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Universal Precautions or Standard Precautions are terms long synonymous with infection prevention and control (IPC) and the application of safe patient care. These terms represent basic measures that must be applied to reduce the risk of transmitting infection to patients, relatives/visitors and ultimately, staff themselves.
The message for healthcare workers (HCWs) in relation to their protection centres on the Health & Safety Act (1974) within Great Britain and similar health and safety legislation (or guidance) internationally.
Generic IPC principles include personal protective equipment (PPE), designed to protect both wearer and patient/client by providing a physical barrier from potentially infectious agents.
Gloves, aprons, gowns, facial protection and types of respiratory protection, or PPE (personal protective equipment) play a pivotal role in preventing the risk of contamination from blood or body substances to the HCW (healthcare worker), or, indeed, the transmission of other infections to patients/clients.
This article reviews such fundamental measures, considering healthcare workers’ effective use of PPE and whether increasing compliance will support the challenge that communicable disease and transmissible organisms present to us now and in the future.
Previous studies and systematic reviews have attempted to understand HCW’s compliance with such an integral IPC requirement and many different methods have been used in attempt to identify the level of compliance and factors influencing compliance. This article considers a handful of studies relating to post-respiratory outbreaks, such as SARS (severe acute respiratory syndrome) and Influenza, and serves as a discussion platform for practitioners to consider the following aspects:
While some countries may have specific legal requirements incorporating the use of PPE in the healthcare setting, others may adopt, adapt, or implement a combination of international standards and guidelines, of which there are many.
Perhaps the most renowned organisation steering preventative measures in healthcare is the WHO (World Health Organization), which provides leadership on global health matters, influences health research, sets standards and promotes evidence based policies for both developed and developing countries (WHO, 2013a).
The WHO website provides freely available resources, including the WHO Patient Safety Curriculum Guide (2011) which covers patient safety topics, including IPC (topic 9). The following table contains an extract from this section’s guidance (Minimizing infection risks through the implementation of basic IPC measures, 2012)
Another organisation with worldwide recognition is the CDC (Centers for Disease Control and Prevention), based in the United States and in existence for more than 60 years. CDC’s publications concerning patients known or suspected to be infected with bloodborne pathogens, became widely recognised as Universal Blood an Body Fluid Precautions or Standard Precautions.
Within the context of universal precautions, blood and certain body fluids of all patients are considered potentially infectious for human immunodeficiency virus (HIV), hepatitis B & C virus, bloodborne and other pathogens.
Despite clear guidance, the challenge to ensure understanding and consistent implementation of these basic, preventative measures has remained ongoing.
Watson & Myers (2001) considered cognitive factors affecting glove use by nurses, suggesting the amount of anticipated contact with blood significantly influenced intention, together with perceived time availability to wear gloves.
Nurses displayed selectivity with respect to glove use based on patient infection status.
In 2007, Flores observed HCW interventions, identifying a 92.3% glove use compliance rate based on task risk, although gloves were overused in 42% of observations. While staff recognised the need for protection, the failure to remove gloves after interventions and continuing with other tasks represented significant risk of onward pathogen transmission within the clinical environment.
For countries adopting international standards from one or more sources, consistent messaging is paramount, as is ensuring a robust method of assessing compliance.
Joint Commission International (JCI) provides a mechanism for improving patient safety and quality with the recognition that local needs vary and diverse cultures often present unique challenges.
Whilst JCI specifies that infection risks and programme activities may differ in each organisation depending on clinical activities, patient population and volume, geographic location and number of employees; the patient safety message (JCIb, 2013) remains consistent for barrier techniques and hand hygiene gloves.
Masks, eye protection, other protective equipment, soap, and disinfectants should be available and used correctly when required.
Information retrieved from the JCI website (JCIb, 30.5.13) identified approximately 600 healthcare organisations accredited by the scheme with 164 of these in the Middle East, 210 in Asia and 155 in Europe. Within the Middle East, 56 accredited organisations are based in Saudi Arabia and 70 in UEA.
The benefit of an additional driver such as accreditation must be considered in relation to improving standards for patient care – and staff health.
User violation issues
The following table gives examples of violations representing sub-optimal, unsafe practise and inappropriate risk assessment by staff that the author has historically noted:
Current and future challenges
The recent emergence of the Middle East respiratory syndrome coronavirus (MERS- CoV) serves as a global reminder to ensure consistency with PPE usage to protect HCWs and prevent onward patient transmission.
Since September 2012, 53 laboratory confirmed cases of MERS and 30 deaths have been reported, with many cases affected by existing co-morbidities. A total of 5 new cases have been reported in Saudi Arabia (SA) since 28.5.13, all originating from the same hospital according to an official from the Saudi Arabia Ministry of Health, with two patients sharing the same room (WHO, 2013b).
In March 2013, the WHO’s report Overview of the emergence and characteristics of the avian influenza A (H7 N9) virus identified 132 laboratory confirmed cases of Influenza A (H7, N9) in at least eight Chinese provinces, with 37 deaths reported.
While in recent weeks the rate of new symptomatic human infections with H7 N9 has decreased, with little evidence of person to person spread, the possibility of further cases not detected in asymptomatic infected individuals cannot be ruled out according to WHO (2013c).
