Summary of Standard Precautions2
The Centers for Disease Control and Prevention (CDC) and the Hospital Infection Control Practices Advisory Committee (HICPAC) have developed (and continue to revise) the CDC Guideline for Isolation Precautions in Hospitals. These guidelines were developed to assist hospitals in maintaining up-to-date isolation practices governing infection control and strategies for surveillance, prevention, and control of nosocomial infections in U.S. hospitals.
Nosocomial infection is a term used to refer only to infections acquired in hospitals. A new term, health care–associated infection (HAI), is used now to refer to infections associated with health care delivery in any setting, such as hospitals, long-term care facilities, ambulatory settings, and home care. This updated term reflects the inability to determine with certainty where the pathogen is acquired, since people can be colonized with or exposed to potential pathogens outside of the health care setting, before receiving health are, or while moving among the various settings within the health care system.2
The guideline recommendations are based on the latest epidemiologic information on transmission of infection in hospitals. The recommendations are intended primarily for use in the care of patients in acute care hospitals, although some of the recommendations may be applicable for some clients receiving care in subacute care or extended care facilities.
The recommendations are not intended for use in day care, well care, or domiciliary care programs. Because there have been few studies to test the efficacy of isolation precautions and gaps still exist in the knowledge of the epidemiology and modes of transmission of some diseases, disagreement with some of the recommendations is expected.
HICPAC recognizes that the goal of preventing transmission of infections in hospitals can be accomplished by multiple means and that hospitals will modify the recommendations according to their needs and circumstances and as directed by federal, state, or local regulations.
No guideline can address all the needs of the more than 6000 U.S. hospitals, which range in size from 5 beds to more than 1500 and serve very different client populations. Modification of the recommendations is encouraged if (1) the principles of epidemiology and disease transmission are maintained, and (2) precautions are included to interrupt spread of infection by all routes likely to be encountered in the hospital.
In 1985, largely because of the human immunodeficiency virus (HIV) epidemic, isolation practices in the United States were altered dramatically by the introduction of a new strategy for isolation precautions, which became known as universal precautions. Following the initial reports of hospital personnel becoming infected with HIV through needlesticks and skin contamination with blood, a widespread outcry created the urgent need for new isolation strategies to protect hospital personnel from bloodborne infections.
The subsequent modification of isolation precautions in some hospitals produced several major strategic changes and sacrificed some measures of protection against client-to-client transmission in the process of adding protection against client-to-personnel transmission.
In acknowledgment of the fact that many clients with bloodborne infections are not recognized, the new universal precautions approach for the first time placed emphasis on applying blood and body fluid precautions universally to all people regardless of their presumed infection status. Until this time, most clients placed on isolation precautions were those with a diagnosis or a suspicion of an infectious disease. This provision led to the new term universal precautions.
In addition to emphasizing prevention of needlestick injuries and the use of traditional barriers such as gloves and gowns, universal precautions expanded blood and body fluid precautions to include the use of masks and eye coverings to prevent mucous membrane exposure during certain procedures and the use of individual ventilation devices when the need for resuscitation was predictable. This approach, and particularly the techniques for preventing mucous membrane exposures, was reemphasized in subsequent CDC reports that contained recommendations for prevention of HIV transmission in health care settings.
The revised guideline contains two tiers of precautions to update universal precautions with a change in nomenclature (universal precautions being replaced by standard precautions): standard precautions and transmission-based precautions. Components of all standard precautions are listed in Table A-1.
Table A-1
Recommendations for Application of Standard Precautions for the Care of All Patients in All Health Care Settings
| Component | Recommendations |
| Hand hygiene | After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts |
| Personal protective equipment (PPE) | See text |
| Gloves | For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin |
| Mask, eye protection, face shield | During procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions |
| Gown | During procedures and patient care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated |
| Soiled patient care equipment | Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene |
| Environmental control | Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas |
| Textiles (linen and laundry) | Handle in a manner that prevents transfer of microorganisms to others and to the environment |
| Needles and other sharps | Do not recap, bend, break, or hand-manipulate used needles; use safety features when available; place used sharps in puncture-resistant container |
| Patient resuscitation | Use mouthpiece, resuscitation bag, other ventilation devices to prevent mouth contact |
| Patient placement | Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment or does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection |
| Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter) | Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 ft if possible |
From Department of Health and Human Services, Centers for Disease Control and Prevention: Supplement I: Infection control in healthcare, home, and community settings, Atlanta, 2005, Centers for Disease Control and Prevention.
Most important, standard precautions are designed for the care of all patients in hospitals regardless of their diagnosis or presumed infection status. Implementation of these standard precautions is the primary strategy for successful nosocomial infection control.
Standard precautions synthesize the major features of universal (blood and body fluid) precautions (designed to reduce the risk of transmission of bloodborne pathogens) and body substance isolation (designed to reduce the risk of transmission of pathogens from moist body substances). Standard precautions apply to (1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) nonintact skin; and (4) mucous membranes.
Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.
Transmission-based precautions are designed only for the care of specified patients known or suspected to be infected or colonized by epidemiologically important pathogens that can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces.
