STANDARD/ UNIVERSAL PRECAUTIONS

Universal precautions refers to the practice, in the health profession , of avoiding contact with patients'
bodily fluids, by means of wearing nonporous articles such as medical gloves, goggles, and face shields.

Universal precautions were introduced by the Centers for Disease Control (CDC) in 1985, mostly in
response to the human immunodeficiency virus (HIV) epidemic. 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.

Universal precautions were designed for nurses,doctors, patients, and health care support workers who
were required to come into contact with patients or bodily fluids. This included staff and others who
might not come into direct contact with patients.

Pathogens fall into two broad categories, bloodborne (carried in the body fluids) and airborne.

Universal precautions were typically practiced in any environment where workers were exposed to
bodily fluids, such as: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid,
pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly
contaminated with blood, and all body fluids in situations where it is difficult or impossible to
differentiate between body fluids.

Any unfixed tissue or organ (other than intact skin) from a human (living or dead) and

HIV containing cell or tissue cultures, organ cultures, and HIV or HBV containing culture medium or
other solutions and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

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.

Every patient was treated as if infected and therefore precautions were taken to minimize risk.

Essentially, universal precautions were good hygiene habits, such as hand washing and the use of gloves
and other barriers, correct handling of hypodermic needles and scalpels, and aseptic techniques.

Equipment

Protective clothing included but was not limited to:

Barrier gowns barrier contraception

Gloves mask

Eyewear (goggles or glasses)

Face shiel

Additional precautions were used in addition to universal precautions for patients who were known or
suspected to have an infectious condition, and varied depending on the infection control needed of that
patient. Additional precautions were not needed for blood-borne infections, unless there were
complicating factors.

Conditions indicating additional precautions:

Prion diseases (e.g., Creutzfeldt–Jakob disease)

Diseases with air-borne transmission (e.g., tuberculosis)

Diseases with droplet transmission (e.g., mumps, rubella, influenza, pertussis)

Transmission by direct or indirect contact with dried skin or contaminated surfaces or any combination
of the above.

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.

Functions of 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.
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

-Before and after any direct patient contact and between patients, whether or not gloves are worn.

-Immediately after gloves are removed.

-Before handling an invasive device.

-After touching blood, body fluids, secretions, excretions, non-intact skin, and contaminated items, even
if gloves are worn.

-During patient care, when moving from a contaminated to a clean body site of the patient.

-After contact with inanimate objects in the immediate vicinity of the patient.

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/Caps

Wear to protect skin or clothing during procedures that may spray or splash blood, body fluids,
secretions, or excretions. Caps are user to protect the hair from picking pathogens

Boots

This is worn to protect the feet while walking around environments where there can be spillage of body
fluids on the floor. Or during a surgical procedure.

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.e.g safety boxes.

Proper disposal of wastes into colour coded waste bags.

There are different colours of waste bags indicating the type of wastes to disposed into them.( Black,
Brown,Red,Yellow).

Use of barrier contraceptives

This can be helpful in protecting against transmission of infections via semen or vaginal secretions,
sexually transmitted infections and blood borne pathogens.

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's Isolation Method

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 Needed

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 filter.

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's Isolation method

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 Needed

Surgical masks should be worn while within 6 feet of the patient.

Patient's movement

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's Isolation Method

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(Isolation). Consultation with infection control
professionals is advised before patient placement.”

PPE Needed

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.

Patient's 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.

Note

*Airborne precautions should be used for the following infections and conditions for the minimum
duration listed:

Aspergillosis if “massive soft tissue infection with copious drainage and repeated irrigations
required.”(duration of illness)

-Herpes Zoster that is disseminated or in immunocompromised patients.(duration of illness)

-Measles (duration of 4 days after onset of rash)

-Monkeypox (duration is until diagnosis is confirmed and smallpox has been excluded).

-Severe acute respiratory syndrome (duration of illness plus 10 days after fever and respiratory
symptoms have resolved or improved).

-Smallpox (duration of illness).

-Tuberculosis: pulmonary or laryngeal (duration until improving clinically on effective therapy with three
negative sputum smears on consecutive days).

