Clinical Precautions

Clinical Precautions
Maintaining Industry Standards Sensibly

By Kathy Dix

Standard precautions may seem just that standard butoftentimes it is difficult for healthcare workers (HCWs) to follow theseguidelines amid the hustle and bustle of a busy medical facility. However, taking a common-sense approach can dramaticallyimprove infection rates, even among the most vulnerable patients.

Judene Bartley, MS, MPH, CIC, is amember of the Communications Task Force for the Association for Professionals inInfection Control and Epidemiology (APIC); she is also the vice president of Epidemiology ConsultingServices, Inc., in Beverly Hills, Mich.

Although there has been much controversy over personalprotective equipment (PPE) and what is overkill versus what isinsufficient for the HCW and the patients protection, Bartley points out thatPPE is irrelevant if essentials like handwashing are neglected.

I think there are frequently people who give a quick waveto standard precautions and then go onto adding more PPE, instead of thinkinghard about why we emphasize standard precautions, because those are things weshould be doing all the time, Bartley says. Its more a question ofverifying that people are carrying out standard precautions correctly, beforethey start adding on gowns, gloves, and other equipment. Hand hygiene, with theaddition of the alcohol-based hand rubs, may have helped, so it has increasedthe attention to hand hygiene.

I think that too frequently, we tend to focus on a particularissue, for example, respiratory protection, which has gotten a lot of attention,instead of thinking of what were doing and what were touching. Theresthis disconnect between the fact that we know most things are spread by contact,and yet by not doing the right thing, we could be just as problematic intransmission, because you can transmit things with dirty gloves.

You emphasize basic standard precautions, and ensure thatpeople really understand those, and if theres going to be a step up, perhapsthe thing to do is some prevalence study or some observation to see if peopleknow and understand what basic precautions are, she adds. For me, thestandard precautions are the hand hygiene, the use of alcohol gel, the use ofgloves when youre going to contact body fluids if its wet, use gloves and gowns if you think youre going to soil your clothing, andeven the use of a mask if you think there is some opportunity for being reallyclose to the patient. Theres a judgment call that one makes in terms of PPEselection.

Basic precautions have a dual function thinking not onlyof protecting yourself as the caregiver but also the patient. When you get tosome specific infection that may call for contact precautions, the differencebetween standard and contact precautions is that youre putting on the gownand gloves as you walk in, because you dont want to take the chance that youwill touch something with your hands or with your clothing and inadvertentlytransmit pathogens to the patient ... but I think theres still an emphasis oncontact. And you must remove PPE when you leave the room, Bartley observes.

Using a private room for contact precautions when youredoing that means limiting the things that could be contaminated by thatparticular organism. It limits the transmission so when the patient leaves orwhen the cleaning is done, youre sure the transmission was confined to thatroom. But all of that depends on if people are aware of what theyve beentouching and contacting related to the patients. Its a thoughtful processthat is important in the training of standard and contact precautions.

Bartley points out that she is not trying to underestimate theimportance of contact precautions, but adds that there are some basicprecautions that should be happening all the time but unfortunately, due totime, or inattention, frequently this is not happening.

Years ago at my hospital, there was a concern fortransmission of an organism; as I recall, it may have been Serratia, and we mayhave had an outbreak at some point. There was concern about whether we werereally needed to put everybody in what they called full isolation, whichwas strict isolation at the time. They wanted signs up, so I put up a signthat said, Standard precautions on every single door on the ICU, trying tomake the point that if you need a sign as a reminder, lets start with whatthat really means. You have to find different ways of reminding staff of whatthey need to do. Its a constant challenge to find new ways, attractive waysjust to get peoples attention, she relates.

Bartley refers to the United States Department of Health andHuman Services (HHS) pandemic influenza plan, which includes both strategy andpublic health guidance for state and local partners. (For details on theserecommendations, visit www.hhs.gov/pandemicflu/plan/pdf/S04.pdf.¹) In thesection relating to recommendations for infection control in healthcaresettings, the document states first that contact should be limited betweennonessential personnel (or visitors) and the infected patient. Not only that,but they also recommend, Protect persons caring for influenza patients inhealthcare settings from contact with the pandemic influenza virus. Persons whomust be in contact should:

• Wear a surgical or procedure mask for close contact withinfectious patients.

