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Compliance With Universal Precautions In A

Medical Practice With A High Rate Of HIV Infection

Sandra W Freeman, R.N., B.S.N., and Christopher V. Chambers, M.D.

AbsIrYlet: Btlcllgnnlllll: Universal precautions have been recommended to limit occupational exposure to
the human immunodeftdency virus (HIV) and other infectious agents, but whether these recommendadons
have been incorporated into routine pradice has not been demonstrated.
Metbotls: Using a one-group, before-after design, we assessed the knowledge and attitudes concerning
universal precautions and the level of compliance with these recommendations. 1be health care
professionals had various levels of training and worked in an ambulatory practice with a high rate of mv.
Atotal of 195 procedures involving potential exposure to various body 80ids were observed.
Renin: No improvement in compliance with recommended precautions was observed following a
didactic educational program for either 1atex glove use (44 percent versus 49 percent, X2 < 1, P > 0.2) or
appropriate use of hand washing (34 percent versus 47 percent, X2 = 3.38, P = 0.07). Faculty demonstrated
the lowest levels of adherence to universal precautions. While knowledge of precautions was high, s1aff
members at all levels overestimated their own compliance with these recommendations.
em.elflSlmls: Although the number of observations limits the conclusions, the results suaest that the basic
protective measures included in universal precautions are not being routinely applied in ambulatory mecIkaI
practice. Furthermore, didactic educational programs might not be suftlclent to improve compliance. Finally,
fawlty in 1raining programs should monitor their own compliance with universal precautions because of
their responsibilities as role models for physidans in 1raining. (J Am Board Fam Prad 1992; 5:313-8.)

In addition to its devastating effects on patients, In response to. increasing concerns regarding
the epidemic of hwnan immunodeficiency virus the infectivity of HIV and hepatitis B virus
(HIV) infection and the acquired immunodefi- (HBV), universal precautions have been pro-
ciency syndrome (AIDS) has posed new problems posed by the CDC for use in all health care cen-
for health care providers. Concerns about pos- ters in the United States to supplement existing
sible acquisition of HIV infection in the work- infection control policies. 3,4 According to these
place are supported by well-docwnented case re- guidelines, health care workers should treat blood
ports of occupational exposure to body fluids with and a limited nwnber of other body fluids from all
subsequent seroconversion in health care workers patients as potential sources of HIV and HBV
who have had no other recognized risk factors. l infections. 3,4
Based on a prospective study of health care work- Previous investigatorss found poor compliance
ers occupationally exposed to HIv, the Centers with these guidelines by health care workers hav-
for Disease Control (CDC) has estimated that the ing regular contact with potentially infected pa-
risk of acquiring HIV after a needle-stick expo- tients, and their study was terminated so that an
sure from a known carrier is approximately 0.4 educational program could be implemented to
percent. 2 The risk of HIV infection from other motivate employees to use safer behaviors. In-
types of occupational exposure is unknown, but service education has improved knowledge and
probably less. changed attitudes regarding the risks of acquiring
HIV infection in other settings,6,7 but meaning-
ful changes in behavior have been more difficult
Submitted, revised, 27 January 1992. to establish. Continuing medical education pro-
From the Department of Family Medicine, Jefferson Medical grams have had limited success in changing phy-
College, Thomas Jefferson University, Philadelphia. Address re- sician practice. 8,9
print requests to Christopher V. Chambers, M.D., Department of
Family Medicine, Thomas Jefferson University, 1015 Walnut The primary goal of this study was to assess the
Street, Room 401, Philadelphia, PA 19107. knowledge and attitudes concerning universal

