| Summary: | Isolation of those ill with contagious disease has been a fundamental
infection control concept for hundreds of years. However, recent studies suggest
that fewer than 50% of health—care workers comply with their hospitals'
isolation precaution policies and that efficacy of some of those policies is
questionable. In response, two new systems, based upon fundamentally different
goals, were promoted. The Centers for Disease Control, prompted by health—care
worker& concerns about occupational risk of human immunodeficiency virus (HIV)
from a growing number of patients with acquired immunodeficiency disease
syndrome (AIDS), issued formal guidelines in 1987. This formed the basis for
Universal Precautions (UP), a unifying strategy for precautions with all patients
regardless of diagnosis intended to reduce risk to hospital staff members. Also
in 1987, one hospital issued guidelines for Body Substance Isolation (BSI),
hygienic precautions to be used with all patients based on recognition that
colonized body substances are important reservoirs for cross—infection to both
patients and staff members. These new strategies have been promoted widely,
but there have been no formal assessments to reconcile controversies they
raised nor to confirm their effectiveness. Further, necessary assessment tools
have not been validated.
This thesis provides new tools and new information to address three vital
questions: Have hospitals adopted Universal Precautions or Body Substance
Isolation? Do their staff members use the new system of precautions in daily
practice? Has reliable use of a new system led to decreased risk of infection?
A confidential mailed survey of all acute—care Canadian hospitals was
conducted to measure rates of guideline receipt and adoption. It also obtained
information on motivations for and perceived effectiveness of strategies adopted. A self—selected group of responding hospitals subsequently participated in
standardized covert observation of their nurses infection control practices, then
had the observed nurses complete a test examining their knowledge and beliefs.
Employee health records were also examined to determine whether needlestick
injury rates had changed since adoption of a new infection control strategy.
Most Canadian hospitals adopted and modified new strategies based upon
reasonable but unproven extensions of logic to protect health—care workers from
HIV. 74% claimed UP (65%) or BSI (9%) but only 5% of 359 claiming UP and 0
of 50 claiming BSI adopted all policies expected. Many hospitals had not
received key guideline publications. Guideline source, hospital size, and other
variables were significantly associated with receipt. Nurses in 35 hospitals
were observed to wear gloves during only z60% of procedures in which gloving
was expected; rates varied widely among hospitals. Direct examination of sharps
disposal containers confirmed compliance with a policy to not recap used needles
(taken as recapping rate of 25%) in only 47% of 32 hospitals. Paired analysis
of needlestick injury rates in 11 hospitals during comparable 90—day periods
before versus after implementing UP/BSI showed no significant difference. 489
nurses completing a written test achieved their highest scores and least
discordance among questions regarding procedural issues established long before
UP/BSI, and lower scores or greater discordance on UP/BSJ concepts of
philosophy, risk recognition and newer procedures. Positive correlation between
knowledge and practice was not evident. UP and BSI now mean different things
in different hospitals and have not been effective in harmonizing health—care
workers’ infection control practices. Carefully standardized assessment methods
are needed to guide their evolution to cost—effectiveness. === Graduate and Postdoctoral Studies === Graduate
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