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in Patient Safety

Standard Precautions- Universal Approach to Infection Prevention and Control.

Dr.Sandeep Chatrath, 1 Apollo Hospitals, Regional CEO (AP & Telangana).

Standard precautions (SPs) one of the cornerstones of infection prevention and control is designed to limit blood borne pathogen exposures among healthcare workers (HCWs) and halt the transmission of healthcare-associated infections (HAIs) to patients.

To review the standard precaution components include hand hygiene, use of appropriate personal protective equipment (PPE), decontamination of environment and equipment, safe use and disposal of sharps, decontamination of environment and equipment, patient placement, and linen and waste management to help enormously to prevent infection in healthcare settings.

In any healthcare division, standard precautions are the minimum infection prevention practices applied to patient care, irrespective of confirmed or suspected infection status of the patient. It is aimed to protect healthcare workers (HCWs) and prevent them from transmitting the infections to their patients.

According to Healthcare Infection Control Practices Advisory Committee (HICPAC), 2007 guidelines, the standard precautions include use of personal protective equipment (such as masks, gloves, and gowns), needle safety, hand hygiene and safe handling of highly contaminated medical equipment or surfaces in the patient environment including respiratory hygiene (cough etiquette) and disposal of sharps, and other clinical wastes properly.

  1. Introduction:

Healthcare workers generally face risk to infection with bloodborne pathogen during routine work in the emergency/trauma triage wards, intensive care units, and so forth. Worldwide, almost three million HCWs experience percutaneous exposure to bloodborne pathogens each year. Health care providers are at increased risk of acquiring bloodborne infections despite infection control precautions and availability of hepatitis B vaccine. These can be prevented by careful adherence to existing infection control precautions, provision of personal protective equipment during the management of emergencies and immunization against hepatitis B during the management of emergencies.

In spite of the detailed guidelines available, the knowledge and compliance with standard precautions vary among HCWs and are found to be inadequate in both developed and developing countries.

  1. Literature

Standard Precaution and Prevention of Infection

Standard Precautions are basically evidence based clinical work practices published by the Centre for Disease Control (CDC) in 1996 and updated in 2007 which prevent transmitting of infectious agents in healthcare settings. Standard precautions must be used for all patients cared for within all healthcare settings. They are designed to prevent the transmission of microorganisms between patients even when the source of infection is not known. We might not be aware of the type of microorganism that has infected the patient. Standard Precautions are designed for use with transmission of infection which occurs when the 6 elements of the “Chain of Infection” are present.

Figure 1 Chain of Infection

Standard Precautions- Universal Approach to infection prevention and control - 1

The goal of Standard Precautions is to break the chain of infection focussed on but not exclusively on the mode of transmission, portal of entry and susceptible host sections of the chain.

Chain of infection describes how a disease gets transmitted from one living thing to another. So 6 elements of the “Chain of Infection” are as follows -:

  1. Infectious agent -:

An infectious agent is an organism that causes disease: bacteria, viruses, fungi, protozoa, prions

There are two sources of infection:

  • Endogenous or self-infection occurs when organisms which are harmless in one site cause infection when transferred to another e.g. E.coli.
  • Exogenous or cross infection happens when organisms are transferred from one source to another e.g. doctor, nurse, other patient, the environment.
  1. Reservoirs -:
    It is a place where an infectious agent lives and grows (e.g. large intestine, blood and mouth).

 

  • Portal of exit -:
    Any opening in the body that allows the infectious agent to leave (e.g. mouth, nose, rectum, breaks in the skin,)
  • Modes of transmission -:
    Modes of transmission is how an infectious agent travels from one infected person to another person e.g. air, contact (indirect and direct)
  • Portal of entry -:
    Portal of entry is any opening which allows infectious agent to enter (e.g. nose, eyes, mouth, eyes, mucous membranes, a device inserted into the skin, a break in the skin etc.,)

 

 

  • A susceptible host -:
    A non-infected person who could get infected.

 

3. Standard Precautions Techniques

Standard Precautions Techniques
The following describes Standard Precautions in detail, which will break the chain of infection and help in infection prevention and Control.

  • 3.1. Occupational Health Programme-:

Prior to commencing work, all HCWs should be assessed by an occupational health team. This assessment should include: immunisations required for HCWs.

  • 3.2. Patient Placement-:

HCWs should have the potential for transmission of infectious agents in patient placement decisions.  Patients who contaminate the environment or cannot maintain appropriate hygiene should be placed in isolation rooms with en suite toilet facilities and ante room.

  • 3.3 Hand Hygiene -:

Hand Hygiene is the most significant procedure for preventing cross contamination (Person to person or contaminated object to person).

