, control, and reduction
of infection remain the triad for safe practice. SP offers the safest standard of
practice for patient care when health care personnel and providers adhere to its
consistent application in each circumstance.
The Requirements
Isolation techniques evolved from the absence of any barriers to the current practice of
fluidresistant, disposable and reusable barriers. Known as personal protective
equipment (PPE) or personal protective attire (PPA), these barriers minimize the risk of
bodily fluid exposures to healthcare personnel by protecting skin and mucous
membranes from potentially infective materials. PPE/A are numerous in design, type,
style, size, color, and effectiveness in the multifaceted arena of patient care. The
selection of appropriate protective attire is dependent on the procedure to be performed
and the anticipated exposure that might occur. Employing the CDC recommendations,
the federal mandate of 1991 delineated these same specific requirements for UP and
PPE/A and added others to include education, post-exposure protocols, record keeping,
and a written exposure control plan. These essentials are applicable for SP despite the
term change.
Gloves are manufactured in many styles using various base materials. They are
available as disposable, reusable, sterile, non sterile, mesh-reinforced, powdered, and
non-powdered, to name a few. Regardless of the many options in selecting glove type,
quality, and price range, user problems associated with continual wearing of gloves
persist. The severity of latex allergies, for example, may pose inherent risks equal to the
direct exposure of hands to contaminated bodily fluids. Despite the 1980s
manufacturing challenges of greater demand than supply, gloves are routine attire for
protection against bodily fluid contact, including blood, mucous membranes, secretions,
excretions and non-intact skin. Gloves also reduce the risk of cross-contamination from
health care personnel to patients, and patient or fomite to health care personnel.
Emphasis on the necessity to wash hands after glove removal remains a sound practice
and federal mandate—it’s the law. Gloves are permitted to have small manufacturingrelated defects, yet be cleared for market and health care–related use in the United
States. Microorganisms are aggressive in their determination to press on, affix, and
invade new frontiers. Their maverick modes of behavior aim to cause their host harm.
Thus, glove use does not negate the handcleansing practice, but reinforces the
essential habit to wash bioburden away after glove removal, regardless if visible soilage
is noted. Gloves are required to be changed when personnel deliver care at one specific
body site and then must move to another body site on the same patient for more care.
For example, touching a patient’s genitals while assessing patency of the Foley
catheter, then changing the surgical dressing. These care tasks require gloves be worn;
however, the gloves are removed and hands cleansed after the Foley assessment and
a fresh pair of gloves are donned before the dressing change occurs. The attending
caregiver does not wear the same gloves for the whole episode of care on this single
patient, as cross-contamination of microbes from one body site can be transmitted to
another body site on this same patient.
Mask choices include disposable or reusable types; individual or with attached eye
protection; efficacy in protection against fluids, microbes, and vapors; different colors;
and various sizes and attributes. Coverage requirements for the nose and mouth and
fluid-resistance apply with this PPA. Protection is focused on unanticipated splashes
from potentially infective bodily fluids. A new mask per episode of patient care is the
norm with more frequent changing if the mask is moist and no longer provides an
effective barrier from exposure. Disposal is immediate after care; the mask should not
be worn around the neck for later use. Gowns and protective apparel are options HCWs
have to protect their clothing and skin from contamination during patient care or indirect
services rendered in support of patient care. Some of these items include aprons, body
suits, jackets, and coats. Protective head covering and footwear are more common in
surgery, mortuary, processing, or trauma situations. The fluid-resistant characteristic
applies to these choices. Like the previous requirements, the selection choices are
numerous; yet efficacy in protection is fundamental. Disposable and reusable items are
worn once per patient contact. If an apparel piece like an apron is shared, it is cleaned
after use and definitely before the next person wears the item.
Eye protection requires preplanning. Donning eye equipment only works before the
splash or spatter occurs, not after the exposure. The fluid-resistance aspect is
fundamental. Whether the item is reusable as in a face shield, community-shared
goggles, or personal athletic eye wear, immediate cleaning of the reusable item is
essential to prevent cross-contamination, namely conjunctivitis, among wearers. For
disposables, the options are frequently attached to disposable masks. The clear plastic
normally protects the entire eye region (front and sides), fits over corrective vision
glasses, and does not hamper visual acuity. The work practices, engineering controls,
immunizations, and other requirements of UP are applicable for isolation containment
and personal protection against blood and bodily fluid exposure. While the focus has
been on isolation evolution, UP and SP are similar in that blood is a source of
pathogens and provides a vehicle of infectious and communicable disease transmission
to others. Although an intraoperative cleaning concept, the contain-and-confine principle
applies to isolation. Every patient and every operation should be considered a possible
source of crosscontamination... the area of contamination should be confined to as
small an area as possible ...to an area close to the patient ... items that become
contaminated must be contained to prevent cross-contamination. This principle has
applications in many health care activities, including isolation.
Summary
The original quarantine of infected patients to infectious disease hospitals occurred in
the late 1800s, but evolved to isolation rooms by the early 1900s due to increasing
knowledge about microorganisms, infectious diseases, and epidemiology of infection.
With differential modes of disease transmission, specific categories of isolation became
disease-specific precautions, as a means to a more tailored approach to patient
uniqueness. These precautions were further diversified into a federally mandated UP
approach focused on minimizing exposures and disease acquisition. The current tiered
system of isolation advocates SP for each patient and transmission based precautions
for special patient needs. Standard precautions are universally applicable to all
patients, are fundamental to patient care, and are the standards of practice by every
HCW. As the epidemiology of microbes, disease processes, and host responses unfold
and expand our knowledge, strategies to prevent, control, and reduce widespread
infections are built on the foundation of contain and confine with the goal of protecting
others from acquiring these adverse conditions.
Instructions
Write T for True or F for False next to each statement. If the statement is false, correct
it.
_____1. Standard precautions only apply to visible blood in bodily fluids.
_____2. Isolation techniques were designed primarily to protect health care workers.
_____3. Infectious disease hospitals preceded the cubicle concept of quarantine.
_____4. Eye protection is a requirement for both universal and standard precautions.
_____5. Negative pressure rooms are essential to standard precautions.
_____6. The danger of disease transmission by blood is a significant threat to HCWs.
_____7. Hands are cleansed of bioburden with soap and water.
_____8. The contain-and-confine approach minimizes communicable disease
transmission.
_____9. Handling of sharp medical devices was advocated before federal mandate.
____10. Isolation practices are designed to isolate the patient, not the disease.