Universal Precautions vs. Patient Dignity

[safe>sorry]

Hello, I've read many articles on allnurses.com and lurked on the forum threads for years and there's just a wealth of valuable information on here. With my first post as an official member of the site I want to say first and foremost thank you to the site owners and members. What an asset!

So I'm currently a CENA at a LTC facility and I'm waiting (waitlisted, ugh) to get into RN clinicals. I've always found a thread or an article on this site in the past whenever I've had a question about what to do concerning the nursing field but today I'm stumped. I have a bit of a dilemma and I need advice on how to proceed:

At my facility, we rotate 'groups' every week. Someone in my next group is suspected to have a bloodborne pathogen. I noticed that the entire two weeks since the patient had arrived, aides had been just using gloves and a standard hospital gown. Without getting into specifics (and respecting patient's rights) I asked my nurse manager yesterday if for this particular resident's room, when I begin care on Monday if I could have a 'universal precautions' cart equipped with ample fiberglass gowns, facemasks and goggles. On my floor (besides goggles) this is the standard measure taken for anyone suspected of having MRSA, C.Diff, ect. My nurse manager became annoyed and said 'no you should be using universal precautions with everyone.' I was very clear that I was not inquiring about the said patient's health status/condition but also that I needed a cart equipped with the proper protective gear (because even though a few rooms down are two such carts situated outside other rooms, those rooms have the protective gear for OTHER residents which obviously cannot be shared between patients.)

She immediately involved the assistant DON in our conversation and she agreed with the manager claiming it would be a violation of 'patient dignity' if I insisted on entering that particular resident's room with the protective gear because I would appear inconsistent for not being insistent on wearing extensive protective gear with other patients. I went to our infection control nurses office to ask her if I was in the wrong in requesting the protective cart and she was horrified when I explained my manager's response. She said there should have already been one there and the wound nurse later even agreed. The infection control nurse came to my unit and shut the door with my nurse manager and had a discussion. After she left and within hour left on my shift yesterday, still no universal precautions cart was installed outside this particular resident's room.

What should I do if come Monday morning there is still no protective cart?

[Altra, BSN, RN]

I appreciate that you want to use caution when describing the situation here on a publicly accessible forum, but it is impossible to really address your question without knowing the suspected pathogen involved.

In any case, if your facility has the resources to have a dedicated infection control nurse, it should have detailed policies spelling out what precautions are used with which suspected or confirmed infectious organisms.

If I were personally in your situation and I had been able to confirm that the policy states that disposable gowns/gloving were required for this patient's condition, I would get the supplies from the cart down the hall if no cart was available outside this patient's room. And I would follow whatever the process was that made carts appear outside of those rooms down the hall.

BTW -- goggles/face shields are considered part of "standard" or "universal" precautions for patient care on any patient which inherently includes a risk of splashing/spurting.

Hope this helps.

[Rose_Queen, BSN, MSN, RN]

The cart you are describing sounds more like supplies used for a patient in isolation. Patients in isolation have a disease (MRSA, VRE, etc.) that can be transmitted by simple contact. That is why they are in isolation.

Patients who have a bloodborne pathogen disease do not automatically need to be placed in isolation. These diseases cannot be transmitted by simple contact, but only by exposure to blood and other body fluids. The only time you would need more than gloves with these patients would be if you are expecting contact with body fluids (starting/removing an IV, etc.). These patients do not require the routine use of gowns, masks, or goggles.

Additionally, you should be using universal precautions on every patient. Just because they do not have a known bloodborne disease does not guarantee that they do not have one.

More information here: http://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf

This specifically states that anything greater than gloves is only required if splashing of fluids is expected.

1. 
   
2. Hand hygiene1
   Summary technique:
    Hand washing (40-60 sec): wet hands and applysoap; rub all surfaces; rinse hands and dry thoroughlywith a single use towel; use towel to turn off faucet.
    Hand rubbing (20-30 sec): apply enough product tocover all areas of the hands; rub hands until dry.
   Summary indications:
    Before and after any direct patient contact andbetween patients, whether or not gloves are worn.
    Immediately after gloves are removed.
    Before handling an invasive device.
    After touching blood, body fluids, secretions, excre-tions, non-intact skin, and contaminated items, even ifgloves are worn.
    During patient care, when moving from a contami-nated to a clean body site of the patient.
    After contact with inanimate objects in the immediatevicinity of the patient.
   
3. Gloves
    Wear when touching blood, body fluids, secretions,excretions, mucous membranes, nonintact skin.
    Change between tasks and procedures on the samepatient after contact with potentially infectious material.
    Remove after use, before touching non-contaminateditems and surfaces, and before going to another patient.Perform hand hygiene immediately after removal.
   
4. Facial protection (eyes, nose, and mouth)
    Wear (1) a surgical or procedure mask and eye pro-tection (eye visor, goggles) or (2) a face shield to protectmucous membranes of the eyes, nose, and mouth duringactivities that are likely to generate splashes or sprays ofblood, body fluids, secretions, and excretions.
   
5. Gown
    Wear to protect skin and prevent soiling of clothingduring activities that are likely to generate splashes orsprays of blood, body fluids, secretions, or excretions.
    Remove soiled gown as soon as possible, and per-form hand hygiene.
   