Transmission-based precautions are designed for patients documented or suspected to be infected or colonized by highly transmissible or epidemiologically important pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission in hospitals.
There are three types of transmission-based precautions: airborne precautions/airborne infection isolation room, droplet precautions, and contact precautions. They may be combined for diseases that have multiple routes of transmission. When used either singly or in combination, they are to be used in addition to standard precautions.
Airborne infection isolation refers to the isolation of patients infected with organisms spread via airborne droplet nuclei less than 5 μm in diameter. The isolation area receives numerous air changes per hour (ACH) (12 or more ACH for new construction as of 2001; 6 or more ACH for construction before 2001) and is under negative pressure, such that the direction of the airflow is from the outside adjacent space (e.g., the corridor) into the room.7
The air in an airborne infection isolation room is preferably exhausted to the outside but may be recirculated provided that the return air is filtered through a high-efficiency particulate air (HEPA) filter. The use of personal respiratory protection is also indicated for persons entering these rooms when caring for tuberculosis or smallpox patients and for staff who lack immunity to airborne viral diseases (e.g., measles or varicella zoster virus [VZV] infection).7
A set of preventive measures termed protective environment has been added to the standard precautions used to prevent HAI. These measures consist of engineering and design interventions that decrease the risk of exposure to environmental fungi for severely immunocompromised recipients of allogeneic hematopoietic stem cell transplant (HSCT) during their highest-risk phase, usually the first 100 days after transplantation, or longer in the presence of graft-versus-host-disease.2
A protective environment is a specialized patient care area, usually in a hospital, with a positive airflow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of HEPA filtration, high numbers of ACH (12 or more ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients who have undergone HSCT.7
Standard precautions are intended to prevent occupational transmission of infectious diseases such as tuberculosis, HIV infection, hepatitis B, and hepatitis C. All body secretions and moist membranes and tissues (excluding perspiration) are considered to be potentially infectious and require the use of barriers and/or isolation techniques to prevent transmission of organisms.2,4
Therapists at greatest risk include those who perform electromyographic studies, therapists in direct contact with clients with tuberculosis (see also Box 15-4), therapists who provide wound management, and those who assess or treat temporomandibular joint (TMJ) disorder or perform manual lymphatic drainage inside the mouth.
Any therapist who assists in toileting or changing diapers (in adults or children) is at increased risk. Other risk factors include human bites and contact with sputum and pleural fluid tinged with blood (bloodborne pathogens). Health care workers are at increased risk of bacterial colonization from damaged skin on the hands after frequent handwashing.
The potential for hepatitis B virus (HBV) and hepatitis C virus (HCV) transmission in the workplace is 20 times greater than that for HIV, but the modes of transmission for these viruses are similar. All have been transmitted in occupational settings only by percutaneous inoculation or contact with an open wound, nonintact skin (e.g., cutaneous scratches; chapped, abraded, weeping, burned, or dermatitic skin), or bloody mucous membranes, blood-contaminated body fluids, or concentrated virus. Blood is the single most important source of HIV, HBV, and HCV in the workplace.
In the hospital and other health care settings, standard precautions should be followed when workers are exposed to blood, certain other body fluids (amniotic fluid, pericardial fluid, peritoneal fluid, pleural fluid, synovial fluid, cerebrospinal fluid, semen, and vaginal secretions), or any body fluid visibly contaminated with blood.
HBV can be transmitted through infected saliva, but saliva has not been implicated in HIV transmission except in the dental setting, in which saliva may be contaminated with blood. HBV and HIV transmission has not been documented from exposure to other body fluids, such as nasal secretions, sweat, tears, urine, or vomitus. However, standard precautions still apply whenever handling any body secretions. People who are sexually active should be aware that HIV is intermittently shed in semen.1
These fluids are most likely to transmit bloodborne pathogens. The hepatitis B vaccine substantially reduces the risk of infection and is available at no charge to all employees who have occupational exposure to the virus. It is considered so important that an employee must sign a letter of declination if declining the vaccine. Currently there are no vaccines available for HCV or HIV.
Any health care worker with HIV or the most virulent form of hepatitis B or C should not perform exposure-prone procedures in which blood contact might occur. Permission and guidance from special review committees are required before an infected health care worker can perform such procedures.
For the therapist, this would primarily exclude wound care, including debridement and dressing changes. According to guidelines drafted by the CDC, at a minimum, the potential client must be informed of the worker’s HIV, hepatitis B, or hepatitis C status if the health care worker will be performing specific exposure-prone procedures.
Exposure to blood and body fluids can be minimized through the proper use of personal protective equipment (PPE). However, PPE is not a substitute for good engineering, work practice, and administrative controls, but should be used in conjunction with these controls to provide for a safe and healthy workplace. The CDC has provided the following guidelines for putting on, using, and removing PPE3:
• All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any person is anticipated.
• Gloves should be worn for touching blood and body fluids, mucous membranes, blisters, lesions, and nonintact skin of all persons; gloves should be pulled up over the cuffs of the gown.
