6.14 – Universal Precautions

Policy

Universal blood and body fluid precautions should be consistently used for all individuals regardless of AIDS (HIV), hepatitis (HBV) or Hepatitis C (HCV) status.  Implementation of Universal Precautions for all individuals eliminates the need for use of the isolation category “blood and body fluid precautions” previously recommended by CDC for individuals known or suspected to be infected with blood-borne pathogens.  Universal Precautions are intended to supplement rather than replace recommendations for routine infection control, such as hand washing and using gloves to prevent gross microbial contamination of hands.

• Universal Precautions apply to blood and their body fluids containing visible blood.  Universal Precautions also apply to tissue, semen, vaginal secretions, cerebral-spinal fluids (CSF), peritoneal fluid, amniotic fluid, synovial fluid, pleural fluid, and saliva in dental procedure.
• Universal Precautions do not apply to nasal secretions, sputum, sweat, or tears, unless they contain visible blood.

Procedure

• All health care workers, including physicians, must routinely use appropriate personal protective equipment (PPE) to prevent skin and mucous membrane exposure when contact with blood, tissue, body fluids containing visible blood or other fluids to which Universal Precautions apply is anticipated.
  • Personal protective equipment will be provided to all staff who may have a job-related risk of exposure to blood or body fluids at no cost to employees
  • Hypoallergenic PPE will be provided to those employees who require it
  • Equipment shall be readily accessible
  • Employees must use equipment during all potentially risky situations
  • All disposable PPE will be discarded after a single use to prevent exposure to blood-borne pathogens
• The type of personal protective equipment should be appropriate for the procedure being performed and the type of exposure anticipated.
  • Wear gloves for touching blood, tissue, body fluids containing visible blood, and other fluids to which Universal Precautions apply, mucous membranes, or the non-intact skin of all individuals
  • Wear gloves for handling items or surfaces soiled with blood, tissue, body fluids containing visible blood, or other fluids to which Universal Precautions apply.
  • Wear gloves for performing venipuncture, when performing finger sticks and other vascular access procedures
  • The type of glove selected should be appropriate for the task being performed:
• Use sterile gloves for procedure involving contact with normally sterile areas of the body
• Use examination gloves for procedures involving contact with mucous membranes, unless otherwise indicated, and for other individual care of diagnostic procedures that do not require the use of sterile gloves
• Change gloves between individual contact
• Do  not wash disinfect surgical or examination gloves for reuse
• Use general-purpose utility gloves (e.g. rubber household gloves) for housekeeping chores involving potential blood contact
  • Wear masks and protective eyewear or face shields during procedures that are likely to generate droplets of blood, body fluids containing visible blood, or other fluids to which Universal Precautions apply, to prevent exposure to mucous membranes of the mouth, nose, and eyes.
  • Wear gowns and aprons during procedures that are likely to generate splashes of blood, body fluids containing visible blood, or other fluids to which Universal Precautions apply.
  • FOR Positive COVID 19, staff must wear appropriate protective equipment including N95 masks, face shield or goggles/eyewear, shoe, and head covers, gowns, gloves, etc.
• Wash hands and other skin surfaces with soap and water immediately and thoroughly if contaminated with blood, tissue, bloody fluids containing visible blood, or other fluids to which Universal Precautions apply.  Wash hands immediately after gloves are removed.
• The following precautions must be taken to prevent injuries caused by sharps:
  • Sharps are defined as:
• All disposable needles, syringes, and scalpel blades.  This includes all syringes of any size to which a needle can be attached, including those use for tube feeding to which a needle could be attached
• Any glass lab tubes which contain blood or body fluids which are to be discarded
• All lancets used for finger sticks
• Any other disposable equipment which potentially could puncture the skin during normal use, such as disposable razors, etc.
  • Limit the use of needles and syringes to situations in which there is no alternative
  • To prevent needle stick injuries, a self-sheathing syringe will be utilized
  • After they are used, place disposable syringes, disposable razors, and other sharp items in puncture-resistant containers for disposal, located the puncture-resistant containers as close as practical to the use area
  • If venipuncture or injection is not performed in an area close to where the needle will be disposed of, take a disposable container with you to the site
  • Never dispose of syringes and needles in regular trash containers.  These containers shall be identified as infectious waste and disposed of appropriately when they are no more than ¾ full.
• Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth, use the resuscitation mouthpieces
• Puncture-resistant containers will be kept available for the disposal of non-electric razors after use
• When the puncture-resistant containers are ¾ full, employees will notify the Departmental Supervising Nurse/designee and a new container will be brought
• The Departmental Supervising Nurse/designee will ensure that all employees are trained on the proper selection, indications, mandated use, and proper procedure for disposal of PPE.

Last Revised: 6/6/22