-Tuberculosis: extrapulmonary, draining lesions (duration until clinically improving and drainage has
stopped or there are consecutively three negative cultures).
-Varicella Zoster (duration until the lesions crust and dry).

*Droplet precautions should be used for the following infections and conditions for the duration listed:

-Adenovirus: pneumonia (duration of illness).

-Diphtheria: pharyngeal (duration is until completion of antibiotics and 2 negative cultures 24 hours
apart).

-Haemophilus influenzae type b: epiglottitis or meningitis (duration is until 24 hours after initiating
effective therapy).

-Influenza, pandemic

-Neisseria meningitis: meningitis, sepsis, or pneumonia (duration is until 24 hours after initiating
effective therapy).

-Mumps (duration is 5 days after onset).

-Mycoplasma pneumonia (duration of illness).

-Parvovirus B19 (duration is 7 days in acute disease, duration of hospitalization in chronic disease of
immunocompromised host).

-Pertussis (duration is 5 days).

-Yersinia pestis: pneumonic plague (duration is 48 hours).

-Group A Streptococcus: pneumonia, pharyngitis, scarlet fever, serious invasive disease (duration is until
24 hours after initiating effective therapy).

-Rhinovirus (duration of illness).

-Rubella (duration is until 7 days after rash onset).

-Severe acute respiratory syndrome (duration of illness plus 10 days after fever and respiratory
symptoms have resolved or improved).

Ebola, Marburg, Crimean-Congo, and -Lassa fever viruses: viral hemorrhagic fevers (duration of illness).

*Contact precautions should be used for the following infections and conditions for the duration listed:

-Abscess, major draining (duration of illness, until cessation of drainage).

-Adenovirus: pneumonia (duration of illness).

-Burkholderia cepacia in Cystic Fibrosis patients.

-Bronchiolitis (duration of illness).

-Clostridium difficile (duration of illness).

-Congenital rubella (duration is until 1 year of age, or urine and nasopharyngeal cultures consistently
negative after 3 months of age).

-Conjunctivitis, viral (duration of illness).

-Diphtheria: cutaneous (duration is until completion of antibiotics and 2 negative cultures 24 hours
apart).

-Staphylococcal furunculosis (duration of illness).

-Rotatvirus (duration of illness).

-Hepatitis A (duration is age specific in incontinent patients: children < 3 years old is duration of
hospitalization; 3-14 years old is 2 weeks after onset; > 14 years old is 1 week after onset).

-Herpes simplex: neonatal, disseminated, severe, or mucocutaneous (duration is until lesions dry and
crust).

-Herpes zoster: disseminated (duration of illness).

-Human metapneumovirus (duration of illness).

-Impetigo (duration is until 24 hours after initiating effective therapy).

-Lice: head (duration is until 24 hours after initiating effective therapy).

-Monkeypox (duration is until lesions crust).

-Multidrug-resistant organisms infection or colonization (duration is while evidence of ongoing or

increased risk of transmission, or while there are wounds that cannot be covered).

-Parainfluenza virus (duration of illness).

-Poliomyelitis (duration of illness).

-Pressure ulcer, major infected (duration of illness).

-Respiratory syncytial virus: infants, young children, and immunocompromised adults (duration of
illness).

-Staphylococcal scalded skin syndrome, -Ritter’s disease (duration of illness).

-Severe acute respiratory syndrome (duration of illness plus 10 days after fever and respiratory
symptoms have resolved or improved).

-Smallpox (duration of illness).

-Staphylococcus aureus skin infection, major (duration of illness).

-Group A streptococcus skin infection, major (duration is until 24 hours after initiating effective therapy).

-Tuberculosis: extrapulmonary, draining lesions (duration is until clinically improving and drainage has
stopped or there are consecutively three negative cultures).

-Vaccinia (duration is until lesions crust and dry).

-Varicella zoster (duration is until lesions crust and dry).

-Ebola, Marburg, Crimean-Congo, and Lassa fever viruses: viral hemorrhagic fevers (duration of illness).

-Wound infections, major (duration of illness).

Clinical Significance

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. 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,g

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 be 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.

Enhancing Healthcare Team Outcomes

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.