• Gloves should be changed and hands washed after contact with each client.
• A thin layer of water-based skin care product (e.g., Aquafor, Eucerin, O’Keeffe’s Working Hands Creme) should be applied after glove removal to prevent skin chapping, which is a potential risk factor for employees. Petroleum-based hand creams or lotions, which can damage latex gloves, should not be used.
• Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes. Goggles or face shields should come equipped with a foam brow band, which prevents blood and body fluids from dripping from the forehead into the eyes. See also Box 15-4 for additional information regarding specific protective masks (called respirators) to wear when treating clients with active tuberculosis.
• Fluid-proof gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other body fluids. The opening is worn in the back and the gown should be secured. If the gown does not close, a second gown with the opening in the front should be worn.
• Therapists treating clients with whirlpool or pulsatile lavage with suction should wear hair cover; mask; face shield; fluid-proof, long-sleeved gown; knee-high, fluid-resistant boots; and gloves covering the gown cuffs. Shoulder-length gloves should be available for those working with whirlpools. See Box A-1.
• Hands should be washed before and after client contact, after removing PPE and gloves, and immediately if hands are grossly contaminated with blood.
• Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed. Antiseptic hand cleaner should be used when handwashing facilities are unavailable.
• Sharp instruments, such as scissors or scalpels, should be handled with great care and disposed of in puncture-resistant containers. Needles should never be manipulated, bent, broken, or recapped.
• Pocket masks or mechanical ventilation devices should be available in areas in which cardiopulmonary resuscitation procedures are likely.
• A mask or particulate respirator should be worn over the nose, mouth, and chin; the flexible nosepiece should be fit over the bridge of the nose and secured with fasteners or elastic. Particulate respirators must fit properly; to check the fit, inhale then exhale: the respirator should collapse during inhalation and there should be no air leaking out during exhalation.
• Health care workers who have exudative lesions or weeping dermatitis should refrain from all direct client care and from handling equipment belonging to the client until the condition resolves.
• Eating, drinking, applying lip balm or lipstick, and handling contact lenses is prohibited in any area where clients or their body fluids are present.
Once the PPE is in use properly, the therapist should avoid touching or adjusting the PPE; keep your gloved hands away from your face. Remove and replace the gloves if they become torn, heavily soiled, or contaminated. Perform hand hygiene before putting on new gloves.6
When the procedure or client visit is completed, remove all PPE except respirators at the doorway before leaving the room. Respirators can be removed outside the client’s door, after closing the door. Continue to practice standard precautions by removing remaining pieces of PPE carefully and correctly avoiding contact with the potentially contaminated exterior surfaces of gloves, face shield, gowns, and so on. Turn gloves and gown inside out as you remove them and discard appropriately. Perform hand hygiene when all pieces of equipment are removed and discarded.6
Frequent handwashing has always been recommended as the most effective means of infection control prevention. The subject of handwashing, indications for handwashing, and proper hand hygiene technique are discussed in detail in Chapter 8 (see Boxes 8-4 and 8-5).
When using an alcohol-based hand rub, the antiseptic must remain in contact with all skin surfaces for 15 seconds to kill viruses and other pathogens. Keep the skin moisturized to prevent dry and chapped hands, which provide an opening for pathogens.
The CDC’s current recommendations can be found at the CDC Hand Hygiene in Healthcare Setting page at http://www.cdc.gov/handhygiene/ (accessed August 9, 2007). Every therapist is strongly encouraged to take the time to read this document regardless of his or her current clinical setting.
Pulsatile lavage with suction (PLWS), a high-pressure irrigation treatment used by physical therapists as a wound debridement system, can aerosolize infectious agents at least 8 feet. Infection control precautions must be used routinely during the procedure (see Box A-1); failure to do so has been linked with an outbreak of multidrugresistant Acinetobacter baumannii from environmental contamination.5
1. Bolyard, E, Tablan, O, Williams, W, et al. Hospital Infection Control Practices Advisory Committee: guidelines for infection control in health care personnel. Am J Infect Control. 1998;26(3):289–343.
2. Centers for Disease Control and Prevention (CDC): Hospital Infection Control Practices Advisory Committee: Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, Atlanta, June 2007, CDC. Available on-line at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html Accessed August 9, 2007.
3. Centers for Disease Control and Prevention (CDC): Personal protective equipment (PPE) in healthcare settings, Atlanta, 2004, CDC. Available on-line at http://www.cdc.gov/ncidod/dhqp/ppe.html Accessed August 9, 2007.
4. Garner, J. Guidelines for isolation precaution in hospitals. Infect Control Hosp Epidemiol. 1996;17:54–80.
5. Maragakis, LL. An outbreak of multidrug-resistant Acinetobacter baumannii associated with pulsatile lavage wound treatment. JAMA. 2004;292(24):3006–3011.
6. Perry, J. Getting the most from your personal protective gear. Nursing2004. 2004;34(12):72.
7. Sehulster, L, Guidelines for environmental infection control in health care facilities. MMWR Recomm Rep. 2003;52(RR10):1–42. Available on-line at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm Accessed August 9, 2007.