• Use contact and airborne precautions, including the use ofN95 respirators, when appropriate.

• Wear gloves (gown if necessary) for contact withrespiratory secretions.

• Perform hand hygiene after contact with infectiouspatients.

A footnote defines masks as follows: Surgical masks come intwo basic types: one type is affixed to the head with two ties, conforms to theface with the aid of a flexible adjustment for the nose bridge, and may beflat/pleated or duck-billed in shape. The second type of surgical mask ispre-molded, adheres to the head with a single elastic and has a flexibleadjustment for the nose bridge. Procedure masks are flat/pleated and affix to the head withear loops. All masks have some degree of fluid resistance, but those approved assurgical masks must meet specified standards for protection from penetration ofblood and body fluids.

When you get down to what should be the PPE, theyrebasically talking masks, Bartley confirms. Basically its transmitted bycontact, and while theres some concern about small particle aerosols, that isall very speculative. Its based on some animal studies. Bottom line, it says to isolate if you can, but protectpersons caring for influenza in healthcare settings and wear a surgicalprocedure mask. They reference the use of N95s when appropriate, and this refersto when you might have someone you are intubating, and producing a fine aerosol.That same language was clarified by the World Health Organization; theypublished a guideline for pandemic influenza last March, and they recentlyupdated it to say exactly the same thing. If youre talking about being withinthree feet or so of an infected patient, you would use a surgical or proceduremask. Either is protective, and I think that brings us back to a common senseapproach.

Bartley references a long-term controversy regarding N95 masksand tubercule bacilli, which, she says, comes down to almost the same issueas influenza. Were talking about how we are exposed to patient secretions.Laboratory studies, she says, cannot assess what actually happens during patientcare. When youre taking care of a patient, youre not getting a perfectbolus of so many particles coming at you at a certain predictable concentration;when a patient is coughing, you are getting sputum. Most of the time, that canbe controlled with a tissue if the person is able, and if theyre not, thenthe worker wears the mask, because theyre really protecting themselvesagainst a spray. For tuberculosis (TB), the same thing still has to happen. Whentheyre coughing up tubercule bacilli, they still have to form and dry andbecome a spore and become airborne before you can have this long distancetransfer of tubercule bacilli that could cause problems later. If you capture TBat the beginning, if you have someone who is active, if theyre able tocontrol their secretions with disposable tissues, theyve really reduced therisk that theres going to be tubercule bacilli that can turn into spores thatcan transfer. Thats why for almost any organism, including TB, when youredealing with real patients in the real world, in a real-life hospital situation,what youre really trying to do is control the source of the infection asclose to the source as possible in this case, the patients mouth. Whenyoure wearing a mask, youre protecting yourself from spray. Diseasestransmitted via the respiratory route do not necessarily require eye protection, but other secretions may have pathogens that cantransmit to the eye. It makes perfect sense to me that for influenza, when weretalking about large droplets transmitted within three feet, we would protectyour mouth and nose from spray coming from a patient who is coughing heavily.

There are differences between TB and influenza, she allows,but that does not mean that protection should be compromised. It does make adifference when were talking about a true airborne disease like TB, vs.influenza or other types of diseases transmitted by large droplets, she says.Even SARS was primarily large droplets. One of the few instances that stillhas people concerned comes back to the fact that they were looking closely atwhen patients are being intubated or suctioned or theres somethingaerosolized during a nebulizer treatment with a fine spray. The difficulty isthat they were using things like a powered air purifying respirator (PAPR). Thequestion is, how much did people touch?

Lets say your hands were covered with gloves, but youdidnt take the gloves off, so they may have been contaminated withsecretions. But now youre touching the PAPR, and who knows what you mighthave touched in the process. When youre in the room with a patient, theresa lot of moisture. You have to have something moist that will hold thesecretions long enough for the organism to survive. Thats one plus of wearinga mask, because youre less likely to touch your nose or your mouth, but thatdoesnt mean your hands are not contaminated from the patient. Pay attentionto what youve touched, and when you remove your gloves, use hand hygiene, andperhaps reglove. The problem with PAPRs is that theyre reusable, and you dontknow how well people clean their hands. When they touch them, then touch thepatient, that could be the route for the organism to enter through a mucousmembrane.

