tive strategy among consumers and voters, who don't like being railroaded on any issue. The intensity of antismoking advocates plays into this perception. The way in which some correspondents have chosen to distort what I wrote only reinforces my point. Charlotte Gray Contributing editor
The application of universal precautions F a or several years the Centers for Disease Control, Atlanta, have recommended "universal precautions" to prevent the transmission of human immunodeficiency virus, hepatitis B virus (HBV) and other bloodborne pathogens in health care settings.' Infection with HBV is a relatively common risk and has been present for many years. In addition, the National Committee for Clinical Laboratory Standards has produced guidelines for the protection of workers from infectious disease transmitted by blood, body fluids and tissue as well as from instrument biohaz-
ards.2'3 The universal precautions, most of which are common sense and good practice, are to be followed for all patients. By emphasizing care and good general hygiene they do help to protect health care workers from occupational health hazards. Universal precautions are simple in theory, but because they tend to be rather general they can become much more complex in practice. The main emphasis has been on the reduction of incidents, in particular by the use of equipment often meant to protect the skin and mucous membranes. However, no risk from the exposure of intact skin has yet been demonstrated. There is no evidence either that OCTOBER 15,1992
any of the documented precautions reduces the risk arising from needlestick or other "sharps" injuries, although the use of two pairs of gloves and the development of puncture-resistant gloves would probably help to achieve this. A basic tenet of universal precautions is that every specimen should be treated with equal care, as though it were hazardous. There has been little criticism of the potential impracticality of this demand. The application of universal precautions is claimed to obviate the need for attaching a warning label to a specimen from a patient known to be infected. It is implied that such a warning would encourage careless handling of all other specimens, but no evidence is presented for this. Although a consistent level of expertise and attention should be maintained it is usually more efficient to allow professionals to apply greater attention to situations that are unique. Full-scale application of the precautions to every situation has little support from any scientific, sociologic or psychologic studies. What ethical justification is there for denying professionals known clinical information essential to the full exercise of their skill and judgement?4 Nevertheless, because the infective status of most fluid or tissue specimens will be unknown when they are first handled it is important to recognize that most of the demands of universal precautions are not excessive and must be applied. We must not be complacent, since there is still room for improvement in their application. Extrapolation from previous experience with infectious diseases suggests that this approach substantially reduces risk by breaking part of the chain of events necessary for infection
lowed because they would take valuable time. Since patients, whether known to be carrying a clinically significant infection or not, present equal risk at autopsy all autopsies should (according to the widely distributed precautions for pathologists) be performed by at least three people, the third being a circulating assistant. The nature of a frozen-section specimen, its required handling and the need for a rapid report do not allow the full application of universal precautions. Patients who have suffered major trauma must have their wounds and blood loss dealt with rapidly. Orthopedic surgery and neurosurgical procedures can lead to bone splinters and aerosol formation. Many surgeons and pathologists find that to wear impenetrable aprons and boots or to be subject to more extensive masking and gloving procedures is uncomfortable and may reduce visibility and manual
of situations in which universal precautions are not always fol-
placed by the dogmatic application of rules.
dexterity. There is no evidence that additional staff have been hired in any hospital because of the application of universal precautions or that there has been a decrease in productivity. The full application of universal precautions would require a third person in most autopsy suites, and again there is no evidence of this. Undoubtedly there has been a significant increase in expenses because of the use of gloves and the increased use of gowns in certain situations. In practice, the easily applied aspects of universal precautions must be followed because they make good sense; for surgeons and pathologists these include good technique. The precautions that are not perceived to be helpful in particular situations are being ignored. The ability to be flexible and to recognize that different medical circumstances can require to occur. .i Autopsies, some surgical pro- a more stringent application of cedures and trauma are examples safety precautions cannot be re-
CAN MED ASSOC J 1992; 147 (8)
1115
There are additional factors making it unlikely that every specimen and test receives the same attention, as required by universal precautions: the pressure to produce rapid test results for very sick patients (particularly in emergency situations), sensitivity to clinical needs, the demands from clinicians and relatives to get autopsy information quickly and the understandable desire that funeral arrangements not be delayed. All these situations require professional judgement. Precautions, if they are to be applied, should facilitate rather than hinder. There is a need for a detailed review of hospital activities to establish what aspects of universal precautions are not being followed and why. If any activities are shown to be impractical in the application of these precautions, consideration must be given as to what should be done. I thank Valerie Dalgetty for her help in the preparation of this letter and Dr. Ingrid Luchsinger for her challenging questions and for her criticisms. Matthew J. McQueen, MB, ChB, PhD, FCACB, FRCPC Chief Department of Laboratory Medicine Hamilton General Division Hamilton Civic Hospitals Hamilton, Ont.
