Remembering universal precautions in the ED

Clinical pearls for ED managers

A recent study found that compliance with universal precautions in the ED was surprisingly poor.1 "We hadn’t expected to find such high levels of non-compliance, so it was a little disconcerting," says Bradley Evanoff, MD, MPH, assistant professor of medicine at Washington University School of Medicine and principal investigator of the study. "It’s very likely that non-compliance is common in EDs."

ED personnel caring for trauma patients were videotaped during 88 cases, and the use of barrier precautions was recorded. Breaks in the use of precautions were recorded in one-third of 304 invasive procedures. The most common break was failure to wear a mask (32.0% of procedures), followed by inadequate eyewear (22.2%), no gown (5.6%), and no gloves (3.0%).

The ED was chosen for the study because it’s one of the highest risk areas in the hospital for infection with bloodborne pathogens, Evanoff says. "The patient population in EDs have an unusually high rate of seroprevalance of hepatitis B and C and HIV. Events are unplanned and sudden, and people are likely to be bleeding or expelling blood or body fluids," he explains.

The study showed that health care providers wore gloves consistently. "Some groups also wore gowns very consistently, although physicians tended not to," says Evanoff. "Inadequate eyewear and failure to wear a mask were the most common breaks in precautions."

Widespread failure to wear protective eyewear was most troubling, says Evanoff, who offers an explanation. "Eyewear is still rather uncomfortable. Shields have a way of fogging up and goggles aren’t completely comfortable," he notes. "And for people who wear prescription glasses, goggles are not necessarily a great solution."

Here are some potential reasons for noncompliance with universal precautions, according to Evanoff:

    • Providers may assume patients don’t have a bloodborne pathogen;

    • Health care providers may feel they’re not going to come into contact with blood and body fluids;

    • A student or attending physician may assume they will be observing, then be called upon to be involved in the case;

    • A perception that need for urgent action is so great that the health care provider can’t take time to fully don barrier protection;

    • Health care providers may believe "it won’t happen to me;" and

    • Eyewear protection is unconfortable.

Measure your own compliance in your ED and feed it back to staff, Evanoff recommends. "You could do a simplified form of what we did in our study," he suggests. "During trauma cases, periodically monitor who is complying with personal protective equipment. We did it with a videotape, but it could also be done with live observers."

Use a simple scoring sheet that looks at one or two behaviors, and count up compliance in a few dozen cases. "You may see a dramatic improvement in compliance after you share the results with your staff," he notes.

In addition to continually educating staff about risks of infection in the ED, make it as easy as possible to comply with universal precautions. Anything that can be done to lower staff resistance to complying is good, says Evanoff. "Make sure masks, gowns, eyewear, and gloves in a range of sizes are present at the door to the room, so staff literally have to walk past it to get into the room."


1. Evanoff B, et al. Compliance with universal precautions among emergency department personnel caring for trauma patients. Ann Emerg Med 1999;33:160-165.