Universal Precaution: A Tool For Safe Healthcare Practice

1. To discuss the concept of universal precaution
2. To discuss the method of precautions in health care practice
3. To discuss the infection control measures by health workers.
4. To discuss the equipments/materials of universal precautions.

Concept of Universal Precautions

Universal precautions are simple infection prevention control measures that reduce the risk of transmission of blood borne pathogens.

In 1983, the centers for disease control (CDC) and prevention established isolation guidelines that allowed health faculties to choose between two systems (garners and Simmons, 1983). Category specific isolation precautions, where based on seven categories strict isolation, contact isolation respiratory isolation, tuberculosis isolation, enteric precaution, drainage/secretions precautions and body blood fluids precautions. (Kozier et al, 2002).

Disease specific isolation precaution provided precautions for specific diseases. The precautions delineated rise of private rooms with special ventilation, having the client share a room with other client infected with the same organism, and gowning to prevent gross spoilage of clothes for specific infectious disease (Kozier et al, 2002).

In 1987, the center for disease control presented recommendation (revised in 1988) for universal precautions (UP), techniques to be used with all clients to decrease the risk of transmitting unidentified pathogens; U.S department of health and human services (USDHHS, 1988). Universal precautions interfere with the spread of blood borne pathogens, those microorganisms carried in blood and body fluids that are capable of infecting other persons with serious and difficult to treat viral infections, namely Hepatitis B, Hepatitis C virus and HIV, the CDC did not recommend that universal precautions replace disease-specific or category – specific precautions, but that they be used in conjunction with them.

The body substance isolation (BSI) system employs generic infections control precautions for all clients except those with few diseases transmitted through air. The BSI system according to Jackson (1993) is based on three premises;

i.)                All people have an increased risk for infection from microorganisms placed on their mucous membrane and intact skin.

ii.)              All people are likely to have potential infections microorganisms in all of their most body sites and substances.

iii.)           An unknown portion of clients and health care workers will always be colonized or infected with potential infectious microorganisms in their blood and other moist body sites substances. The term body substance isolation includes blood, some body fluids and urine, feces, wound drainages, oral secretions and either body products or tissue (Kozier et al, 2002).

In addition to other actions and precautions discussed in this work, significant emphasis is placed on avoiding injury due to sharp instruments, measures to blood-borne pathogens, and communication about biohazards to employees. Federal regulations require that in most cases warning labels be affixed to containers of regulated waste and refrigerators and freezers containing blood or other potentially infectious material. The label required is fluorescent orange or orange red and feature the biohazard legend (Kozier et al, 2002)

Methods of Universal Precautions

Various infection control measure are used to decrease the risk of transmission or microorganism in hospitals. Universal precautions are sometimes called isolation precaution (Kozier et al, 2004). The hospital infection control practices advisory committee (HCCPAC) of the centre for disease control and protection presented new guidelines were divided were divided into two:

i) Standard Precautions and

ii) Transmission Based precaution (Kozier et al, 2004).

Standard Precautions

1. The current model of beat practice in infection control, a synthesis of universal precaution and body substance isolation. This body substance isolates system employs generic infections control precautions for all clients except those with few diseases transmitted through air (Jackson, 1993). Standard precautions are designed to reduce the risk of transmission of blood borne pathogens in hospital, from both recognized and unrecognized sources of infection, and apply to all patients all the time. Their implementation requires that nurses and health care workers take appropriate measures. Example wear gloves, to avoid contact with blood, all body fluids, secretions except sweat, regardless of whether or not they contain visible blood, non intact skin and mucous membranes (Kozier et al, 2004).

Transmission Based Precautions

ii. Precautions designed to be applied to patients known or suspected to be infected with pathogens that are highly transmissible or epidemiologically important and for which additional measures beyond standard precautions are needed to interrupt transmission in hospital. These precautions are used in addition to standard precautions for clients with known or suspected infection that are spread in one of three ways by airborne or droplet transmission or by contact. These three types of transmission – based precaution may be used alone or in combination but always in addition to standard Precaution (Kozier, et al, 2004).

Tools of Universal Precautions

All health care providers must apply clean or sterile gloves, gowns, masks and protective eye wear according to the risk of exposure to potentially infective materials.

