4.3 Standard Precautions, Bloodborne Pathogens & PPE Donning/Doffing

Standard Precautions: The Universal Infection Prevention Standard

Standard Precautions represent the primary tier of infection prevention guidelines established by the Centers for Disease Control and Prevention (CDC). The core philosophy of Standard Precautions is simple yet uncompromising: Every healthcare worker must treat all human blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes as potentially infectious, regardless of the resident's diagnosed status or perceived health.

Standard Precautions apply to ALL residents, in ALL healthcare settings, at ALL times—from independent living and long-term care to acute hospitals and home health.

+-------------------------------------------------------------------------+
|                    SCOPE OF STANDARD PRECAUTIONS                        |
|                                                                         |
|   [ APPLIES TO ]  --->  • ALL human blood and blood products            |
|                         • ALL body fluids, secretions & excretions      |
|                           (Urine, feces, sputum, saliva, emesis, pus)   |
|                         • Non-intact skin (wounds, cuts, skin tears)    |
|                         • Mucous membranes (mouth, nose, eyes, genitals)|
|                                                                         |
|   [ SOLE EXCEPTION ] -> SWEAT (unless visibly contaminated with blood)  |
+-------------------------------------------------------------------------+

Clinical Rationale for Universal Application

A common and dangerous misconception is that healthcare workers only need to take precautions when a resident is known to be "sick" or carries an infectious diagnosis on their chart. In reality:

• Many individuals infected with chronic bloodborne viruses (such as Hepatitis B, Hepatitis C, or HIV) or colonized with multidrug-resistant bacteria (such as MRSA or VRE) are completely asymptomatic and unaware of their carrier status.
• Diagnostic laboratory results are not always immediately available upon resident admission.
• Applying precautions universally eliminates discrimination, protects staff from unknown exposures, and prevents silent cross-transmission between residents.

OSHA Bloodborne Pathogens Standard & Sharps Safety

The Occupational Safety and Health Administration (OSHA) enforces federal regulation 29 CFR 1910.1030, known as the Bloodborne Pathogens Standard. This legal standard mandates that healthcare employers protect workers from occupational exposure to pathogenic microorganisms transmitted through human blood and other potentially infectious materials (OPIM).

Primary Bloodborne Pathogens

Sharps Injury / Biohazard Exposure Protocol:

Step 1: Immediate First Aid
        -> Wash puncture wound thoroughly with soap and running water.
        -> Flush eyes/mucous membranes with sterile saline or water for 15 minutes.
Step 2: Immediate Reporting
        -> Report incident immediately to supervising charge nurse and DON.
Step 3: Medical Evaluation & Testing
        -> Source patient testing (HIV, HBV, HCV) and employee baseline blood draw.
Step 4: Post-Exposure Prophylaxis (PEP)
        -> Initiate PEP within 2 hours (under medical guidance) if indicated.
Step 5: Factual OSHA Documentation
        -> Complete formal incident log (device brand, location, mechanism of injury).

Sharps Safety & Biohazard Waste Rules

• Never Recap Needles by Hand: The majority of accidental needlesticks occur when workers attempt to slide a plastic cap back onto a used needle. If recapping is unavoidable in rare medical emergencies, workers must use the one-handed scoop technique (sliding the needle into the cap resting on a flat surface without touching the cap).
• Never Bend, Shear, or Break Needles: Manipulating sharp devices increases puncture risk and aerosolizes blood droplets.
• Point-of-Use Disposal: Used disposable razors, lancets, safety needles, and glucose test strips must be placed immediately into rigid, puncture-resistant, leak-proof, red Biohazard Sharps Containers located directly in the resident care area.
• The Fill Line Rule: Sharps containers must be closed, locked, and replaced when they reach the manufacturer's fill line (2/3 to 3/4 full). Never force, stuff, or shake sharps into an overfilled container.

Personal Protective Equipment (PPE): Selection and Clinical Utility

Personal Protective Equipment (PPE) includes specialized clothing, barriers, and equipment worn by healthcare personnel to prevent skin, mucous membrane, and clothing exposure to infectious materials.

Selecting appropriate PPE depends on the nature of the clinical procedure and the anticipated degree of contact with blood or body fluids.

+-------------------------------------------------------------------------+
|                        PPE CLINICAL SELECTION MATRIX                                    |
+------------------------------------+-----------------------+----------------------------+
| Clinical Scenario / CNA Task       | Anticipated Exposure  | Required PPE Selection     |
+------------------------------------+-----------------------+----------------------------+
| Measuring oral vital signs on      | Intact skin contact   | **No PPE Required**        |
| alert resident with intact skin    | only; no fluids       | (Clean hands before/after) |
+------------------------------------+-----------------------+----------------------------+
| Assisting with morning toothbrush- | Saliva, blood from    | **Clean Gloves**           |
| ing or denture care                | gums, oral mucosa     |                            |
+------------------------------------+-----------------------+----------------------------+
| Providing perineal care for an     | Urine, feces, genital | **Clean Gloves**           |
| incontinent bedbound resident      | secretions, skin tears| (+ Gown if bed is soaked)  |
+------------------------------------+-----------------------+----------------------------+
| Emptying a urinary catheter bag or | Splashes/sprays of    | **Gloves + Eye Protection**|
| rinsing a heavily soiled bedpan    | contaminated urine    | (+ Gown if splash likely)  |
+------------------------------------+-----------------------+----------------------------+
| Assisting nurse with complex wound | Heavy pus exudate,    | **Gloves + Gown + Mask &** |
| irrigation / extensive debridement | high splash risk      | **Goggles / Face Shield**  |
+------------------------------------+-----------------------+----------------------------+