Universal Precautions 313

precautions and the level of compliance with presence was unobtrusive to the staff, who were,
these recommendations by health care profes- by design, unaware that observations were being
sionals at various levels of training in a family made. For each potential exposure, she recorded
medicine residency program. The outpatient the training level of the person observed, the
practice where this study was conducted is located body fluid for which potential contact was antici-
in a large metropolitan hospital in the mid- pated, and the appropriate use of gloves and hand
Atlantic region of the United States. Epidemio- washing. Observations were made for 1 hour each
logic data from the CDC have suggested that the day in the office laboratory and at nursing stations
number of mY-infected patients is likely to be on a rotating schedule in an attempt to minimize
higher in this region than in other geographic any systematic bias in the selection of staff
areas of the United States.l According to the observed.
computerized practice database, more than 200 At the end of this observation period, a ques-
mY-infected patients have received ongoing care tionnaire was distributed to all the office staff at a
in this office. AIDS also has been the most com- regularly scheduled conference. Ten questions
mon admitting diagnosis to the practice inpatient addressed attitudes and perceptions regarding
service since 1987. Given the high visibility of staff behaviors, and ten items explored knowledge
AIDS-related care in the office and the formal of universal precautions and isolation procedures
and informal teaching relating to the clinical care in the family medicine setting. Response options
of mY-infected patients, we hypothesized that consisted of 5-point scales that ranged from
compliance with universal precautions would be strongly disagree to strongly agree.
high and that physicians with the most training The intervention consisted of a didactic lecture
and experience in caring for mY-infected pa- given by the second author after collecting the
tients would be the most compliant with these questionnaires at the staff meeting. The risks of
recommendations. A second goal of this study was occupational exposure were reviewed using ma-
to measure any changes in compliance with uni- terials provided by the CDC (Hospital Infections
versal precautions following a didactic, educa- Program, Health Care Worker Surveillance
tional program designed to make clinicians more Project, August 15, 1983-April 20, 1989), and
aware of these recommendations. the importance of universal precautions was
Methods Compliance with universal precautions was
This study was conducted in a university-based measured in the same manner for the second
family practice outpatient office, where 12 at- 3-week period, after which the questionnaire was
tending physicians and 18 residents provide on- again distributed.
going primary care to approximately 10,000 ac- Data from the clinical observations and the
tive patients. An average of 8 3rd-year medical questionnaires were analyzed, and the chi-square
students rotate through the office every 6 weeks statistic was used to compare preintervention and
for a required clerkship. Eight registered nurses postintervention compliance. Because of small
and 5 medical technicians perform venipuncture subgroup sizes, tests of statistical significance
and assist with other procedures involving poten- were not used in the subgroup analyses. Selected
tial exposure to various patient body fluids. data from the self-administered questionnaires
Data for this study were collected over two are summarized in Table 1, also without statistical
consecutive 3-week periods using a one-group, reference, because the preintervention and
before and after (preexperimental) design. The postintervention groups did not consist entirely
6-week study duration was chosen to allow inclu- of the same individuals.
sion of the same group of medical students in the
observation periods both before and after the Results
educational intervention. In the first 3 weeks, Ninety-seven potential exposures to various body
single-blinded observations of behaviors related fluids were observed in the preintervention pe-
to universal precautions were recorded. The ob- riod, and 98 exposures were observed during the
server was a registered nurse who also served as post-intervention period. Of al1195 observations,
the coordinator for clinical trials in the office. Her 163 (84 percent) involved the handling of open

314 JABFP May-June 1992 Vol. 5 No.3

Attitudes Mean Preintervention and Postintenention Values*
Attending Resident Medical Medical
Physician Physician Student Nurse Technician
Pre Post Pre Post Pre Post Pre Post Pre Post
(n -8)(n .. 5) (n-14) (n=l3) (n .. 10) (n .. 9) (n = 3) (n =3) (n =4) (n .. 4)
I feel I understand universal 4.1 4.1 4.1 4.8 4.1 4.2 3.3 3.7 4.3 4.8
All patients should be 3.0 3.2 4.1 4.9 4.7 4.6 5.0 4.7 4.0 5.0
considered potentially
infected with mv
The facilities make fOllowing 2.8 3.2 3.7 3.4 3.6 3.9 4.3 4.7 4.5 4.8
universal precautions easy
I feel my peers fOllow universal 2.5 2.0 2.5 2.1 3.2 2.7 3.0 3.3 4.3 4.0
precautions at all times
I feel I follow universal pre- 3.1 2.8 3.0 3.1 3.5 3.8 4.0 2.7 4.0 4.3
cautions at all times
*Mean values on a scale from 1 .. strongly disagree to 5 strongly agree.

containers or wet specimens, including urine were included in the 34 personnel who completed
(93 exposures), vaginal discharge (68), and penile the second questionnaire. In both instruments
discharge (4) in the office laboratory. The remain- factual knowledge of all staff regarding HIV
ing 32 (16 percent) involved venipuncture and transmission and universal precautions was high
needle disposal. (range, 90 to 100 percent correct). The majority
Latex gloves were worn during 44 percent of of the staff (88 percent) agreed or strongly agreed
the potential exposures in the preintervention pe- that they understood universal precautions as out-
riod and 49 percent of the exposures after the lined by the CDC. (fable 1). Consistent with this
educational program (X2 < 1, P > 0.2). Glove use understanding, most of the staff (81 percent)
was observed during 12 (52 percent) of 23 veni- agreed or strongly agreed that all patients should
punctures before and 5 (55 percent) of 9 veni- be considered potentially infected with HIv. The
punctures after the intervention. For each of the exceptions were the attending staff, who neither
other body fluids, gloves were worn during less agreed nor disagreed with this statement. The
than 50 percent of the potential exposures ob- members of each professional group tended to
served. The wearing of latex gloves was examined rate their own compliance with universal precau-
in relation to the professional level of the tions as higher than that of their peers.
staff person observed (Figure 1). Attending Staff members were also asked to estimate the
physicians who completed their residency train- percentage of time that they wore gloves for han-
ing before 1981 had the lowest rate of glove use dling specific body fluids. Attending and resident
and did not improve after the educational physicians estimated that they wore gloves when
program. handling blood 61 to 80 percent of the time,
Appropriate hand washing was observed fol- whereas students, nurses, and technicians esti-
lowing 34 percent of the potential exposures mated their own use at between 81 and 99 per-
in the preintervention period and following 47 cent. Overall, attending physicians judged them-
percent after the educational program (X2 = 3.38, selves as least compliant of all staff groups, and
P = 0.07). When blood specimens were handled, technicians estimated themselves as most compli-
hand washing was recorded for only 28 percent of ant regarding glove usage.
the observations made. Rates of hand washing
were similar for attending physicians, residents, Discussion
students, and technicians. Although universal precautions are recom-
A total of 39 personnel completed the first mended for all medical settings to prevent trans-
questionnaire, and most of these same individuals mission of infectious agents, including mY,3,4