  • Make sure of hand hygiene before and after patient contact, after you contact blood, body fluids, excretions, secretions, mucous membranes, contaminated items or broken skin and after gloves have been removed.
  • Alcohol-based and hand sanitizers may be used as an alternative to hand washing if hands are visibly clean.

Hand hygiene is recommended;

  1. Before an aseptic task.
  2. Before and after contacting the patient
  3. After contact with body fluids, blood secretions or excretions, whether or not gloves are worn.
  4. After handling soiled/contaminated equipment, materials or the environment(After contact with patient surrounding)
  5. Immediately after removing gloves or other protective clothing.

Fig -2: Five Moments for Hand Hygiene

Standard Precautions- Universal Approach to infection prevention and control - 2

Fig-3: Hand wash and Hand rub

Standard Precautions- Universal Approach to infection prevention and control - 3

Standard Precautions- Universal Approach to infection prevention and control - 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  • 3.4 Respiratory Etiquette/ Cough Etiquette -:

Educating healthcare workers on the significance of control measures to contain respiratory secretions to prevent droplet and contact transmission of respiratory pathogens, during seasonal outbreaks of viral respiratory tract infections (e.g., respiratory syncytial virus, influenza etc) in the community.

Healthcare institutes are required to  ensure that supplies of tissues, foot operating waste bins and hand hygiene facilities are present in all departments including waiting areas throughout the facility.

  • 3.5 Information for patients/visitors/public -:

Educating patients/visitors/carers on respiratory etiquette and cough hygiene using some or all of the following:

  1. Welcome packs
  2. Patient information leaflets.
  3. Posters in all departments especially waiting areas

Other Precautions during times of increased prevalence of respiratory infections

During increased prevalence of respiratory infections in the community, masks to coughing patients and other symptomatic persons should be provided (e.g., persons who accompany ill patients) while entering into the facility and encouraging them to maintain special separation, ideally a distance of at least 3 feet, from others in common waiting areas.

  • 3.6 Use of Personal Protective Equipment (PPE)

According to the risk of exposure,a proper personal protective equipment should be chosen. Health care workers should check if they are at risk of exposure to blood, body fluids secretions or excretions and choose their items of personal protective equipment according to this risk.

  • Personal protective equipment (PPE) for healthcare personnel
    PPE is basically a variety of respirators and barriers which are used alone or in combination to protect mucous membranes, skin, airways and clothing from contact with infectious agents. Selection of PPE depends on the nature of the patient interaction and/or the likely mode(s) of transmission. A recommended procedure for donning and removing PPE preventing skin or clothing contamination is in the guideline for Isolation Precautions (2010). Designated waste bins or containers for used disposable PPE should be kept conveniently to the site of removal to help disposal and containment of contaminated materials. Hand hygiene is the final step after removing and disposing of PPE.

Physical barriers should be used : Protective goggles, face masks and aprons should be used during splashes and spills of any body fluids (excretions and secretions) are likely e.g., cleaning instruments and other items. Change PPE between patients.

Facial Protection: Use visor, mask or goggles when splashing is anticipated. Masks are basically used for three primary purposes in healthcare settings:

  1. When placed on health care personnel, they help protect from contact with infectious materials from patients e.g., respiratory secretions and sprays of body fluids or blood, consistent with standard precautions and droplet precautions.
  2. As they are placed on health care personnel while they are engaged in procedures requiring sterile technique (i.e when placing a catheter or injecting into the spinal or epidural space), to protect patients from exposure to infectious agents in a healthcare worker’s mouth or nose.
  3. Place a coughing patient away from other patients to prevent potential dissemination of infectious respiratory secretions (i.e., respiratory hygiene/cough etiquette).

Face protection should be;

  • A Single use or single person use
  • Goggles and facial shields can be reused by the same HCW but must be adequately cleaned and disinfected between patients by the user.
  • Masks may be used with goggles to protect the mouth, nose and eyes, or a face shield used instead of a mask and goggles, to provide a complete protection for the face.

Choice of eye protection for specific work situations (e.g., goggles or face shield) is dependent on the circumstances of exposure, other PPE used, and personal vision needs. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Removal of goggles, mask and face shield can be performed safely once gloves are removed, and hand hygiene performed. ties, ear pieces and/or headband that are used to secure the equipment to the head are “clean” and safe to touch with bare hands. The front of a mask, goggles and face shield are considered contaminated.