Component Functions and Rules

• Gloves: Protect hands from direct contact with blood, body fluids, mucous membranes, non-intact skin, and contaminated surfaces. Gloves do not replace hand hygiene. Always wash hands before putting gloves on and immediately after removing them. Change gloves during resident care if moving from a contaminated ("dirty") body site to a clean body site (e.g., after perineal care before providing oral care).
• Gowns: Fluid-resistant, long-sleeved gowns protect the caregiver's arms and clothing from soaking or splashing. Gowns must cover the torso from neck to knees and arms to wrists, fastening securely at the neck and waist.
• Masks: Surgical masks cover the mouth and nose, protecting mucous membranes from large respiratory droplets and fluid splashes. The flexible nose wire must be molded over the nasal bridge.
• Goggles and Face Shields: Protect eye conjunctiva from splashes, sprays, and respiratory droplets. Personal eyeglasses do NOT qualify as eye protection because they lack top and side shields.

CDC Sequences for Donning and Doffing PPE

The sequence for putting on (donning) and taking off (doffing) PPE is strictly standardized by the CDC. Following this precise sequence prevents healthcare workers from self-contaminating their skin, hair, clothes, and mucous membranes during equipment removal.

+-------------------------------------------------------------------------+
|                      CDC PPE DONNING & DOFFING                          |
|                                                                         |
|    [ DONNING (Putting On) ]        --->  [ DOFFING (Taking Off) ]       |
|    1. GOWN                               1. GLOVES (Dirtiest item)      |
|    2. MASK OR RESPIRATOR                 2. GOGGLES OR FACE SHIELD      |
|    3. GOGGLES OR FACE SHIELD             3. GOWN                        |
|    4. GLOVES (Over gown cuffs)           4. MASK OR RESPIRATOR          |
|                                          5. IMMEDIATE HAND HYGIENE      |
+-------------------------------------------------------------------------+

Step-by-Step Donning Protocol (Outside Resident Room)

1. Step 1: GOWN
   • Unfold the gown and slide arms through the sleeves. Ensure the gown covers the torso from neck to knees and wraps completely around the back. Securely tie the fasteners at the back of the neck, then tie the fasteners at the waist.
2. Step 2: MASK OR RESPIRATOR
   • Place the mask over your nose and mouth. Secure ties behind the head or slip elastic loops over both ears. Pinch the flexible metallic band firmly over the bridge of your nose to create a secure seal. Pull the bottom edge of the mask snugly down under your chin.
3. Step 3: GOGGLES OR FACE SHIELD
   • Place goggles or face shield over eyes and face. Adjust the elastic headband so it rests securely around the crown of your head without slipping.
4. Step 4: GLOVES
   • Put on clean gloves. Pull the cuffs of the gloves over the wrist cuffs of the isolation gown. This overlapping barrier ensures zero exposed skin at the wrists during clinical movements.

Step-by-Step Doffing Protocol (At Doorway or Inside Anteroom)

1. Step 1: GLOVES (Glove-in-Glove Technique)
   • The outside of gloves is heavily contaminated! Grasp the outside edge of one glove near the wrist with the opposite gloved hand. Peel the glove down and away from the hand, turning it inside out. Hold the removed, balled-up glove in the remaining gloved hand. Slide two un-gloved fingers cleanly under the wrist cuff of the remaining glove, peeling it off inside out over the first glove. Discard both inside-out gloves into the waste receptacle.
2. Step 2: GOGGLES OR FACE SHIELD
   • The front and sides of goggles are contaminated! Do NOT touch the front of the eye protection. Grasp the clean ear pieces or headband from the back, lift upward and away from your face, and place in a designated reprocessing bin or discard in the waste container.
3. Step 3: GOWN
   • The gown front and sleeves are heavily contaminated! Untie the neck ties, then untie the waist ties. Reaching up, peel the gown forward and down away from your neck and shoulders, touching only the clean inside of the gown. Turn the gown inside out as you pull your arms out of the sleeves. Roll the gown into a tight bundle with the contaminated outside rolled inward. Discard into the waste hamper.
4. Step 4: MASK OR RESPIRATOR
   • The front of the mask is heavily contaminated! Never touch the front of the mask. Grasp the bottom ties or elastics first, then grasp the top ties or elastics. Lift the mask away from your face without touching your skin or clothes, and drop it directly into the trash receptacle.
5. Step 5: PERFORM IMMEDIATE HAND HYGIENE
   • Clean hands immediately using soap and running water or alcohol-based hand rub before touching any other surface or exiting the area.