Universal vs. standard precautions: Do you know which you use?
Protect staff, patients from airborne and contact contagions
All home health agencies have policies to prevent the spread of infection but with recent focus on the threat of a pandemic, home health managers need to look more closely at how well prepared their agency will be for a situation that requires a higher level of protection than universal precautions, say experts interviewed by Hospital Home Health.
"Universal precautions are mandated for home health agencies but the type of pathogens that exist today require standard precautions that protect staff and patients against more threats of infection than universal precautions," says Barbara B. Citarella, RN, BSN, MS, CHCE, president and CEO of RBC Limited, a home care consulting firm located in Staatsburg, NY. It is also important to note that the Centers for Disease Control and Prevention (CDC) guidelines for pandemic flu require standard precautions as opposed to universal precautions, she adds. (For tips on recognizing seasonal flu vs. pandemic flu, see chart on below.)
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The first step in evaluating your infection control program's readiness for pandemic flu is to understand the difference between universal and standard precautions, says Citarella.
"Universal precautions were developed in 1991 to address the risk of bloodborne pathogens because at that time the majority of high-risk infectious disease was transmitted through blood," explains Citarella. "Now, with the threat of avian flu, West Nile virus, biological weapons, and pandemic flu, we face the risk of contact and airborne transmission as well as bloodborne transmission," she says.
Standard precautions were developed by the CDC to synthesize the major features of universal precautions, which were designed to reduce the risk of transmission of bloodborne pathogens, and body substance isolation, which was designed to reduce the risk of transmission of pathogens from moist body substances.
"It is important to recognize that even if a pathogen is usually transmitted by contact, the pathogen can be aerosolized by saliva," points out Citarella. For this reason, gloves alone won't protect the employee, she adds.
"We use standard precautions, so all of our clinicians have gloves, masks, goggles, aprons, and gowns in their bags," says Frances Traver, RN, BSN, quality improvement manager for St. Francis Home Health Care in Poughkeepsie, NY. "Aprons, gowns, and goggles are important in wound care if there is a risk of splash back when irrigating the wound," she says.
Respirator masks essential
Gloves, masks, goggles, and gowns are required by standard precautions in specific situations, but the most important piece of infection control equipment that many agencies don't have or don't have in adequate quantities is an N95 respirator mask, says Citarella. "I recommend that every agency have enough respirator masks for every employee for a three- to four-week period," she says. While the masks can be worn repeatedly, if a mask is contaminated, it must be replaced, so one mask per employee won't be enough, she adds.
Linda Rashba, RN, BSN, MS, administrator of St. Francis Home Health, says that although every employee has one respirator, she plans to purchase extra respirator masks. "Every new employee of our hospital system is fit-tested when they are hired and all home care nurses carry their respirator masks with them," she says. Even though the agency nurses have the mask, Rashba admits that in the case of a pandemic, nurses should have backup masks that can be used immediately if the first mask is contaminated.
"Fit-testing is required because there is no one size fits all with N95 respirator masks," says Citarella. "An employee who wears glasses will be more comfortable with a flexible mask as opposed to a pre-formed mask," she says. "Of course, in an emergency any respirator mask is better than none," she says.
Respirator masks cost about $1.25 per employee per mask, says Citarella. "I recommend that agencies start building their inventory slowly," she says. Even though some state public health departments have plans to distribute respirator masks at a central location in a pandemic situation, no agency manager should rely upon an outside organization to protect agency employees, she emphasizes. "OSHA [the U.S. Occupational Safety and Health Administration] requires home health agencies to provide protective equipment to employees," she says. "If an employee becomes ill because you are waiting for the state to provide the equipment, you are responsible," she points out.
Although respirator masks have no expiration date, be sure that they are checked regularly for signs of deterioration, suggests Citarella. "Heat, humidity, and light can affect the rubber parts of the masks so you do want to inspect masks that you are storing," she says.
In addition to making sure that employees have the proper protective equipment, be sure to continue to educate employees about the importance of handwashing, says Traver. Because her agency tracks the incidence of flu and multiple drug resistant organisms in her agency's population and reports the information to staff members, all employees are very aware and knowledgeable about practices that minimize risk of infection, she says. "We also educate patients and their families about the importance of handwashing and give them a handout that they can use to educate other family members," she adds.
"Our office staff is also very aware of the importance of keeping their workspace clean," points out Traver. She says, "I don't know if our nursing staff's focus on infection prevention caused this increased awareness but I've noticed that office staff employees regularly wipe down their workspace, desk top, and computer keyboards."
Don't forget to thoroughly clean telemedicine equipment as well, suggests Rashba. "We have a protocol for cleaning telemedicine equipment when it is returned to us so that we can be sure we are not transporting pathogens to a new patient's home."
As agency managers evaluate their infection control plan, Citarella suggests that they look at moving toward implementation of standard precautions for all patients at all times. She explains, "We are seeing more guidelines require standard precautions as opposed to universal precautions so I believe that standard precautions will become the regulatory requirement for home health agencies in the future."
Additional Resources
- www.pandemicflu.gov
Select "health care planning" on the top navigational bar. Scroll down to "checklists" and select "home health services checklist" to find policies, guidelines, and resources.
- http://www.cdc.gov/ncidod/dhqp/index.html
This is the web site for the Centers for Disease Control and Prevention's Division of Healthcare Quality Promotion. Guidelines related to handwashing, multiple drug-resistant organisms, catheter site infections, and other infection control issues are located on this site.
- The Home Care Handbook of Infection Control, a home care-specific quick reference was developed by the Missouri Alliance for Home Care (MAHC) and the Association for Professionals in Infection Control and Epidemiology (APIC). To order a copy, go to www.homecaremissouri.org and select "MAHC products" on the left navigational bar. Scroll down to Home Care Infection Control Handbook to print a copy of the order form. The cost of the book for members of MAHC and APIC is $29 and the cost to non-members is $38.
Sources
For more information about infection control and preparation for a pandemic, contact:
- Barbara B. Citarella, RN, BSN, MS, CHCE, President and CEO, RBC Limited, 48 West Pine Road, Staatsburg, NY 12580. Phone: (845) 889-8128. Fax: (845) 889-4147. E-mail: BarbaraCitarella@rbclimited.com.
- Linda Rashba, RN, BSN, MS, Administrator, St. Francis Home Health, 115 Delafield Avenue, Poughkeepsie, NY 12601. Phone: (845) 483-5550. E-mail: lrashba@sfhhc.org.