Plastic Aprons/Fluid Repellent Gown should be used to avoid contact with infected patients, excretions, contaminated equipment or materials. Isolation gowns are basically used as specified by Standard and Transmission-Based Precautions, to protect HCWs arms and exposed body areas and limit contamination of clothing with body fluids, blood, and other potentially infectious material. Type and choice of isolation gown depends on patient interaction, including the degree of contact with infectious material and the possibility for blood and body fluid penetration of the barrier. Change PPE between each patient. After removing and disposing of PPE hand hygiene is always the final step after removing and disposing of PPE.

Gloves

  • Before touching broken skin, blood mucous or other body fluids, or soiled instruments and contaminated waste materials or before performing invasive procedures, gloves should be worn on both hands
  • Gloves should be single use items and should conform to as per hospital infection control guidelines and NABH Standards.

Gloves are recommended;

  1. For all activities which carry a risk of exposure to body fluids, blood, secretions or excretions, sharps or contaminated instruments.
  2. When touching mucous membranes and nonintact skin.
  3. When handling contaminated equipment.

Gloves should be;

  1. Used only once.
  2. Should be sterilised if contact anticipated with sterile body site.
  3. Should be put on immediately before an episode of patient contact, and removed as soon as the activity is completed.
  4. Change between patients caring for different patients and between different care activities on the same patient, disposed off as health care risk waste if contaminated with blood or body fluids.
  • 3.8 Donning of PPE

Donning of PPE is the most important step to prevent infection. Before handling any PPE, hands needs to thoroughly cleaned with an alcohol-based hand rub. When your hands are dry, PPE can be put in the following order-:

  1. Gown
  2. Mask or Respirator
  3. Goggles/face shield
  4. Gloves

Removal of PPE
Remove PPE when the procedure is completed. PPE should be removed in the following manner and disposed of into healthcare risk waste if contaminated with blood and/or body fluids.

  1. Gloves
  2. Goggles/face shield
  3. Gown
  4. Mask or Respirator
  • 3.10 Environmental Decontamination -:
  1. To cut down the number of microorganisms in the environment, routine environmental cleaning is required.
  2. Particular attention should be given to regularly touched surfaces and those places where it is anticipated to be contaminated with blood or body fluids e.g. bed rails, mattress, commodes, bedside tables, doorknobs, sinks, surfaces and equipment close to the patient.
  3. Chemical disinfectants are basically NOT recommended for routine environmental cleaning.
  4. While using disinfectants, staff should follow the manufacturer’s instructions for dilution and contact times.
  • 3.11 Patient Care Equipment & Decontamination of Medical Devices -:

Medical devices which are designated as “Single Use Only” must not be reprocessed or reused under any circumstances.
Non Critical equipment

Non critical equipment should not either get in contact with a patient or in contact with healthy skin. Such equipment should be:

  1. In a state of good repair to facilitate effective cleaning.
  2. Must be cleaned thoroughly before to use on another patient. If soiled with blood or body fluids, disinfect needs to be done as per manufacturer’s instructions, rinse and dry.
  • 3.12 Reusable Invasive Medical Devices (RIMD) -:
  1. RIMD is a equipment classified as semi critical or critical. RIMD’s are in contact with sterile body sites, mucous membranes, breaks in the skin. HCWs must ensure that RIMD‘s are not used for another patient until it has been cleaned and reprocessed appropriately.
  2. Ensure medical devices labeled as “Single Use Only” are not reprocessed or reused. Ensure “Reusable Equipment” is appropriately decontaminated between patients.
  3. Appropriate decontamination of healthcare equipment must be in line with Infection Prevention and Control principles and manufacturer’s instructions.
  • 3.13 Disposal of sharps -:

Prevention of sharps injuries is an essential part of Standard Precautions. These include measures to handle needles and other sharp devices in a manner which will prevent injury to the user and to others using the device during or after a procedure.

  1. Adoption of work practices that minimize risk of injury.
  2. Assemble sharps box correctly, do not overfill.
  3. Position sharps box in a safe place close to point of use.
  4. Discard all sharps/sharp items in a sharps box immediately after use.
  5. Needles and syringes must be disposed of as a single unit preferably in Puncture Proof Container (PPC).
  6. Sharps boxes should be stored out of reach of clients, visitors and children
  7. Needles should not be bent, broken, recapped or disassembled. A needle hub cutter needs to used in case of a needle to be destroyed.
  8. Sharps should not be passed from person to another person by hand. it should handled by trained healthcare workers.