References 1. Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MMWR 1988; 37: 377387 2. National Committee for Clinical Laboratory Standards: Protection of Laboratory Workers from Instrument Biohazards: Proposed Guideline (publ I 17-P), NCCLS, Villanova, Pa, 1991 3. Idem: Protection of Laboratory Workers from Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Tentative Guideline (publ M29-T2), NCCLS, Villanova, Pa, 1991 4. McQueen MJ: Conflicting rights of patients and health care workers exposed to blood-borne infection. Can Med Assoc J 1992; 147: 299-302 1116
CAN MED ASSOC J 1992; 147 (8)
Universal precautions not justified
Numerous policies and procedures are being subjected to an analysis of cost-effectivene-s. According to a 1990 study by Stock, I disagree with the conclusion Gafni and Bloch4 the economic of Dr. Marie Louie and asso- validity of universal precautions ciates in "Prevalence of is questionable, and there is minibloodborne infective agents mal documentation of their effecamong people admitted to a Can- tiveness. Therefore, the assumpadian hospital" (Can Med Assoc J tion made by Louie and associates 1992; 146: 1331-1334) that the perpetuates but does not substanuse of universal precautions is tiate the perception that universal justified by prevalence rates of precautions are justified. 2.1% for hepatitis B surface antigen and 0.6% and 0.5% for anti- John Hardie, BDS, FRCDC, FICDC bodies to the human immunodefi- Head of Dentistry ciency virus (HIV) and the hepati- Department British Columbia's Health Sciences Centre tis C virus (HCV) respectively. Vancouver, BC Such an inference would be possible if the use of universal precau- References tions were the only reason for infective agents not being trans- 1. National Surveillance of Occupational Exposure to the Human Immunodefimitted to health care workers. The ciencv Virus, Federal Centre for AIDS, investigation failed to show this. Ottawa, 1992 The surveillance study' of the 2. Kiyosawa K, Sodeyama T, Tanaka E et al: Hepatitis C in hospital employees Federal Centre for AIDS demonwith needlestick injuries. Ann Intern strated that health care workers Med 1991; 115: 367-369 were exposed to HIV-infected 3. Universal precautions for prevention of transmission of human immunodefiblood no matter what form of ciency virus, hepatitis B virus, and protection was worn but that such other bloodborne pathogens in healthexposure did not result in serocare settings. MMWR 1988; 37: 377conversion. This should not be 388 surprising, since HIV transmis- 4. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transsion does not occur through the mission to health care workers: an ecoroutes protected by barrier technomic analysis. Can Med Assoc J 1990; niques. These findings weaken 142: 937-946 rather than support the use of universal precautions to avoid the occupational spread of HIV. Inexperience with HCV explains the uncertainty regarding Program evaluation its transmission to health care in health care workers. However, gloves would not have protected the 1 10 workhis article by the Health ers mentioned by Louie and assServices Research Group ociates from exposure through (Can Med Assoc J 1992; needlestick injuries.2 146: 1301-1304) describes the Finally, the authors fail to field as it was about 25 years ago. indicate that the most effective Program evaluation continues method of avoiding occupational to be viewed by some of its practitransmission of the hepatitis B tioners as a method of systemativirus is vaccination. The Centers cally collecting and analysing data for Disease Control, Atlanta, do about a specific program in order not include this among their uni- to summarize or improve its overversal precautions3 but consider it all performance. Over the past few to be an important adjunct to decades, however, this insular persuch preventive techniques. spective on the purposes of evaluLE
15 OCTOBRE 1992
The application of universal precautions F a or several years the Centers for Disease Control, Atlanta, have recommended "universal precautions" to prevent the transmission of human immunodeficiency virus, hepatitis B virus (HBV) and other bloodborne pathogens in health care settings.' Infection with HBV is a relatively common risk and has been present for many years. In addition, the National Committee for Clinical Laboratory Standards has produced guidelines for the protection of workers from infectious disease transmitted by blood, body fluids and tissue as well as from instrument biohaz-
ards.2'3 The universal precautions, most of which are common sense and good practice, are to be followed for all patients. By emphasizing care and good general hygiene they do help to protect health care workers from occupational health hazards. Universal precautions are simple in theory, but because they tend to be rather general they can become much more complex in practice. The main emphasis has been on the reduction of incidents, in particular by the use of equipment often meant to protect the skin and mucous membranes. However, no risk from the exposure of intact skin has yet been demonstrated. There is no evidence either that OCTOBER 15,1992
