Standard precautions – what are they and how do they affect our return to an open society
Ask any health care worker what standard precautions are and you’ll get the same answer; treat every patient as if they are infected. Standard precautions are an axiom in health care regardless of whether you work in a nursing home, urgent care or regional trauma center. Regardless of your role in direct patient care, you simply do not deviate from the philosophical approach to patient care described in standard precaution guidelines.
Standard precautions in health care include:
- Hand hygiene.
- Use of personal protective equipment (e.g., gloves, masks, eyewear).
- Respiratory hygiene / cough etiquette.
- Sharps safety (engineering and work practice controls).
- Safe injection practices (i.e., aseptic technique for parenteral medications).
- Sterile instruments and devices.
- Clean and disinfected environmental surfaces.
The long and sordid history of standard precautions in health care
If Hungarian physician Ignaz Semmelweis (1818-1865) was alive today, he would smile at the challenges faced by society to reintegrate post COVID-19. Semmelweis was an obstetrician working in Vienna, Austria who famously noted that hand hygiene saved lives. Semmelweis’s findings came before the discovery of germ theory, and as such, Semmelweis was unable to scientifically explain why hand hygiene significantly reduced the rate of purepural fever. Mocked by his peers for promoting a program that would one day become standard precautions, Semmelweis sustained a mental break down and was institutionalized. Fourteen days into his ‘therapy’, Semmelweis was beaten by guards and died of his wounds at the age of 47 years old. (1) Revolution in science (as in society) is often hard fought and frequently met with peer resistance. (Just ask Copernicus).
Do standard precautions change the provider/patient relationship?
For a patient who has never been to the hospital for an emergency room visit or a hospitalization, they might be surprised by the number of steps that are taken to implement standard precautions. Sure, standard precautions do increase the amount of disposable material used in patient care, but as Semmelweis would have found, the impact on outcomes and costs are substantive. Standard precautions do change the provider/patient relationship in a number of positive ways:
- Protects the patient from cross transmission of infection from other patients
- Decreases cost of caring for infected patients
- Decreases duration of hospital stays
- Protects the health care provider from infection
- Why are standard precautions important to all of us as we re-open society following the initial COVID-19 infection?
Standard precautions are a mindset, a way of thinking. When admitted to a hospital for an infection, a foot wound would be placed in private room with orders for contact precautions. Contact precautions are an elevated level of standard precautions specific to wound and skin infections. Protective gowns and gloves are worn with patient contact and hand washing is performed both entering the room and upon exiting the patient’s room. Think of contact precautions as a layer that rests on top of standard precautions for treatment of bacterial infections.
In addition to standard precautions, what precautions are taken with COVID-19?
COVID-19 presents with very different set of precaution challenges when compared to contact precautions. Where contact precautions are intended for prevention of bacteria, COVID-19 precautions are also intended to limit contact, droplet and aerosol transmission of the virus. When exercised in a controlled environment with skilled, educated staff, the combination of contact, droplet and aerosol precautions are significantly effective. Each of these methods of contact precautions builds upon the work of Semmelweis and his concept of standard precautions.
How do we open society post COVID-19?
Re-opening society is going to be fraught with fits and starts. The Center for Disease Control (CDC) has been unable to act independently to disseminate timely and meaningful guidance to the general public. Instead, state and local government has been forced to define their own rules that are only partially accepted and followed by the public at large.
At the core of re-opening are standard precautions – the same standard precautions that health care workers have universally accepted. There may be some new terms - social distancing, frequent hand washing, avoidance of crowds such as public transportation and isolation when sick. Semmelweis would be proud. But Semmelweis would also expect the social backlash from those who simply don’t understand. In 1865 it was the right of an OB/gyn to not have to wash his hands between autopsy and delivery. Fortunately, 150 years later, our medical providers have let go of the social stigma of washing their hands.
Each of us creates our own reality through the lens of our personal experiences. How these different realities intersect is what we’re faced with today with the reintegration of our society. If standard precautions or simply the mindset of standard precautions had been at the forefront of reintegration, I would feel much more comfortable as we all come together. Unfortunately, I feel a bit like Semmelweis; proud as hell of the team of providers that is work with but afraid for the innocents who will be affected by what are being labeled civil liberties.
Got to go wash my hands.
- WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.
Additional references for re-opening