1. Gloves; Gloves are worn for three reasons: firstly they protect the hands when the nurse is likely to handle any body substances for example blood, urine, feces, sputum, mucous membranes and non intact skin. Secondly, gloves reduce the likelihood of nurses transmitting their own endogenous microorganisms to individuals receiving care Nurses who have open sores or cuts on the hands must wear gloves for protection. Thirdly, gloves reduce the chance that the nurse’s hands will transmit microorganism from one clients or a fomite to another client. In all situations, gloves are changed between client contacts. The hands are washed each time gloves are removed from two primary reasons: The gloves may have imperfections or be damaged during wearing so that they could allow microorganism entry and the hands may become contaminated during glove removal (Kozier et al, 2004)
2. Gowns: Clean or disposable impervious (water resistant) gowns or plastic aprons are worn during procedures. When the nurse/health workers uniform is likely to become soiled. Single use gown, the nurse technique (using a gown only once before it is discarded or laundered) is the usual practice in hospitals. After the gown is worm, the nurse discards it (if it is paper) or places it in a laundry hanger. Before leaving the clients room the nurse washes his/her hand. Sterile gowns are always indicated when a nurse changes the dressing of a client with extensive wounds (e.g. burns) (Kozier et al, 2004).
3. Face masks: Masks are worn to reduce the risk of transmission of organism by the droplet contact and airborne routes, and by splatters of body substances. The centre for disease control and prevention (CDC) recommends that makes be worm under the following condition. – By those close to the client if the infection (e.g. measles/mumps or acute respiratory disease in children) large particles aerosols are transmitted by close contact and generally travel short distances about one meter or three fits.  By all person entering the room if the infection e.g. pulmonary tuberculosis and severe acute respiratory syndromes) is transmitted by small particles aerosols (droplet nuclei). Small particles aerosols remain suspended in the air and this travel greater distance by air. Special masks that provide a tighter face seas and better filtration may be used for these infections. During certain techniques requiring surgical aspects (sterile techniques) masks are worn. – To prevent droplet contact transmissions of exhaled microorganism to the sterile field or to a client’s open wound and – to prevent the nurse from splashes of body substances from the client (Kozier et al, 2004).
4. Eye Wear: Protective eye wears (goggles, glasses or face shields) and masks may be indicated in situations where body substances may splatter the face. If the nurse wears prescription eye glasses, goggles may be worn over the glasses. The protective eye wear must extend around the sides of the glasses. (Kozzier et al, 2004).

Isolation Practices

Initiation of practices to prevent the transmission of microorganism is generally a nursing responsibility and is based on a comprehensives assessment of the client normal defense mechanisms, the client’s ability to implement necessary precautions, and the source and mode of transmission of the infections agents (Kozier, et al 2004).

The nurse then decides weather to wear gloves, gowns, masks and protective eye wear. In all clients’ situations, nurses must wash their hands before and after giving care (Kozier, et al 2004).

In addition, to the precautions cited the nurse implements aseptic precautions when performing any aseptic therapies. The following are some examples.

The use of strict aseptic technique when performing invasive procedure (e.g. inserting an intravenous needle or catheter, suctioning an airway, and inserting a urinary catheter) and when changing surgical dressings.

Handle needles and syringes carefully to avoid needle-stick injuries.

• Change intravenous tubing and solution containers according to hospital policy (e.g. Every 48 to 72 hours)

Check all sterile supplies for expiration date and intact packaging.

• Prevent urinary infection by maintaining a closed urinary drainage system with a downhill flow of urine. Do not irrigate a catheter unless ordered to do so. Provide regular catheter care and clean the perianal areas with soap and water. Keep the drainage bag and spout off the floor.

Implement measures to prevent impaired skin integrity and to prevent accumulation of secretions in the lungs (for example encourage client to move cough, and breathe deeply at least every 2 hours) (Kozier et al, 2004)

Infection Control Measures By Health Workers

Infection control measures by health workers can be discussed using the following subtopics.

1. Personal Hygiene (Hand Decontamination): the importance of hands in transmission of hospital infections has been well emphasized and can be minimized with appropriate hand hygiene. Optimal hand hygiene requirements includes

• Running water: large washbasins which require little maintenance with antiseptic devices and hand- free controls.
• Products: soap or antiseptic depending on the procedure
• Facilities for drying without contamination (disposable towels if possible).

Specific hand disinfectants, alcoholic rubs with antiseptic and emollient gels which can be applied to physical clean hands.

Personal hygiene requires that nails must be clean and kept short. False nails should not be worn. Hair must be worn short or pinned up. Beards and moustaches must be kept trimmed short and clean (Ducell G, Fabry J, Nicolle L, 2002).

2 Use of Protective Covering: the Protective covering includes clothes, masks gloves etc. mask and gloves have been discussed earlier in this work, therefore clothing shall be discussed.

Clothing

• Working clothing health workers should wear a personal uniform covered by coat. The working outfit must be made of a material easy to wash and decontaminate. If possible a clean outfit should be worn each day. An outfit must be changed after exposure to blood or if it becomes wet through excessive sweating or other fluid exposure (Ducel et al, 2002).

Shoes

• In aseptic units and in operating rooms health workers must dedicated shoes (i.e. flat, noiseless, comfortable shoes) which must be easy to clean)

Cap

• When performing selected invasive procedures or in operating rooms, health workers must wear caps or hoods which completing cover the hair (Ducel et al, 2002).

3 Vaccinations

• Immunization recommended for health workers includes: hepatitis A, and B yearly influenza, measles, mumps, rubella, tetanus; diphtheria. Immunization against vericella may be considered in specific cases. The examples include the Monteux skin test will document a previous tuberculosis infection and must be obtained as a baseline specific post exposure. Policies must be developed and compliance ensured (Ducel et al, 2002).

Proper disinfection of patient’s equipment/materials. Disinfection removes microorganisms without complete sterilization to prevent transmission of organisms between patients. Disinfections procedures must.

