Description of the condition
While infections in both community and healthcare settings have been a concern of healthcare providers, organisations and governments for centuries, there has been an increased focus on the prevention and control of healthcare-associated infections (HAIs) in the past few decades. Global estimates of the prevalence of HAIs are not available, but it has been estimated that over four million patients in Europe and 1.7 million in the US develop an infection each year, with higher prevalence in developing countries (Allegranzi 2011; WHO 2011). HAIs are associated with increased length of stay, excess mortality, billions of dollars in associated hospital costs, as well as psychosocial and economic impacts on the people involved, their families and their communities (Andersson 2010; WHO 2011).
HAIs can occur when susceptible patients are exposed to infectious microorganisms during their stay in the healthcare setting. Patients in hospitals and long-term care facilities are frequently more susceptible to infections than those in the community because of their illness, use of immunosuppressive therapy, exposure to invasive procedures, or contact with others who have infections. Infectious agents are most frequently spread by direct contact with contaminated hands, or indirect contact via contaminated objects, such as patient care equipment, healthcare workers' uniforms, or environmental surfaces.
In 1996, the Centers for Disease Control and Prevention in the US introduced guidelines, called 'Standard Precautions', which summarise strategies to be used to prevent transmission of microorganisms in healthcare settings. Standard Precautions replaced previously used guidelines such as 'Universal Precautions' (introduced in 1985) and 'Body Substance Isolation' (introduced in 1987). These previously used guidelines had varied in terms of strategies used and the conditions to which they applied, whereas Standard Precautions recommends strategies to be used on all patients at all times in all settings. Standard Precautions are based on the assumption that all patients carry transmissible microorganisms although the patients may be asymptomatic.
Strategies included in Standard Precautions include: 1) Appropriate hand hygiene (handwashing with soap and water or use of an alcohol-based hand rub) and appropriate use of gloves to disrupt the spread of microorganisms from one patient to another by healthcare workers' contaminated hands (Armstrong-Evans 1999; Johnson 1990; Tenorio 2001); 2) use of gowns to disrupt transmission of microorganisms carried on healthcare workers' uniforms; 3) appropriate cleaning and disinfection of patient care equipment and environment surfaces to reduce transmission by the indirect contact route; 4) use of appropriate facial protection (e.g. masks (Health Canada 1999; Siegel 2007; Wong 2004) and goggles (Siegel 2007; Wong 2004)) or an N95 respirator to reduce exposure of healthcare workers to infectious agents spread by the droplet or airborne route; 5) management of used needles and other sharp objects to prevent exposure from percutaneous injury; 6) management of clinical waste and used linen to reduce environmental contamination; and 7) cough etiquette to reduce droplet transmission and contamination of the environment. All of these strategies protect patients in the setting or healthcare workers from exposure to infectious agents, or both.
Standard Precautions guidelines also include specific transmission-based precautions to be taken when patients are known or suspected to have an infection. There are three categories of transmission-based precautions: airborne, contact and droplet. They involve additional strategies to those of Standard Precautions that are based on the route of transmission of the known or presumed causative microorganism.
Standard Precautions have been adopted worldwide, with periodic updates since they were first released. In Canada, a similar system, called 'Routine Practices and Additional Precautions', has been in place since 1999 (Public Health Agency of Canada 2012). While multiple guidelines have been published for the control of specific microorganisms, such as Clostridium difficile or norovirus, they build on, rather than replace, Standard Precautions.
In spite of widespread adoption of Standard Precautions by organisations, there are gaps in their implementation by healthcare workers (Clock 2010; Gammon 2008). The barriers reported by the healthcare professionals include inadequate infrastructure such as lack of handwashing facilities; lack of information about transmission and insufficient personal protective equipment (Oliveira 2010). Interventions have, therefore, been used to promote implementation of Standard Precautions as the basis for infection prevention and control.
Description of the intervention
Interventions can be categorised into three approaches: educational, behavioural, or technical. While these categories differ from the Cochrane Effective Practice and Organisation of Care (EPOC)'s usual taxonomy of professional, financial, organisational and structural interventions (EPOC 2012), they are more reflective of the actual interventions implemented with respect to promoting Standard Precautions. Educational approaches, one aspect of professional interventions, include educational campaigns, instruction and training, use of pamphlets and posters, and audits with feedback. Education may be provided to individuals or directed to groups. Behavioural interventions, also reflective of professional interventions, include raising risk awareness, or providing penalties or rewards for the desired behaviours. Financial interventions may also be used to influence behaviour. Technical interventions illustrate both organisational and structural interventions; examples include provision and placement of materials required to implement Standard Precautions and eliminating barriers to their use.
How the intervention might work
Educational interventions can increase healthcare workers' knowledge of what strategies to use to reduce transmission of microorganisms, when to use these strategies, and how to implement them correctly. Behavioural interventions might increase awareness of specific individual behaviours and their consequences, and provide motivation for change, such as inducing shame if not adhering to guidelines or pride if adherence is appropriate. Technical interventions, such as ensuring availability of personal protective equipment or adequate housekeeping staff, may reduce barriers that prevent optimal adherence to Standard Precautions. By promoting knowledge of, and belief in, the value of Standard Precautions guidelines or enabling their application, or both, adherence can be improved.
We have not identified a systematic review of interventions to improve adherence to Standard Precautions although there is a review of interventions to improve hand hygiene (Gould 2010).
Why it is important to do this review
The results will be useful to provide healthcare professionals involved in healthcare settings with evidence of the best approach (educational, behavioural, technical, or a combination of these) to improve adherence to Standard Precautions in the provision of care.