any of the documented precautions reduces the risk arising from needlestick or other "sharps" injuries, although the use of two pairs of gloves and the development of puncture-resistant gloves would probably help to achieve this. A basic tenet of universal precautions is that every specimen should be treated with equal care, as though it were hazardous. There has been little criticism of the potential impracticality of this demand. The application of universal precautions is claimed to obviate the need for attaching a warning label to a specimen from a patient known to be infected. It is implied that such a warning would encourage careless handling of all other specimens, but no evidence is presented for this. Although a consistent level of expertise and attention should be maintained it is usually more efficient to allow professionals to apply greater attention to situations that are unique. Full-scale application of the precautions to every situation has little support from any scientific, sociologic or psychologic studies. What ethical justification is there for denying professionals known clinical information essential to the full exercise of their skill and judgement?4 Nevertheless, because the infective status of most fluid or tissue specimens will be unknown when they are first handled it is important to recognize that most of the demands of universal precautions are not excessive and must be applied. We must not be complacent, since there is still room for improvement in their application. Extrapolation from previous experience with infectious diseases suggests that this approach substantially reduces risk by breaking part of the chain of events necessary for infection
lowed because they would take valuable time. Since patients, whether known to be carrying a clinically significant infection or not, present equal risk at autopsy all autopsies should (according to the widely distributed precautions for pathologists) be performed by at least three people, the third being a circulating assistant. The nature of a frozen-section specimen, its required handling and the need for a rapid report do not allow the full application of universal precautions. Patients who have suffered major trauma must have their wounds and blood loss dealt with rapidly. Orthopedic surgery and neurosurgical procedures can lead to bone splinters and aerosol formation. Many surgeons and pathologists find that to wear impenetrable aprons and boots or to be subject to more extensive masking and gloving procedures is uncomfortable and may reduce visibility and manual
of situations in which universal precautions are not always fol-
placed by the dogmatic application of rules.
dexterity. There is no evidence that additional staff have been hired in any hospital because of the application of universal precautions or that there has been a decrease in productivity. The full application of universal precautions would require a third person in most autopsy suites, and again there is no evidence of this. Undoubtedly there has been a significant increase in expenses because of the use of gloves and the increased use of gowns in certain situations. In practice, the easily applied aspects of universal precautions must be followed because they make good sense; for surgeons and pathologists these include good technique. The precautions that are not perceived to be helpful in particular situations are being ignored. The ability to be flexible and to recognize that different medical circumstances can require to occur. .i Autopsies, some surgical pro- a more stringent application of cedures and trauma are examples safety precautions cannot be re-
CAN MED ASSOC J 1992; 147 (8)
1115
There are additional factors making it unlikely that every specimen and test receives the same attention, as required by universal precautions: the pressure to produce rapid test results for very sick patients (particularly in emergency situations), sensitivity to clinical needs, the demands from clinicians and relatives to get autopsy information quickly and the understandable desire that funeral arrangements not be delayed. All these situations require professional judgement. Precautions, if they are to be applied, should facilitate rather than hinder. There is a need for a detailed review of hospital activities to establish what aspects of universal precautions are not being followed and why. If any activities are shown to be impractical in the application of these precautions, consideration must be given as to what should be done. I thank Valerie Dalgetty for her help in the preparation of this letter and Dr. Ingrid Luchsinger for her challenging questions and for her criticisms. Matthew J. McQueen, MB, ChB, PhD, FCACB, FRCPC Chief Department of Laboratory Medicine Hamilton General Division Hamilton Civic Hospitals Hamilton, Ont.
