Infection Control
The Evolution of Standard Precautions
John A. Molinari, PhD
John A. Molinari, PhD, is a professor and chairman in
the Department of Biomedical Sciences at the University of Detroit Mercy
School of Dentistry Detroit, Mich.
Copyright 2003 Journal of the California Dental Association.
Permission
Reprinted with permission from the Compendium of Continuing Education
in Dentistry. Molinari JA, The evolution of standard precautions.
Compend Contin Educ Dent 24:190-2, 2003.
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Clinical applications of universal precautions are familiar to virtually every health care professional who provides dental, medical, or other patient care. This longstanding set of routine infection control precautions was developed in 1985 to prevent the transmission of hepatitis B virus, human immunodeficiency virus, hepatitis C virus, and other bloodborne pathogens during treatment procedures. In 1996, the CDC developed and published new guidelines for isolation precautions in hospitals. These were termed standard precautions. Standard precautions apply primarily to hospital settings; however the CDC is currently developing new infection control guidelines that apply specifically to dentistry.
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Clinical applications of universal precautions are familiar to virtually every health care professional who provides dental, medical, or other patient care. This longstanding set of routine infection control precautions was developed in 1985 to prevent the transmission of hepatitis B virus, human immunodeficiency virus, hepatitis C virus, and other bloodborne pathogens during treatment procedures. After the guidelines were published, dental professionals took special note of the statement that blood and other body fluids, including saliva, were considered potentially infectious for occupational pathogens.1
Although HBV had been clearly documented as being far more infectious than HIV in occupational health care settings, many people regarded the prevention of HIV transmission as the primary rationale for the introduction of universal precautions. This was evident in publications issued by the Centers for Disease Control and Prevention,2-4 as illustrated in the following excerpt:
"Universal precautions: Since medical history and examination cannot reliably identify all patients infected with HIV or other bloodborne pathogens, blood and other body-fluid precautions should be consistently used for all patients. This approach, previously recommended by CDC, and referred to as ‘universal blood and body-fluid precautions’ or ‘universal precautions,’ should be used in the care of all patients, especially in emergencies when the risk of blood exposure is increased and the infection status of the patient is usually unknown."3
The introduction and recommendation of universal precautions replaced the previous rules included in the 1983 publication, CDC Guidelines for Isolation Precautions in Hospitals.5 The primary purpose of universal precautions was to prevent infections transmitted via direct or indirect contact with infectious blood and other body fluids.
A key feature of the proposal was the empowering of hospital personnel to determine the patient’s category of infection risk. This was an improvement over earlier isolation-based infection control guidelines that were published in 1975.6 An extensive series of category-specific recommendations now required hospitals to decide whether to institute disease-specific isolation precautions or to develop unique isolation systems for their individual facilities. These isolation systems included:
* Blood and body fluids precautions;
* Strict isolation;
* Contact isolation;
* Respiratory isolation;
* Tuberculosis isolation;
* Enteric precautions; and
* Drainage/secretion precautions.
Because many health care workers were especially concerned with occupational blood exposure and HIV risks, the introduction of universal precautions began to overshadow isolation precautions. Although the adoption and routine use of universal precautions proved effective in minimizing the potential for transmission of HBV, HIV, and HCV the practices did not eliminate the need to implement category or disease-specific isolation precautions for nonbloodborne infections in medical facilities.
In 1987, the CDC introduced a body substance isolation system that focused on reducing the transmission of infectious material from any moist body substance.7,8 Body substance isolation systems were designed to address isolation procedures of all moist, potentially infectious body substances, regardless of their presumed infection status. The body substances covered by this system included blood, feces, urine, sputum, saliva, and wound exudates. The distinguishing feature of these systems was the recommendation that health care workers wear gloves when anticipating contact with blood, secretions, mucous membranes, nonintact skin, and moist body substances during treatment of all patients. The CDC also recommended immunization for health care professionals against selected infectious diseases (i.e., measles, mumps, rubella, varicella) transmitted by airborne or droplets modalities, as well as the wearing of appropriate barriers, such as gowns.
In Garner’s 1996 review and proposal for current infection and control precautions in hospitals, she summarized both the successes and controversial elements of the 1987 body substance isolation system.9 Central to the subsequent development of the combined system, which incorporated the best protective elements of universal precautions and the body substance isolation programs, was the recognition that: 1) health care workers were confused about universal precautions and body substance isolation; 2) body substance isolation did not cover all of the necessary precautions necessary to prevent transmission, including droplet transmission of certain bacterial agents in children; and direct or indirect contact cross-infection of important nosocomial pathogens (i.e., Clostridium difficile and vancomycin-resistant enterococci).9,10
In recognition of these concerns, in 1996 the CDC developed and published new guidelines for isolation precautions in hospitals. These were termed standard precautions. They incorporated the major features of universal precautions and BSI11 (Table 1). Standard precautions apply primarily to hospital settings; however the CDC is currently developing new infection control guidelines that apply specifically to dentistry. The CDC infection control guidelines published in 199811 are already similar in many areas to current dental recommendations for infection control.
References
1. CDC, Recommendations for preventing transmission of infection with human T-lymphotropic virus type III/lymphadenopathy-associated virus in the workplace. Morb Mortal Wkly Rpt 34:681-5;691-5, 1985.
2. CDC, Update: human immunodeficiency virus infections in health care workers exposed to blood of infected patients. Morb Mortal Wkly Rpt 36:285-9, 1987.
3. CDC, Recommendations for prevention of HIV transmission in health care settings. Morb Mortal Wkly Rpt 36:1S-18S, 1987.
4. CDC, Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings. Morb Mortal Wkly Rpt 37:377-82;387-8, 1988.
5. Garner J, Simmons BP, CDC Guideline for Isolation Precautions in Hospitals. Atlanta: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control, 1983.
6. CDC, Isolation Techniques for Use in Hospitals. 2nd ed. Washington, DC: US Government Printing Office; 1975. HHS publication 80-8314.
7. Lynch P, Jackson MM, et al, Rethinking the role of isolation practices in the prevention of nosocomial infections. Ann Intern Med 107:243-6, 1987.
8. Lynch P, Cummings M, et al. Implementing and evaluating a system of generic infection precautions: body substance isolation. Am J Infect Cont 18:1-12, 1990.
9. Garner JS, Guideline for isolation precautions in hospitals. Infect Cont Hosp Epid 17:54-80.
10. Borton D, Isolation precautions. Clearing up the confusion. Nursing 27:49-51, 1997.
11. Bolyard EA, Hospital Infection Control Practices Advisory Committee. Guideline for infection control in health care personnel, 1998. Am J Inf Cont 26:289-354, 1998.
To request a printed copy of this article, please contact/John A. Molinari, PhD, University of Detroit Mercy School of Dentistry, 8200 W. Outer Drive
Detroit, MI 48219-0900.
Table 1. Standard Precautions
Standard precautions combine major features of universal precautions and body substance isolation precautions into a single set of recommendations.
Standard precautions
* Are designed to reduce the risk of transmission of pathogens, from both recognized and unrecognized infection sources, to patients and health care professionals.
* Apply to blood, all body fluids, secretions and excretions (except perspiration), nonintact skin, and mucous membranes.
* Should be used in the care of all patients, regardless of infection status.
* Include precautions based on transmission routes: airborne, droplet, or contact.
* Describe specific syndromes highly suspicious for infection.
* Identify appropriate transmission-based precautions until diagnosis can be made.
