Universal precautions are primarily designed to protect the health care worker from what?

Compliance with Universal Precautions

Universal precautions are termed ‘universal’ because they are intended for use at all times, in any circumstance where there is the risk of transmission of a bloodborne infection from an HCW/PSW to a patient or vice versa. As with all regulations, they only work if they are used properly. Unfortunately, despite predictions that their use could lower risk dramatically, significant evidence exists that these guidelines have not always been followed either consistently or well in the necessary settings. This has been true in both developed and less developed countries. In a 1994 study of emergency department physicians, nurses and other personnel at a university hospital in California, 22% of 322 recappable needles were recapped using a two-handed technique, and four sharps were inadvertently discarded into the trash. Overall, the estimated increased risk to the HCWs from noncompliance with universal precautions was 27%, and the risk to patients and other hospital personnel was 12% (Moss et al., 1994). In Thailand, even though roughly 95% of doctors and 86% of nurses were knowledgeable about UPs, only 47% and 28%, respectively, reported that they would take these precautions with all patients (Danchaivijitr et al., 1995). In a 1992 Scottish study, despite regulations passed down from the Association of Anaesthetists for the adoption of UPs with all patients, only 16% of anesthetists routinely wore gloves and one-third still recapped used needles (O'Donnell and Ashbury, 1992). Among surgeons in France, as recently as 2006, only 10% of accidental needlesticks were reported, and the rate of intraoperative percutaneous exposure continued to be high (Tarantola et al., 2006).

A comprehensive survey of 322 surgeons in Houston, Texas, addressed not only the rates of compliance but also predictors of compliance with 11 different UP items. Guidelines regarding the wearing of gloves and disposal of sharps were followed by 94% and 92%, respectively; but only 55% wore protective clothing, and 56% avoided the unnecessary recapping of needles. Overall compliance with all items was between 31 and 38%. Logistic regression revealed that noncompliant physicians tended to be 37 years old or older, to report high levels of work-related stress, and to perceive a conflict of interest between providing good patient care and protecting themselves. Conversely, compliant physicians were more likely to be knowledgeable and to have received training in UPs, to perceive that UPs are effective, and to believe that their organization was committed to HCW and patient safety (Michalsen et al., 1997).

In another study assessing reasons for noncompliance in three hospitals dispersed across the United States (mid-Atlantic, Southwest, and Midwest regions), compliance again was noted to be strongly correlated with perceived organizational commitment to safety, and strongly negatively correlated with a perceived conflict of interest between workers' need to protect themselves and their need to provide medical care to patients (Gershon et al., 1995). Other strong positive correlations were with perception of risk, knowledge regarding routes of HIV transmission and prior UP training. Females had higher overall compliance scores than males, and overall compliance scores were highest for nurses and lowest for physicians. A risk-taking personality was strongly negatively correlated with UP compliance. In a Dutch study, a variety of HCWs were found to overestimate their knowledge regarding risks and procedural skills, and their compliance with UPs was influenced by their perception of risk (van Gemert-Pijnen et al., 2006). Appreciation of risk also was found to be important among emergency department personnel, where anticipated exposure to blood and more training experiences with UPs resulted in HCWs being more likely to wear gloves and less likely to recap needles; conversely, lack of time, the perception that a given patient was of lower risk for hepatitis or HIV infection and perceived interference with technical performance were barriers to glove use.

One potential source of ‘noncompliance’ might be termed ‘selective compliance,’ which stems from the ill-advised belief that UPs only are necessary when a patient is known or suspected to have a bloodborne infection. However, in a study at a Veterans Administration hospital in Washington, DC, 3.7% of all hospital admissions were HIV positive, and only 24% of these were known prior to testing (Gordin et al., 1990). This apparent failure to identify the majority of HIV-positive patients may be because most HIV-positive individuals do not have any readily distinguishable traits. Some high-risk groups also may be unrecognized. Finally, in terms of exposure rates to bloodborne infections, there appears to be no benefit associated with knowing a patient's HIV status.