1. 
   

[safe>sorry]

Thanks for the quick response!

Ok lets say I encounter a person on my floor with advanced AIDS (not HIV.) This theoretical person consistently coughs spits up sputum and bleeds from open wounds.

Ideally I would want a cart for this individual but yes I agree, I like my life and in this scenario I would most likely grab the gear from the other cart, regardless. I don't feel its worth losing my life over. The one problem is that goggles aren't usually included in the cart.

[Altra, BSN, RN]

I understand what you are saying, that the AIDS patient is at higher risk of contracting an infection with an organism requiring isolation; however, the diagnosis of HIV or AIDS does not in itself require anything more than standard precautions. If the patient has displayed symptoms of a secondary infection, respiratory or otherwise, the patient may have been placed in isolation while cultures or other testing is completed to confirm the presence or absence of infection requiring isolation. This may or may not have occurred with the patient you are concerned about.

Having said that -- standard precautions include PPE protection from bodily fluids. Common sense dictates appropriate barriers to shield from bodily fluids and that includes both the sputum from an end-stage AIDS patient and the everyday-garden-variety emesis from a 6-year old who "OD'd" on Doritos & birthday cake.

The presence of a cart hinges on whether or not this particular patient has been placed in isolation. Neither the presence of frequent sputum, nor a diagnosis of HIV and/or AIDS, necessarily indicate isolation, just commonsense standard precautions.

[safe>sorry]

The cart you are describing sounds more like supplies used for a patient in isolation. Patients in isolation have a disease (MRSA, VRE, etc.) that can be transmitted by simple contact. That is why they are in isolation.

Patients who have a bloodborne pathogen disease do not automatically need to be placed in isolation. These diseases cannot be transmitted by simple contact, but only by exposure to blood and other body fluids. The only time you would need more than gloves with these patients would be if you are expecting contact with body fluids (starting/removing an IV, etc.). These patients do not require the routine use of gowns, masks, or goggles.

Additionally, you should be using universal precautions on every patient. Just because they do not have a known bloodborne disease does not guarantee that they do not have one.

More information here: http://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf

This specifically states that anything greater than gloves is only required if splashing of fluids is expected.

Yes that is correct that is 'isolation' and they are more appropriately referred to as 'isolation carts' as a matter of fact. In my job, however, I come in contact with many bodily fluids (urine, feces, mucus, blood, sputum, vomit) multiple times a day. Differentiating between 'isolation' and 'bloodborne' seems moot. What are my options?

[safe>sorry]

I understand what you are saying, that the AIDS patient is at higher risk of contracting an infection with an organism requiring isolation; however, the diagnosis of HIV or AIDS does not in itself require anything more than standard precautions. If the patient has displayed symptoms of a secondary infection, respiratory or otherwise, the patient may have been placed in isolation while cultures or other testing is completed to confirm the presence or absence of infection requiring isolation. This may or may not have occurred with the patient you are concerned about.

Having said that -- standard precautions include PPE protection from bodily fluids. Common sense dictates appropriate barriers to shield from bodily fluids and that includes both the sputum from an end-stage AIDS patient and the everyday-garden-variety emesis from a 6-year old who "OD'd" on Doritos & birthday cake.

The presence of a cart hinges on whether or not this particular patient has been placed in isolation. Neither the presence of frequent sputum, nor a diagnosis of HIV and/or AIDS, necessarily indicate isolation, just commonsense standard precautions.

So basically I am entitled to use goggles, face mask, protective gown as needed when doing care but there just cant be an 'isolation' cart set up right?

[Altra, BSN, RN]

Yes that is correct that is 'isolation' and they are more appropriately referred to as 'isolation carts' as a matter of fact. In my job however, I come in contact with many bodily fluids (urine, feces, mucus, blood, sputum, vomit) multiple times a day. Differentiating between 'isolation' and 'bloodborne' seems moot. What are my options?[/quote']

I'm sure it's accurate to say that you are in the presence of urine, feces, mucous, blood, sputum & vomit multiple times per day. But contact? Gloves and body mechanics should prevent *contact*. You'll learn quickly not to touch bed linens without gloves on and (as I learned the hard way as a nursing student ) not to lean against beds and other furniture.

[caroladybelle, BSN, RN]

Yes that is correct that is 'isolation' and they are more appropriately referred to as 'isolation carts' as a matter of fact. In my job however, I come in contact with many bodily fluids (urine, feces, mucus, blood, sputum, vomit) multiple times a day. Differentiating between 'isolation' and 'bloodborne' seems moot. What are my options?[/quote']

Then you need to be using apppropriate PPE for every single pt that you deal with that has reasonable potential to expose you to urine, feces, mucus. blood sputum and vomit. Bloodbourne disease or not, it makes no difference.

Bloodbourne disease requires universal precautions. It does not require (in and of itself) any additional precautions.

A vast number of people that you come in contact with, that have HIV/Hepatitis/STDs/MRSA/VRE/Acibobacter, you will not know that they have it. Universal precautions and appropriate PPE will protect you, but you need to recognize that the run of the mill bloodbourne disease pts, require no more than universal precautions, barring them openly bleeding, etc.