Standard in, universal out in final CDC isolation rule

New rules cover wide range of exposures

Universal precautions -- the term that became synonymous with infection control measures to protect health care workers from HIV and other bloodborne pathogens in the 1980s -- has officially been replaced with "standard precautions" by the Centers for Disease Control and Prevention in Atlanta.1

Though there was much discussion about the name change, the CDC Hospital Infection Control Practices Advisory Committee (HICPAC) has adopted the new nomenclature in the final version of its patient isolation guidelines. The new standard precautions essentially combine the key elements of the body substance isolation (BSI) system used in many hospitals with the old universal precautions as recommended by the CDC. Standard precautions are designed to protect both patients and workers from all body fluids and substances through barrier precautions, hand washing, and other infection control measures. (See precautions, p. 54.)

Standard precautions comprise the basic infection control component in the CDC's new two-tier patient isolation system. The second tier consists of additional infection control measures for airborne (i.e., measles), droplet (i.e., pertussis), and contact isolation (i.e., multidrug-resistant bacteria.) The additional measures condense the old CDC category- and disease-specific measures, which some have found cumbersome.

"It looks very straightforward and much more easy to understand than the combination of universal precautions and disease-specific precautions that we were previously doing at this hospital," says George Risi, MD, director of infection control at St. Patrick Hospital in Missoula, MT.

Risi plans to implement the guidelines just as proposed, dropping the use of the universal precautions and re-educating staff about the new standard approach.

"We are committing the resources to doing this now because I have not been satisfied with the understanding on the floors of the current system," he says. "Since we have to improve what is currently being done, switching over to a more user-friendly system is going to save us a lot of hassle in the long run."

As previously reported, the CDC considered revising the draft version after many infection control professionals questioned the wisdom of dropping the entrenched "universal precautions" term. (See Hospital Infection Control, May 1995, pp. 60-62.) In that regard, some ICPs are opting not to change names or approaches, particularly those in hospitals already using systems much like that recommended by the CDC.

"I don't think they should have changed names, but I tell [health care workers], 'Depending on which hospital you are in, it may be body substance precautions, universal precautions, standard precautions -- they all mean pretty much the same thing,'" says Angela Goetz, RN, infection control practitioner at the VA Medical Center in Pittsburgh.

The problem in HICPAC's view was that so many hospitals were using elements of different systems under different names that a new beginning under the "standard precautions" title seemed necessary to avoid further confusion, explains Walter J. Hierholzer Jr., MD, HICPAC chairman and epidemiologist at Yale-New Haven (CT) Hospital. The problem was only compounded by the use of the term universal precautions in the Occupational Safety and Health Administration's bloodborne pathogen standard, which is designed for the protection of workers from blood exposures.

"What we have tried to do now is make quite specific the [recommendations] under this new term and say precisely what we mean by it," he says. "We think that's the best way to do it with the least confusion."

At any rate, the new patient isolation measures are merely guidelines that can be modified at the local level as ICPs see fit, he notes.

"We are quite satisfied that this is the CDC and HICPAC's recommendation," he says. "Nobody should have any uncertainty what this means. If they wish to call it something else, they can do that. We tried to clarify that certain institutions may find it to their best benefit to make modifications.

There will undoubtedly be a transition period before many of the nation's hospitals adopt the new isolation system, Hierholzer says, noting he doesn't expect to make the changeover in his own hospital until next year because of more pressing projects. Regardless, it will be primarily a nomenclature change since the amended BSI system already in place at the hospital is very similar to the new standard precautions, he says.

"Now if some hospitals are using [the old] universal precautions that do not protect against some of these body fluids, I would recommend that they review the transition earlier," he says.

The new approach should be no more expensive in terms of infection control labor, signs, barrier precautions, and the like, he adds.

There have been concerns expressed that the number of infections warranting contact precautions is too extensive and may ultimately translate to heightened expenses for gloves, gowns, and other barrier precautions equipment. However, Hierholzer notes that many of the conditions requiring contact isolation are infections in patients who are diapered or have incontinence related to their disease.

"When you put in those caveats, it doesn't happen very frequently," he says.

There have also been questions raised about the use of the "1B" ranking for all the standard precautions recommendations, a definition that means they are highly recommended by experts in the field based on strong rationale and suggestive evidence -- but definitive scientific studies have not been done.

"We think these are all terribly important," Hierholzer says. "They vary in the strength of literature support, but that is largely because in most cases, they cannot be studied either for ethical or statistical reasons.

Reference

1. Centers for Disease Control and Prevention. Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17:53-80. *