Despite this apparent lack of complete compliance with UP guidelines, needlestick injuries are decreasing in some countries. In the United States, for example, the estimated number of accidental needlesticks decreased from 1 million annually in 1996 to 385 000 in 2000. This decrease has been attributed to the protection afforded by the Occupational Health and Safety Administration's (OHSA) Bloodborne Pathogens Standard, which includes the elimination of needle recapping, the use of safer needle devices and sharps boxes, and adherence to other universal precautions. Other measures that have led to decreased injuries are the ‘no-touch suturing’ technique and increased training in bloodborne infection risk and universal precautions for all trainees. Table 3 lists other potential means of lessening HIV transmission risk.

Table 3. Other ways to protect yourself against exposure to bloodborne infections

1.

Stay informed about risks and any changes to precaution guidelines or policies

Inform supervisors and/or administration of undue risks

Use the ‘no touch’ technique for suturing

Be extremely careful when handling hospital garbage or patient clothing or linen

Be especially careful around high-risk patients or in high-risk settings

Use special devices (e.g., spring-loaded syringes) to lower risk, if proven effective and when available

Some attempts have been made to lessen risks further via the development of spring-loaded syringes that allow the needle to retract immediately after extraction from the patient's skin; but these syringes are rarely used due to their high costs. Similarly, needle-less intravenous delivery systems have been developed, but have not yet achieved popular use. Hence, the mainstay of risk reduction, with respect to the transmission of HIV and other bloodborne infections, continues to be universal precautions.

Implications

Precautions

Universal precautions against infectious diseases should be practiced during every skin examination or cutaneous procedure. Handwashing with soap and warm water or the use of hand sanitizing gels or foams ensures that the physician is taking appropriate steps to avoid spreading organisms from a previous patient. As patients become more aware of the spread of infections by health care providers, it can be useful for the physician to cleanse his or her hands in the presence of the patient, rather than outside the examination room. When examining intact skin, it is not necessary to wear gloves. For the protection of both the patient and physician, gloves should be worn when the physician touches nonintact skin surfaces. Because of the increasing incidence of allergies to latex in the health care setting, the use of nonlatex gloves should be considered for all patients. Gloves should be discarded after the examination is complete or after touching the mouth or the genital area.

Biohazard Cases

Universal precautions to minimize the spread of infectious disease should be employed with each body removal regardless of its infectious state, and all bodies treated as potentially infectious; personal protective equipment should always be worn. However, certain cases are deemed high risk purely due to their nature. These high-risk cases include intravenous drug users, prostitutes, homosexuals, or persons recently imprisoned. If this is the situation, extra care should be taken to avoid contact with body fluids and safety glasses, surgical masks, and double gloves may be worn. Staff should always be observant for sharps and other foreign objects. To prevent splashes, a towel or absorbent material can be placed over any open wounds or the face of the deceased person. In cases where there is identified risk for an airborne biohazard such as tuberculosis or severe acute respiratory syndrome (SARS), a towel should be placed over the face to prevent the escape of sputum or other fluids, and an appropriate face mask or respirator worn by the body transporters.

PROCEDURAL

Technique

Universal precautions should be used during the entire procedure. Connect the needleless access port to the extension tubing and flush saline through both the port and the tubing (unless phlebotomy is to be performed at the time of IV line insertion). Remove any topical anesthetic (if applicable), and apply a tourniquet proximal to the desired location. Clean the site with appropriate skin cleanser, and spray topical anesthetic (if applicable). Using the catheter with the bevel side up, enter the skin at approximately a 30- to 45-degree angle, just distal to the desired entry point into the vein (Fig. 202-2). Because the needle enters the vein before the catheter does (Fig. 202-3), continue to insert the needle and catheter just slightly once there is a flash of blood in the hub of the catheter to ensure that the catheter is in the vein (Fig. 202-4). Slide the catheter over the needle into the vessel (Fig. 202-5). Apply pressure proximal to the IV catheter to prevent blood from flowing out of it. Remove the needle, leaving the catheter in place, by pressing the button to autoretract the needle or simply by removing it (depending on the type used). Connect the extension tubing and needleless access port to the IV line. Apply tape or a transparent occlusive dressing on top to hold the catheter in place. Remove the tourniquet, and flush the catheter (or obtain a phlebotomy specimen). If the catheter does not flush easily, it may not be placed intravenously. If there is swelling at the site, the IV line should be removed. Secure the catheter to the patient, applying a board and cover as needed.