Skin Contact

Although much fuss has been made over community-acquiredmethicillin-resistant staphylococcus aureus (CA-MRSA),Bartley points out that CA-MRSA and hospital-acquired MRSA do not actdifferently from normal Staphylococcus aureus interms of how they are killed in the environment; the only difference betweenthese resistant and non-resistant types is how they are killed within thepatient. So the organisms are transmitted inthe same way, she points out.

We expect the transmission to be the same, so whether weretalking about staph or some other organisms such as Pseudomonasthese are all transmitted by touch. When there arethings transmitted by touch, if there is moisture on your hands or on somethingyoure touching, they tend to survive longer than if theyre on dry, hardstainless steel. Most of them are easily killed by hot water, soap, certainlyalcohol, but we forget what weve touched after weve touched secretions.Thats my own pet peeve that people think in terms of protectingthemselves with gowns and gloves, but what they have done in the process is usethose dirty gloves to contaminate other things that someone else thinks isclean.

That, Bartley says, brings her full circle, back to the handhygiene. If you think youve soiled your hands or gloves when you go on todo another procedure for a patient, remove those gloves, clean your hands, thenput on a clean pair of gloves. There are many of us who think that we couldprevent a tremendous amount of transmission if we really used hand hygiene andgloves almost universally and carefully when we handled any kind of patientsecretion, whether its sputum, a wound, or urine.

Facilities that already have a good handle on hand hygiene andstandard precautions have another challenge, she says. If you have a facilitylooking to improve, and theyve already done well with their standardprecautions, it allows you to focus more closely on what it takes to get you toa zero infection rate. Thats where I think things are exciting today ifwe can take one more step. In Michigan, weve had a project called theKeystone ICU project. We have looked at infection prevention in every intensivecare unit (ICU) in every hospital across the state. We have the data from CDCsaying that if we do certain things, we can prevent infection. We looked atbloodstream infections, caused by many different kinds of organisms, and said,Lets bundle all these precautions together. They developed a checklistfor putting in a catheter. You should wash your hands, put on gloves, put a fulldrape on the patient, prep the skin. So what they have is a culture shift inthe ICU, where everyone on the team agrees that everyone must do all thesethings all the time. Its not just the physician who gets to make the call; anybody on the team can call and say I didnt see youwash your hands and we cant move ahead until you do. Almost 55 percent ofthe hospitals have gone almost six months without a single bloodstreaminfection. I think its mind-blowing, because as much as we thought somethings were not as preventable as others, it shows that if you do all the rightthings, all the time, you can achieve tremendous infection prevention.

Hand hygiene is the first step, she notes. The next step isensuring that patients do not get infections when they have medical devicesinserted. Whether its an IV catheter, a Foley catheter, a chest tube, thatswhere we put little tracks going into the patient that permit organisms to getin, she adds. Here, they did everything right, they tracked it, andeverybody has agreed to do it, and when they did it, this is what happened. Nowtheyre doing the same thing with ventilator-associated pneumonia. They arebundling how the patients head should be elevated, etc., and if someonemisses a step, theyre called out. It makes for tremendous team spirit, fortremendous morale. If you can imagine, across the entire state, 120 ICUs havingthis kind of success in preventing infection, you can bet people are excited. Tome, instead of chasing after trying to put on PPE Im not saying theresanything wrong with protective clothing, but its the issue of knowing whatyoure doing when you do it, paying attention that youre putting the gloveon and taking it off at the right time, knowing what youve touched, what youvedone.

Bartley adds that HCWs should cement a ritual of hand hygieneas a matter of respect, and as a habit. I would love to see healthcareworkers hitting that alcohol and rubbing their hands so the patient can see themdoing that when they walk into the room, she hopes. If that were a universal approach across theboard, I bet we would reduce transmission of contact organisms tremendously. Often were so much in a hurry, thats when the mistakesoccur and it doesnt take but one chance to ruin it for a patient.

Note: The Healthcare Infection Control Practices AdvisoryCommittee (HICPAC) has drafted guidelines for isolation precautions that wereclosed for comment in February 2005. It is APICs understanding that theguidelines will be available sometime early in 2006, according to David Love,director of communications at APIC.

References:

1. www.hhs.gov/pandemicflu/plan/pdf/S04.pdf

2.www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual/annex1-5.htm