• Meet criteria for killing of organism
• Have a detergent effect
• Act independently of the number of bacteria present, the degree of hardness of the water, or the presence of soap and proteins (that inhibit some disinfectants). To be acceptable in the hospital environment e.g. must also be;
• Easy to use
• Non-volatile
• Not harmful to equipment, staff and patients
• Free from unpleasant smells
• Effective within a relatively short time

We have different levels of disinfectants depending on the product or process.

1. High level disinfection (critical); this will destroy all microorganisms with the exception of heavy contamination by bacterial spores.

2. Intermediate disinfection (semi-critical) this inactivates mycobacterium tuberculosis, vegetative bacteria, most viruses and most fungi but does not necessarily kill bacterial spores.

1. low level disinfection (non critical) this can kill most bacteria, most viruses and most fungi, but cannot be relied on for killing more resistant bacteria such as M. tuberculosis or bacterial spores. These levels of disinfection are attained by using the appropriate chemical product in the manner appropriate for the desired level of disinfection. (Duccel et al, 2002).

Proper disposal of waste: proper disposal of waste product is of high providing on infection control. This can be achieved by practice of universals precautions by the health care worker.

• Needle stick injuries should be avoided. Shredding continues to be an important method of dealing with needles, or all used needles and sharps should be deposited in thick walled puncture resistant containers. Bending, reshaping should be prohibited, do not recap the needles to avoid needle stick injuries. All used disposable syringes and needles should be discarded into bleach solution at the work station before final disposal.
• Linen – all soiled hospital linen should be soaked in 1.100 bleach solutions for 30 minutes. Used autoclaving as the most ideal procedure for decontaminating linen.
• Spillage of blood/body fluids
• Never wipe the spillage with working wet mop. Cover the spills with paper and pour 1 hypochlorite or bleaching powder to decontaminate the spills with the HIV/HBV virus
• Metal instruments- hold all contaminated metal instruments with gloved hands. Subject all metal instruments to washing with soap and water.
• Bagging contaminated articles need to be enclosed in a sturdy bag impervious to microorganism before they are removed from the room of any client. Some agencies use labels or bags of a particular color that designates them as infective wastes (Duccel et al, 2002).
• Education – health workers who handle patients in emergency and off emergency period should be adequately trained in basic principles of universal health care precautions. Also participation of subordinate will make a lot of difference in the work environment.

Materials of Universal Precautions

–      Soap

–      Warm running water

–      Disposable or sanitized towels

–      Alcohols

–      Nose masks

–      Hand gloves etc (Kozier et al, 2004)

Implication of Universal Precautions in Nursing

In nursing practice, failure to imbibe the habit or use of regular universal / standard precaution can result in an easy contraction of diseases from patients at every level of health care.

The improper use of universal precaution especially on patients that needs isolation or suffering from communicable disease can predispose the nurse to the infection or disease condition and other patients in the ward, and the patient’s relative.

Other implications includes; fear of the nurse to come close to his / her patient, which will limit heath care, and also failure to monitor aseptic techniques including hand washing.

Conclusion

There is so much written about universal precaution that is gradually being replaced by standard precautions, due to some procedures that have being included like the isolation procedure. It is also necessary that health workers especially the nurse comply to the universal precautions, because this can improve the effectiveness of care giving to patients and also enable the nurse to monitor aseptic technique that will ensure safe health to the nurse and patient.

Recommendations

A written plan of the use of personal protective equipments should be posted in the hospital, especially at the delivery and surgical wards.  The personal protective equipments should be made available by the authorities of the health facilities.

All health facilities should establish a post exposure prophylaxis program for the protection of health care workers who experience needle sick injuries.

Posters should be posted in the facilities to remind health care workers of the need to comply with universal precaution.

All health workers should be vaccinated) against hepatitis B virus) to reduce the risk of hepatitis B, blood infection.

Above all, health workers should receive adequate and periodic training on universal precautions, with a view to improving overall safety of patients and health care providers.

References

Barbara K, Glenora E, Audrey B, Sherlee S, (2004) Fundamentals of Nursing concept, process and Practices, seventh edition United state of America. Julie  Alexander.

Ducel G, Fabry S, Nicolle L, (2002) Health workers in Prevention of Hospital – acquired infection, second Edition united state of America. Publisher world health Organization.

Ducel G, Souza S (2002) Nurse understands of Universal Precaution. Retrieved November 10, 2002, http:/www:/scielo. Br/ scielo.php?scritp.

Sadoh W. E, Fawole. O., sadoh A. E, Oladimeji A. O, Sotiloye  O. S, Journal of the national medical Assocviation Vol. 981, No %, May 2006.

Smeltzer S. C, Bare B. G., Hinkle j. l,  Cheever K. H,  (2002)

Standard precaution in Brunner and Suddarth’s  Textbooks of  Medical surgical Nursing, Eleventh Edition. Lippincott William and Wilkins.

Weller B.  f, (2005) Universal Precaution in Bailliere’s nurses Dictionary. Twenty Fourth editions. United Kingdom. Elsevier.

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