5.1 Standard & Transmission-Based Precautions (Infection Control)

5.1 Standard & Transmission-Based Precautions (Infection Control)

Infection Prevention and Control (IPC) is a fundamental pillar of nursing practice in Singapore. Under the Singapore Nursing Board (SNB) Code for Nurses and Midwives (2023 revision) and the Nurses and Midwives Act (Cap. 209), registered nurses hold a direct professional and ethical legal duty to maintain a safe, clean clinical environment and prevent Healthcare-Associated Infections (HAIs). The Singapore Ministry of Health (MOH), in collaboration with the National Centre for Infectious Diseases (NCID), establishes national infection control directives that govern all acute restructured hospitals, community hospitals, long-term care facilities, and primary care polyclinics.

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Standard Precautions: The Foundation of Patient Care

Standard Precautions represent the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status, in any setting where healthcare is delivered. They are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents.

Core Elements of Standard Precautions

1. Hand Hygiene Compliance — Recognized by MOH as the single most effective intervention to interrupt pathogen transmission.
2. Personal Protective Equipment (PPE) — Selected based on risk assessment of potential exposure to blood or body fluids.
3. Respiratory Hygiene / Cough Etiquette — Source control strategies for patients, visitors, and healthcare personnel.
4. Safe Injection & Sharps Safety — Strict non-recapping policy and immediate disposal into rigid yellow sharps containers.
5. Environmental Cleaning & Waste Management — Systemic cleaning of clinical surfaces and correct bio-hazard waste disposal.
6. Safe Handling of Linen & Patient Equipment — Preventing contamination of clothing and clean environment surfaces.

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Hand Hygiene Standards: WHO 5 Moments in Singapore Practice

Singapore healthcare institutions enforce the WHO 5 Moments for Hand Hygiene framework. Nurses must perform hand hygiene at each critical clinical juncture:

• Moment 1: Before touching a patient — e.g., before taking blood pressure, radial pulse, or physical examination.
• Moment 2: Before a clean / aseptic procedure — e.g., before peripheral IV insertion, eye drop administration, or wound dressing.
• Moment 3: After body fluid exposure risk — e.g., after blood sampling, emptying urinary drainage bags, or suctioning.
• Moment 4: After touching a patient — e.g., after assisting with positioning, shaking hands, or personal hygiene care.
• Moment 5: After touching patient surroundings — e.g., after touching bed rails, IV pump buttons, or overbed tables.

Alcohol-Based Hand Rub (ABHR) vs. Soap & Water

• Alcohol-Based Hand Rub (70% Ethyl/Isopropyl Alcohol): Preferred method for routine clinical hand hygiene when hands are not visibly soiled. Requires 20 to 30 seconds of vigorous mechanical friction covering all hand surfaces until completely dry.
• Soap and Water Handwashing: Mandatory when hands are visibly soiled with blood or body fluids, after using the restroom, and after caring for patients with spore-forming pathogens such as Clostridioides difficile or non-enveloped viruses (e.g., Norovirus). Requires 40 to 60 seconds of thorough scrubbing under running water, followed by single-use paper towel drying.

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Transmission-Based Precautions

When Standard Precautions alone cannot prevent pathogen cross-transmission, Transmission-Based Precautions are empirically or definitively initiated. They are categorized into Contact, Droplet, and Airborne Precautions.

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Respiratory Protection & Aerosol-Generating Procedures (AGPs)

In Singapore clinical practice, respiratory protection against airborne pathogens requires mandatory annual qualitative or quantitative N95 fit testing for all nurses. Prior to entering an Airborne Infection Isolation Room (AIIR), nurses must execute a user seal check (positive and negative pressure check) every single time an N95 respirator is donned.

High-Risk Aerosol-Generating Procedures (AGPs)

AGPs generate high concentrations of infectious respiratory aerosols. Key AGPs in nursing practice include:

• Endotracheal intubation and extubation
• Open airway suctioning (without closed-inline suction systems)
• Manual ventilation prior to intubation
• Bronchoscopy and sputum induction
• Administration of nebulized medications or high-flow nasal cannula (HFNC >30 L/min)

Enhanced AGP Protection Standard: Performing an AGP on any patient with suspected or confirmed transmissible respiratory illness requires an N95 respirator or Powered Air-Purifying Respirator (PAPR), full face shield, fluid-resistant long-sleeved gown, and gloves in an AIIR facility.

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Clinical Scenario & Nursing Workflow

A 48-year-old male presents to an emergency department in Singapore with a 3-week history of night sweats, weight loss, hemoptysis, and chronic productive cough. Chest X-ray reveals right upper lobe cavitation, suspecting active open Pulmonary Tuberculosis.

1. Immediate Isolation: The nurse immediately places a surgical mask on the patient and transfers him to an Airborne Infection Isolation Room (AIIR) with negative pressure monitoring.
2. PPE Donning: Before entering the room, the nurse performs hand hygiene, dons a fit-tested N95 respirator, conducts a user seal check, and puts on clean gloves.
3. Inter-Professional Handover: When arranging diagnostic sputum acid-fast bacilli (AFB) testing or radiology transport, the nurse uses ISBAR (Identify, Situation, Background, Assessment, Recommendation) structured communication, explicitly informing the receiving unit of the patient's Airborne Precaution status.
4. Environmental Governance: Negative pressure (≥2.5 Pa) and ventilation (≥12 ACH) are verified on the room monitor and documented in the clinical log.