The current global situation indicates that PPE compliance remains crucial not just in relation to BBV risks, but also the presence of respiratory pathogens in symptomatic and asymptomatic patients.
Awareness raising for universal precautions in 1987 by the CDC (predominantly BBVs) may account for some of the findings in post-pandemic PPE surveys (higher compliance with aprons/gloves), but the challenge remains for improving compliance with protective respiratory equipment.
Staff exerting risk assessment based on the person not the procedure, or deviating from local policy need to understand the very tangible clinical risks to themselves and also patients. During the first wave of the 2009 H1N1 influenza pandemic, Banach et al (2011) observed more unprotected exposures in patients not presenting with influenza-like illness.
While not unexpected as they were not identified by the screening protocol, the delay in considering influenza as a potential diagnosis results in prolonged exposure and impacts on the implementation of recommended IPC measures and the protection of both staff and patients.
Newly emerging, re-emerging infections, the increasing burden of multidrug resistant organisms triggering global alerts, or the threat of a pandemic situation should ideally represent real time reminders for staff in relation to IPC measures.
Prior to the 2009 H1 N1 pandemic, Daugherty et al demonstrated that more than 50% of respondents (256) believed there was a 45% chance of an influenza pandemic occurring within the following five years. Only 41% reported knowing how to protect themselves during an outbreak and despite the shared belief that a pandemic was likely, 59% reported only minimal knowledge of the risks of and protective strategies required.
Assessing HCW compliance with appropriate PPE usage in order that improvements can be made represents a similar arena to that of hand hygiene.
To improve practise there has to be understanding of local compliance rates and reasons for violations, appreciation of peer experiences and review of meaningful research data. Monitoring HCW compliance in relation to types of observation and self-reporting methodologies reported independently of each other may produce unreliable results.
The concern with self-reporting studies is well documented, with the range of variance appearing to differ according to the comparison methodology used.
Alyce et al (1999) found that 80% of studies using both self-report and objective measures (charts, documentation, simulation) supported the existence of response bias. On reviewing 326 studies, self-reported adherence was overestimated by 27% overall and in 87% of the 37 comparisons, self-reported rates exceeded objective rates.
This was also highlighted in Xiaoyun’s study where significant gaps between perception and practise were common in ICU, indicating overestimation of clinical practise judged by self-reported behaviour.
The delivery of patient care behind a door or screen may affect accurate observations or assessment of IPC opportunities within a specific clinical area.
Van de Mortel and Murgo (2006) highlighted the potential for inaccuracy if sampling reduces for this reason, or if opportunities for hand hygiene interventions are missed.
The need to gain staff and patient permission to conduct observations adds further bias in relation to altered or enhanced performance during observed practise.
This factor is well documented in many hand hygiene observation studies as the Hawthorne effect (Eckmanns et al 2006), where some people work harder and perform better when they are participants in an experiment/study, but remains practically unavoidable in clinical areas if patient dignity and confidentiality is to be maintained.
Many studies and systematic reviews identify that more research is needed to accurately assess HCW compliance with PPE and other IPC interventions. While this may be true, there is an argument for suggesting that efforts could be better utilised proactively, by promoting localised safety environments with cultures that appreciate the link between everypatient/client intervention and the application of effective IPC measures.
Shekelle et al (2011) describe a clear need to secure improvement in healthcare due to patients remaining at risk through preventable harm, with care often falling short of evidence based best practise.
Ward (2012) examined student nurses’ perceptions of IPC and concluded that the participants viewed such practises as an additional workload, and not integral to the safety of patients and delivery of quality care. This study supports previous work by Anderson et al (2010) who suggest that clinical tasks are seen as separate to IPC practises and not part of existing processes and treatment.
The authors’ five reasons for this reiterate the thread of this article and may benefit from further exploration by IPC practitioners in order to promote greater consistency and sustainability:
IPC practitioners, managers and supervisors striving to improve practise may benefit from taking a straightforward approach and focusing on simple, achievable measures, including:
As suggested by Parker and Lawton (2003), violations are not intentional.
To ensure consistency – and consequently staff and patient safety – the occurrence of routine, situational and exceptional violations indicate that the why could easily be resolved by exploring the what, when and the how.
Organisational cultures, clinicians and working processes should ensure that human elements are factored into every patient pathway and care intervention to safeguard against future challenges within the sphere of infection prevention, and protection against communicable disease and potentially transmissible infections.
Karen Egan, RGN, MSC Health Protection
Karen has worked within the speciality of IPC for 15 years and covered both the hospital and community settings. Within this time Karen has been involved in national projects and training initiatives, contributed to the IPC education agenda by presenting at various national/international conferences and facilitated a degree level IPC module for the last 11 years.
Her key interests are environmental hygiene and decontamination, proactive strategies for the reduction of healthcare acquired infections, IPC governance frameworks, legislation and legal aspects of IPC and the patient’s perspective of infection prevention practise.
Barriers to Infection – The Use ...
A Press Release by Karen Egan, RGN, MSC Health Protecti...
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