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:
- PPE as a basic, but essential component of IPC
- Staff perception of risks to themselves, patients/clients
- Defining risks and why staff may not comply with PPE requirements
- Influencing staff and effecting change
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)
|Personal Protective Equipment|
|Gloves- The use of gloves does not replace the need for hand hygiene by either hand rubbing or hand washing; Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, or non-intact skin will occur; Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient; When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to either another body site (including non-intact skin, mucous membrane or medical device) within the same patient or the environment; The reuse of gloves is not recommended|
|Gowns and Face Masks– Aprons/gowns prevent contamination of clothing with blood, bodily fluids and other potentially infectious material. Health-care providers should: Wear disposable plastic aprons when in close contact with patients, material or equipment, or when at risk of contamination; Dispose of plastic aprons after each procedure. Non-disposable protective clothing should be sent for laundering; Wear full-body, fluid-repellent gowns when there is a risk of extensive splashing of blood, bodily fluids, secretions or excretions, with the exception of perspiration; Wear face masks and eye protection should be worn when there is a risk of blood, bodily fluids, secretions and/or excretions splashing into the face and eyes|
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:
|Example/PPE violation||Inappropriate risk assessment||Possible motivational factors|
|Dentistry Perpetual reuse of the same pair of sterile gloves in between patients Washing gloved hands after each examination/treatment||Significant risk of contamination from bloodborne viruses (BBVs) and other pathogens Assumption that patients do not have BBVs, or other infections Potential for glove puncture Inability to decontaminate gloved hands and risk of dermatitis||Cost Time/convenience Perceived dexterity of sterile gloves compared to non-sterile vinyl or synthetic|
|Dentistry Reusing vinyl gloves for the same group of family members Changing gloves and washing hands only after family has been examined/treated||Significant risk of contamination from BBVs and other pathogens Assumption that family members do not have BBVs, or other infections Potential for glove puncture Inability to decontaminate gloved hands||Cost Time/convenience Perception that family members are ‘immune’ to each other’s infections, or ‘share the same bugs’|
|Phlebotomy Cutting the tips off glove fingers to improve dexterity while undertaking venepuncture||Significant risk of contamination from BBVs and other pathogens No protection if needle stick injury sustained or skin broken by needle Patient exposed to contaminated staff fingers||Perceived risk of needle stick injury or failure of procedure due to the reduced dexterity of intact gloves|
|ICU (isolation side room) Reusing disposable gowns for same patient care episodes while carrying out barrier nursing procedures Protecting the gown with a disposable apron each time patient care delivered and disposing of apron only||Apron will not protect the surface area of gown from contamination due to extensive handling and contact with patient Used gowns hung up outside room remain contaminated and potentially reintroduce infection to next wearer, or patient through contact transmission||Cost Time/convenience Perception that aprons provide adequate protection and coverage Poor understanding of barrier nursing processes and transmission risks|
|ICU (isolation side room) Same pair of disposable gloves kept on throughout the delivery of minor patient care procedures and writing notes, while patient barrier nursed Drinking a mug of tea with same pair of gloves on||Significant risk of transmission within and around the environment; to patient/staff Contamination of patient notes Risk to staff drinking while wearing contaminated glove – oral faecal route of transmission Dermatitis risk with prolonged glove use and risk of puncture with glove use||Cost Time/convenience Perception that gloves represent ‘clean hands’ and hand hygiene not required Poor understanding of barrier nursing processes and transmission risks|
|General Ward Disposable white apron kept remaining on for shift, with coloured apron for food handling applied on top of white apron while serving or feeding patients Removing coloured apron after food service||Significant risk of transmission due to continual use of apron – risks to patients and staff Existing contamination from white apron transferring to food apron and subsequently food/crockery||Cost Time/convenience Poor understanding of PPE usage: single apron for single activity for each patient and then disposal Breach of Food Safety and Hygiene regulations|
|General Ward Disposable apron rolled up and tucked into pocket for staff breaks||Significant risk of transmission due to continual use of apron – risks to patients and staff Uniform and pocket becomes contaminated||Cost Time/convenience Poor understanding of PPE usage: single apron for single activity for each patient and then disposal|
|Midwifery Reluctance for midwives to wear facial protection during deliveries in case it affected communication and the HCW/patient relationship||Significant risk of transmission to midwife from splashing of body fluids||Poor understanding of PPE usage: perception that mucous membranes would not be at risk as a route of transmission Presumption that patient would be adversely affected by facial protection|
|Nursing Home Scabies outbreak in a home that stated they ‘didn’t need or use gloves because they didn’t have any infections’||Multiple routes of transmission and infection sources from body fluids, wounds, environment, equipment Significant risk of infection to residents, staff and also visitors||Cost Time/convenience Poor understanding of PPE usage Perception that only ‘known’ infections require gloves|
|Nursery Staff changing soiled nappies with no gloves||Risk to staff from body fluids Risk of contaminating environment and onward transmission to infants||Perception that babies and infants don’t have infections and gloves not required|
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:
- Delay between omission and consequence
- Lack of connection in the HCW’s mind with a patient and a positive laboratory result
- Time, pressure and workload
- Lack of consistent IPC cues/reminders
- The invisibility of microbes
IPC practitioners, managers and supervisors striving to improve practise may benefit from taking a straightforward approach and focusing on simple, achievable measures, including:
- Reviewing organisational PPE compliance levels by clinical observation, conversations with nursing, medical, domestic/housekeeping staff and as a crude proxy marker, a possible comparison of consumables
- Understanding what influences or contributes to HCW behaviour by using a behaviour model such as Michie et al (2011) whereby behaviour is broken down into three areas requiring equal consideration:
- Capability – Knowledge and skills
- Opportunity – Equipment, staffing
- Motivation – Habit, risk taking, decision making
- Making compliance easier with improved IPC/PPE products, cues and reminders that are user friendly, staff group/speciality targeted and widely accepted by staff. Additionally, policies/training that represent the actual level of practise required and instil clinician ownership, rather than a sweeping organisational approach
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.