STANDARD PRECAUTIONS

Although universal precautions were designed to address the transmission of blood-borne infections through blood and certain body fluids, they do not address other routes of disease transmission, which were addressed at the time by body substance isolation guidelines. Additionally, confusion developed as to whether one should use universal precautions and body substance isolation guidelines, because both guidelines dealt with similar circumstances but offered conflicting recommendations. The guideline for isolation precautions in hospitals was revised in 1996 by the CDC and the Hospital Infection Control Practices Advisory Committee (HICPAC), which had been established in 1991 to serve in a guiding and advisory capacity to the Secretary of the Department of Health and Human Services (DHHS), the Assistant Secretary of Health of the DHHS, the Director of the CDC, and the Director of the National Center for Infectious Diseases with respect to hospital infection control practices and U.S. hospital surveillance, prevention, and control strategies for nosocomial infections. The CDC guideline revision was designed to include the following objectives:

(1) to be epidemiologically sound; (2) to recognize the importance of all body fluids, secretions, and excretions in the transmission of nosocomial pathogens; (3) to contain adequate precautions for infections transmitted by the airborne, droplet, and contact routes of transmission; (4) to be as simple and user friendly as possible; and (5) to use new terms to avoid confusion with existing infection control and isolation systems.

(Garner, 1996)

The new guidelines were designed to supersede universal precautions and body substance isolation guidelines and in essence combined parts of both these previous guidelines. This synthesis of guidelines allows patients who were previously covered under disease-specific guidelines to now fall under standard precautions, a single set of recommendations. For patients who require additional precautions (defined as transmission-based precautions, for use when additional transmission risk exists [e.g., from airborne or droplet contamination]), additional guidelines have been developed to go above and beyond those of standard precautions (Garner, 1996) (see Table 2-1).

Transmission of HIV to Children

The majority of HIV infections in children occur as the result of mother-to-child transmission. Without interventions, approximately 25–40% of infants born to infected women will acquire HIV about 5% intrapartum, 15% during labour and delivery, and the remainder after birth, primarily through breast-feeding. These risks can be reduced substantially (to <1% in optimal situations) through administration of antiretroviral drugs to the mother, infant or both.56,78 In 2010, an estimated 64% (57–71%) of pregnant women living with HIV in eastern and southern Africa received an effective antiretroviral regimen to prevent mother-to-child HIV transmission and the percentage of infants born to women living with HIV who received antiretroviral prophylaxis increased from 14% in 2005 to 55% in 2010.1

The risk of mother-to-child transmission is increased at all stages of pregnancy if a woman has acquired HIV recently,79 and transmission during delivery is augmented by certain infections (e.g. HSV-2)80 and certain obstetric practices (e.g. artificial rupture of membranes, operative vaginal delivery with forceps or a vacuum extractor, and episiotomy).81 Transmission during breast-feeding appears to occur at a rate of approximately 2% during the first month and 1% per month thereafter – rates of transmission are highest when the infant receives mixed feeding (other infant food in addition to breast milk) in the first 6 months of life rather than being exclusively breast-fed.56 Acquisition of HIV in utero, compared with acquisition during delivery or from breast-feeding, predicts rapid disease progression in the absence of treatment. Less common modes of HIV transmission to children include pre-chewing or food-mastication82 and through breast milk from an HIV-infected wet nurse. Sexual abuse of children, which is common in certain settings and often under-reported,83,84 can be an important contributor to HIV transmission and should be considered when HIV is documented in a child, particularly if the mother does not have HIV.