Universal Precautions 315

_ Preintervention n=11
~ Postintervention



Attending t Attending Nurse * Resident Student Technician
Latex gloves worn
Figure 1. Percen1age of obsenations for which latex gloves were wom during potential body fluid exposure.
*lnadequate number of obsenations for a postintervention measurement.
tResidency completed before 1981.
~idency completed after 1981.

there are few data that show whether these rec- versal precautions can improve following an
ommendations have been adopted into routine educational intervention, 6 a didactic program
practice. In this study in an ambulatory family might not be sufficient to change how routine
practice setting, both professional and nonprofes- clinical procedures are performed. Results of
sional staff demonstrated poor compliance with research in related areas have indicated that
glove use and hand-washing recommendations. more creative educational interventions might
Given the large number of patients receiving be necessary to change these behaviors. 8,9 We
treatment for AIDS and other InV-related con- are currendy evaluating the effect of providing
ditions in this medical practice, the finding that feedback to physicians regarding their compli-
the basic protective measures of glove use and ance with universal precautions relative to their
hand washing were employed for less than 50 peers.
percent of the potential body fluid exposures was A disturbing finding in this study was the in-
surprising and suggests that clinicians have not verse relation between years of formal education
made these practices routine. and adherence to universal precautions. Modeling
Authors of a previous study of adherence to by faculty is an important part of the medical
universal precautions by medical staff in an emer- training of medical students and residents. The
gency department reported similar levels of com- clinical skills and behaviors of attending physi-
pliance. 5 Their study was aborted prematurely so cians have a strong influence on residents' sub-
that an in-service training program for employees sequent practice behaviors. ll ,12 In this study
could be implemented to effect changes in com- attending staff were less compliant with recom-
pliance. In our study, substantive changes in be- mendations for latex glove use than either resi-
haviors were not observed after a traditional edu- dents or students. Faculty who completed their
cational program. There are limited published residency training prior to the recognition of
data that address whether medical education pro- AIDS (i.e., before 1981) demonstrated the lowest
grams can alter physician behavior. 8,9 Although levels of compliance with universal precautions.
provider knowledge and attitudes regarding uni- Because of the recency of the InV epidemic,

316 JABFP May-June 1992 Vol. 5 No.3

senior clinicians might not be appropriate role tially infectious to eliminate a clinical judgment
models for medical students and residents, who prior to taking appropriate protective measures.
are learning to incorporate universal precau- Excluding the observations relating to urine
tions (formally recommended in 1987) into their would reduce further the already small number of
clinical routine. Quill 11 has suggested that a true exposures in this study. Even so, although the
special effort should be made to educate or re- sample size limits the conclusions, glove use and
educate physicians who serve as preceptors and hand washing were observed to be low for all body
role models in areas where they demonstrated fluids. Finally, the before-after study design did
low compliance. Researchers 13 involved in a not control for exposure to those influences, other
large survey of primary care physicians in Eng- than the planned educational intervention, that
land suggested that physicians in general prac- might have affected compliance with universal
tice are reluctant to change their infection precautions. These limitations do not diminish
control procedures. Physicians in training pro- the finding that basic protective measures against
grams, however, might need to monitor their HIV infection are not being routinely used by
own behaviors more carefully because of their health care personnel in the ambulatory setting.
responsibilities as role models for physicians in This study should be replicated with larger sam-
training. ple sizes to assess more adequately the interac-
All staff and trainees tended to overestimate tions of factors that underlie this poor compliance
their compliance with universal precautions. An before programs to change behavior can be
interesting observation was that medical stu- designed.
dents, residents, and attending staff all stated
that their own compliance with universal pre-
cautions was greater than that of their peers. A
study of emergency department personnel also References
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Universal Precautions 317

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