Management of Needlestick Injuries (NSI) and blood and body fluid exposure:
All the facilities should have a local guideline on the management of needle stick injuries and blood and body fluid exposure. This guideline should include;

  1. First aid
  2. Screening and risk assessment of source patient (if known)
  3. Risk assessment for chemoprophylaxis.
  • 3.15 Laundry Care -:
  1. Handling and transporting of laundry should be in such a manner that it should prevent transmission of microorganisms to other patients, HCWs or the environment. Healthcare organisations use different colour coded bags to handle infected and uninfected clothing.
  2. The staff who handles soiled linen should wear gloves and a disposable plastic apron.
  3. Segregation and transportation of used laundry should be in accordance with the hospital guidelines.
  4. Staff should not manually soak or wash soiled or infected linen /clothing.
  • 3.16 Spillages -:

Spillages of body fluid (e.g. urine, faeces or vomit) must be dealt with immediately wearing protective clothing.

  1. Soak up the material visible with disposable paper towels.
  2. Dispose soiled paper towels according to national guidelines.
  3. By using warm water and general purpose neutral detergent, clean the area
  4. Just disinfect by using a chlorine-releasing solution of 1000ppm or equivalent as per manufacturer’s’ instructions, rinse and dry.
  5. Remove gloves and apron according to national guidelines (see 2.9)
  6. Decontaminate hands (see 2.3)
  7. Chlorine-based disinfectants should not be applied directly onto spillages of urine as it may result in the release of chlorine vapour.

For blood spillages;

  1. All blood spills should be decontaminated with a chlorine based disinfectant (e.g. powder, granules or liquid containing 10,000ppm available chlorine) or a suitable substitute, with the local policy and manufacturer’s instructions.
  2. Spillage should be wiped with disposable paper towels and discarded into a yellow healthcare risk bag or rigid container (see 2.9)
  3. The area should be washed with a general purpose neutral detergent and water.
  4. Discard gloves and apron into healthcare risk bag
  5. Decontaminate hands.
  • 3.17 Safe Injection Practices Administration -:

HCWs administering injections on the importance of safe injection practices should be educated.

All facilities must have a guideline on the use of multiple dose vials

Preparation of Injections

All injections must be prepared in a neat and clean area. This area should not be used for disposing of handling blood samples used needles and syringes or any material contaminated with blood or body fluids.

An aseptic technique should be used while drawing up injections

  1. Needles, syringes and cannulae being sterile, single use items must not be reused for any other patient nor should it access a medication or solution that might be used for a subsequent patient.
  2. Wherever possible single dose vials should be used.
  3. Single dose vials should not be used for multiple patients.
  4. Do not combine leftovers for later use.
  5. A surgical mask should be worn when placing a catheter or injecting material into the spinal canal or subdural space.

Multiple vials

  1. Multiple dose vials must be used when really necessary
  2. Use of multiple dose vials to a single patient should be restricted wherever necessary.
  3. Vial should be labelled with patient’s name and date opened.
  4. Vials should be discarded if sterility is compromised or questionable.
  5. Multiple dose vials should not be left at a patient’s bedside.
  6. Use a sterile syringe and needle every time a medication vial is accessed even it is a 2nd dose of the same drug for the same patient.

Infusions and intravenous sets

  1. Do not use bags or bottles of intravenous fluids as a common source of supply for multiple patients.
  2. Intravenous fluids and intravenous sets are single use sterile items for use by a single patient.
  3. Do not consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient.

Conclusion:
This study concluded that the importance of the optimal and consistent practice of standard precautions in the healthcare setting prevent infection control. It is the responsibility of department heads to ensure that healthcare staffs who report to them adhere standard precaution guidelines. All healthcare workers who are involved in patient care have a responsibility to observe the precautions as per hospital laid guidelines at all times. Healthcare workers (HCWs) have a professional responsibility to ensure that protective clothing is worn appropriately.

Each facility should have an infection prevention committee and they should work with a supportive supervision, monitoring and evaluating standard precautions practice as one of their responsibility.

References:

  1. Cleaning Manual for Acute Hospitals. National Hospital Office, Health Services Executive. 2006, Dublin. Ireland
  2. WHO (2004) Reducing risks, promoting healthy life. Geneva, Switzerland World Health Organization.
  3. World Health Organisation, “Healthcare Worker safety” http://who.int/injection_safety
  4. S. Muralidhar, P. K. Singh, R. K. Jain, M. Malhotra, and M. Bala, “Needle stick injuries among health care workers in a tertiary care hospital of India,” Indian Journal of Medical Research, vol. 131, no. 3, pp. 405–410, 2010. View at Google Scholar • View at Scopus.
  5. Infection Control and Practice of Standard Precautions Among Healthcare Workers https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3958986/
  6. Compliance with Standard Precautıons of Students inClinical Practicehttps://www.jscimedcentral.com/FamilyMedicine/familymedicine-2-1064.pdf
  7. Infection control standard precautions in healthcare – www.who.int/csr/resources/publications/4EPR_AM2.pdf

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