Standard Precautions Policy

1. Policy Statement

It is the policy of this organization that standard precautions shall apply during all patient care procedures and in all clinical settings where potential exists for exposure to blood, body fluids, secretions, excretions (excluding sweat), nonintact skin, and mucous membranes. These precautions provide baseline protection for both patients and clinicians regardless of known or suspected infection status. Personal protective equipment selection and use must be guided by the nature of the anticipated patient interaction and the potential for exposure to blood, body fluids, or infectious agents.

2. Purpose

This policy exists to:

• Define the fundamental components of standard precautions required in all patient care settings.
• Establish clear requirements for PPE selection, use, and removal across clinical scenarios.
• Address respiratory hygiene and cough etiquette practices for clinicians, patients, and visitors.
• Establish standards for equipment cleaning, disinfection, and environmental surface management.
• Define requirements for safe care practices across transitional settings including home and long-term care.

3. Scope

This policy applies to:

• All clinical personnel involved in direct or indirect patient care in any setting.
• All patient care environments, including inpatient, ambulatory, home care, and long-term care.
• Patients, family members, and visitors who interact within the care environment.
• Organizational leadership and infection prevention personnel responsible for compliance oversight.

4. Policy Requirements

4.1 Foundational Standards

4.1.1 Standard precautions apply during all patient care procedures and in all clinical settings where potential exists for exposure to blood, body fluids, secretions, excretions (excluding sweat), nonintact skin, and mucous membranes. These precautions provide baseline protection regardless of known or suspected infection status.

4.1.2 Personal protective equipment selection and use must be guided by the nature of the anticipated patient interaction, the potential for exposure to blood, body fluids, or infectious agents, and any transmission-based precautions in effect for specific communicable diseases or immunocompromised patient populations.

4.1.3 Environmental surfaces in close proximity to patients and frequently touched areas within the patient care environment require cleaning and disinfection more frequently than other surfaces, using healthcare-grade disinfectants appropriate for the setting.

4.1.4 Blood spills and spills of other potentially infectious materials must be cleaned and decontaminated promptly according to established facility protocols.

4.1.5 Durable medical equipment requires cleaning and disinfection after each patient use, following manufacturer instructions for use and organizational policies.

4.2 Hand Hygiene in Standard Precautions

4.2.1 Hand hygiene constitutes a primary component of standard precautions. Facilities must ensure accessibility of appropriate hand hygiene supplies at all care locations, including ABHR dispensers and access to soap, water, and paper towels. Refer to the Hand Hygiene Policy for complete requirements.

4.2.2 Hand hygiene must occur immediately if contamination occurs during PPE removal, immediately following complete removal of all PPE, and before exiting the patient’s environment. The sequence of PPE removal shall be carefully followed to minimize contamination risk.

4.3 Personal Protective Equipment

4.3.1 General Principles

Sufficient quantities of appropriate PPE must be available and readily accessible at the point of care. When any type of PPE is worn, removal must occur at the end of the specific task and before leaving the patient care space, following established doffing sequences to prevent self-contamination (CDC HICPAC, 2017; WHO, 2009; Occupational Safety and Health Administration, 2019).

4.3.2 Gloves

Gloves providing appropriate fit and extending to cover the wrist (or the cuff of an isolation gown when worn) are required when potential exists for contact with blood, body fluids, mucous membranes, nonintact skin, or contaminated equipment. This includes phlebotomy, venipuncture, and all vascular access procedures.

Gloves must be changed during patient care when torn or punctured, when heavily contaminated, and when moving from a contaminated body site to a clean body site within the same patient.

Clinicians must understand that gloves do not substitute for hand hygiene. Research demonstrates a potential inverse relationship between glove use and hand hygiene compliance, and touch contamination risk remains present even when gloves are worn (King et al., 2020; Li et al., 2022). Hand hygiene must occur before donning and after removing gloves.

Gloves are single-use items and must never be reused or worn for care of more than one patient.

4.3.3 Gowns and Aprons

Single-use or disposable gowns or aprons, used according to manufacturer specifications, protect skin and clothing during procedures or activities with anticipated contact with blood or body fluids. Local regulatory requirements and institutional policies define specific attire requirements for various clinical scenarios.

A single gown or apron must not be worn for care of more than one patient. Removal technique must prevent contamination of underlying clothing, and hand hygiene must follow gown removal.