Molecular Epidemiology

There are two main types of HIV (a lentivirus): HIV-1 and HIV-2. HIV-1 comprises three phylogenetically distinct groups, termed group M (main), group O (outlier), and group N (non-M, non-O) [16]. A fourth group (group P) has been proposed based on a single infection with a genetically unique HIV strain [17]. Each group has likely evolved from independent cross-species transmissions of chimpanzee simian immunodeficiency virus (SIVcpz) to humans [18–20]. HIV-1 group M has spread to every region of the world and is the virus responsible for the current global pandemic [21]. Group O infections are uncommon and limited to people living in, or epidemiologically linked to, Central Africa (especially Cameroon) [22]. Group N infections have been described rarely and only in Cameroon [23].

HIV-2 is a primate lentivirus related to HIV-1 that is less pathogenic and transmissible (see HIV-2 section) [24, 25]. HIV-2 evolved from the cross-species transmission of sooty mangabey SIV (SIVsm) to humans [19, 26]. Although HIV-2 infections have been reported throughout the world, they are most prevalent in Guinea-Bissau [27, 28] and in surrounding West African countries, as well as other nations with economic or cultural links to the region (e.g. Portugal, India, Angola, Mozambique, Cote d’Ivoire, Senegal, France) [24]. Recent data suggest the prevalence of HIV-2 in Guinea-Bissau has declined to less than 5% [27, 28]. Dual infection with HIV-1 and HIV-2 has been described but the viruses do not appear to recombine with each other [29].

High rates of viral replication coupled with continuous mutation and recombination events have resulted in the rapid genetic diversification of HIV-1 group M viruses into 9 distinct subtypes (or clades) and over 49 circulating recombinant forms (CRFs) [30]. The number of described CRFs is cataloged at the Los Alamos HIV sequence database [30]. There are also a variety of unique recombinant forms (URFs) that have only been identified in a single person or in an epidemiologically linked pair of persons. The effects of variation between HIV-1 subtypes on pathogenesis, transmission, drug resistance, and immune control are not well understood.

The initial genetic diversification of HIV-1 group M viruses likely occurred in Central Africa, where the greatest diversity and earliest cases of HIV-1 have been identified [31]. Subsequently, HIV-1 subtypes have spread with a geographically heterogeneous distribution (Fig. 27.3) [21]. Subtype C, the dominant subtype in Southern Africa, Ethiopia, and India, causes nearly half (48%) of HIV infections worldwide [21]. The predominance of subtype C, especially in countries with high-prevalence epidemics driven by heterosexual sexual contact, has led to speculation that subtype C might have an increased fitness for transmission [32, 33]. Subtype A accounts for 12% of infections worldwide and has a broad geographic distribution. CRF01_AE and CRF02_AG are two additional recombinant viruses involving subtype A that are epidemiologically important in Southeast Asia and West Africa respectively [21]. The emergence of these CRFs has raised concern that recombination may contribute to the selection of viruses with increased fitness, immune escape or transmissibility [34]. Subtype B predominates in the Americas, western and central Europe, and Australia. Finally, URFs are important components of the epidemics in East Africa, Central Africa, West Africa, and South America, and it is expected that some of these URFs will emerge as important CRFs in the future [21, 35–37].

Hemodialysis

Strict use of universal precautions is the best form of prevention of HIV transmission in dialysis units. HIV-infected patients do not have to be isolated from other patients or dialyzed on separate machines. Reprocessing of dialyzers from HIV-positive patients should not place staff members at increased risk for infection if necessary sterile precautions are undertaken. The risk of HIV seroconversion after a needle stick injury from an infected patient is estimated to be about 0.3%. Art may reduce the risk of transmission following a needle-stick injury and should be considered under certain circumstances, as recommended by the Centers for Disease Control and Prevention. Native arteriovenous fistulas are the preferred types of access because of excellent patency once established and lower complication rates compared with those associated with other access options.