References 1. Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MMWR 1988; 37: 377387 2. National Committee for Clinical Laboratory Standards: Protection of Laboratory Workers from Instrument Biohazards: Proposed Guideline (publ I 17-P), NCCLS, Villanova, Pa, 1991 3. Idem: Protection of Laboratory Workers from Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Tentative Guideline (publ M29-T2), NCCLS, Villanova, Pa, 1991 4. McQueen MJ: Conflicting rights of patients and health care workers exposed to blood-borne infection. Can Med Assoc J 1992; 147: 299-302 1116
CAN MED ASSOC J 1992; 147 (8)
Universal precautions not justified
Numerous policies and procedures are being subjected to an analysis of cost-effectivene-s. According to a 1990 study by Stock, I disagree with the conclusion Gafni and Bloch4 the economic of Dr. Marie Louie and asso- validity of universal precautions ciates in "Prevalence of is questionable, and there is minibloodborne infective agents mal documentation of their effecamong people admitted to a Can- tiveness. Therefore, the assumpadian hospital" (Can Med Assoc J tion made by Louie and associates 1992; 146: 1331-1334) that the perpetuates but does not substanuse of universal precautions is tiate the perception that universal justified by prevalence rates of precautions are justified. 2.1% for hepatitis B surface antigen and 0.6% and 0.5% for anti- John Hardie, BDS, FRCDC, FICDC bodies to the human immunodefi- Head of Dentistry ciency virus (HIV) and the hepati- Department British Columbia's Health Sciences Centre tis C virus (HCV) respectively. Vancouver, BC Such an inference would be possible if the use of universal precau- References tions were the only reason for infective agents not being trans- 1. National Surveillance of Occupational Exposure to the Human Immunodefimitted to health care workers. The ciencv Virus, Federal Centre for AIDS, investigation failed to show this. Ottawa, 1992 The surveillance study' of the 2. Kiyosawa K, Sodeyama T, Tanaka E et al: Hepatitis C in hospital employees Federal Centre for AIDS demonwith needlestick injuries. Ann Intern strated that health care workers Med 1991; 115: 367-369 were exposed to HIV-infected 3. Universal precautions for prevention of transmission of human immunodefiblood no matter what form of ciency virus, hepatitis B virus, and protection was worn but that such other bloodborne pathogens in healthexposure did not result in serocare settings. MMWR 1988; 37: 377conversion. This should not be 388 surprising, since HIV transmis- 4. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transsion does not occur through the mission to health care workers: an ecoroutes protected by barrier technomic analysis. Can Med Assoc J 1990; niques. These findings weaken 142: 937-946 rather than support the use of universal precautions to avoid the occupational spread of HIV. Inexperience with HCV explains the uncertainty regarding Program evaluation its transmission to health care in health care workers. However, gloves would not have protected the 1 10 workhis article by the Health ers mentioned by Louie and assServices Research Group ociates from exposure through (Can Med Assoc J 1992; needlestick injuries.2 146: 1301-1304) describes the Finally, the authors fail to field as it was about 25 years ago. indicate that the most effective Program evaluation continues method of avoiding occupational to be viewed by some of its practitransmission of the hepatitis B tioners as a method of systemativirus is vaccination. The Centers cally collecting and analysing data for Disease Control, Atlanta, do about a specific program in order not include this among their uni- to summarize or improve its overversal precautions3 but consider it all performance. Over the past few to be an important adjunct to decades, however, this insular persuch preventive techniques. spective on the purposes of evaluLE
15 OCTOBRE 1992