4.3.4 Eye and Face Protection

Eye and face protection, including goggles with face mask or face shields, must be worn when potential exists for splash or spray of blood, respiratory secretions, or other body fluids to the mouth, nose, or eyes.

Reusable eye protection requires appropriate decontamination between uses and whenever visibly soiled, following manufacturer guidelines and facility protocols.

4.3.5 Universal PPE During High Transmission Periods

During periods of high community transmission of communicable diseases, universal PPE may be indicated for all patient encounters. Specific requirements vary based on the pathogen and its transmission characteristics but may include universal respiratory protection (surgical masks or respirators as indicated) and universal eye protection (CDC, 2021).

4.4 Respiratory Hygiene and Cough Etiquette

4.4.1 Education of clinicians, patients, family members, and caregivers shall address respiratory hygiene practices, including covering the mouth and nose with tissue when coughing or sneezing, prompt disposal of used tissues, and immediate hand hygiene following tissue use.

4.4.2 Placement of a face mask on coughing individuals, when tolerated, assists in source control. However, source control measures do not replace the requirement for caregivers to wear appropriate PPE when indicated by the clinical situation.

4.4.3 Clinicians with symptoms of respiratory illness shall remain home from work to prevent transmission to patients and colleagues.

4.5 Equipment Cleaning and Disinfection

4.5.1 Durable medical equipment including intravenous poles, infusion pumps, flow-control devices, and vascular visualization equipment must be cleaned and disinfected using appropriate products (such as EPA-registered disinfectants) after each patient use (Rutala & Weber, 2019; Scott et al., 2017).

4.5.2 Organizational procedures for equipment cleaning and disinfection must align with manufacturers’ instructions for use. Clear separation between clean and soiled equipment must be maintained to prevent cross-contamination.

4.6 Practices for Care Across Settings

4.6.1 When providing care in home settings or transitioning between patient care locations, practices must minimize transmission risk between patients.

4.6.2 Clinical bags transported between homes or patient care settings require routine cleaning of both interior and exterior surfaces at intervals defined by organizational policy.

4.6.3 Hand hygiene must be performed before opening the clinical bag to retrieve supplies, after removing supplies and before direct patient contact, after contact with the patient’s intact skin, and after contact with inanimate objects in the patient’s environment (Bakunas-Kenneley & Madigan, 2009; McGoldrick, 2017).

4.7 Education and Training

4.7.1 A multimodal approach to standard precautions education and training benefits all clinical disciplines and has demonstrated effectiveness in improving adherence (Moralejo et al., 2018; Xiong et al., 2017; Sadeghi et al., 2018).

4.7.2 Training shall address rationale for precautions, proper technique for all components, recognition of situations requiring enhanced precautions, and methods for self-monitoring compliance. Regular competency assessment and refresher education sustain practice standards over time.

5. Compliance

5.1 Monitoring. Compliance shall be monitored through direct observation, PPE supply consumption audits, competency assessments, and integration into infection prevention audit tools.

5.2 Key Performance Indicators.

• PPE compliance rate for observed patient care activities (target: ≥95%).
• Healthcare-associated infection rates stratified by care setting and procedure type.
• Equipment cleaning and disinfection compliance rates tracked on audit.
• Annual staff competency completion rate for standard precautions training (target: 100%).

5.3 Enforcement. Observed deviations from standard precautions shall be addressed through immediate coaching and, for repeated violations, through the organization’s performance management processes. Leadership is responsible for ensuring PPE availability at all points of care; supply shortages must be escalated to administration immediately.

6. Exceptions

6.1 When PPE supplies are critically limited during declared public health emergencies, the organization shall follow crisis standards of care established by local, state, or federal public health authorities. No exception to standard precautions shall be granted without documented crisis-level justification and leadership authorization.

6.2 Individual patient clinical situations may occasionally make full PPE use impractical. Clinicians shall document the clinical rationale and apply the maximum feasible level of protection.

7. Related Documents

• Hand Hygiene Policy (this collection)
• ANTT® Policy (this collection)
• Transmission-Based Precautions Policy (this collection)
• POL-006: Interprofessional Safety and Care Transitions
• POL-015: Hazardous Drug Management
• Bloodborne Pathogen Exposure Control Plan
• OSHA Standard 29 CFR 1910.1030 — Bloodborne Pathogens
• CDC/HICPAC Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings
• Organizational PPE Program

8. Revision History