Raising the bar: the need for standardizing the use of "standard precautions" as a primary intervention to prevent occupational exposures to bloodborne pathogens.

Since 1987, healthcare institutions have invested substantial resources in implementing “Universal” or “Standard” Precautions. The publication of the Occupational Safety and Health Administration (OSHA) “Bloodborne Pathogen Standard” in 1991 mandated not only the use of these precautions in healthcare facilities but also annual training of all staff at risk for occupational exposures to bloodborne pathogens.1 Reducing occupational risks for bloodborne pathogen infection remains a focus of occupational medicine and hospital epidemiology programs throughout the United States and around the world. The apparent efficacy of postexposure antiretroviral chemoprophylaxis for occupational exposures to human immunodeficiency virus has added an additional “secondary prevention” arrow in the quiver of the team involved in postexposure management2,3; however, the antiretroviral agents used for postexposure prophylaxis are toxic, poorly tolerated, and less than 100% effective. Preventing exposures—primary prevention—offers the best, and by far the safest, opportunity to reduce occupational infections with bloodborne pathogens. Despite the fact that the implementation of Universal or Standard Precautions has been shown to be associated with a reduction in cutaneous4 and, in some settings, percutaneous5,6 exposures to blood, adherence to these precautions remains less than optimal. In this issue of the Journal, Beekmann and coworkers demonstrate in a large cross-sectional study of (primarily community) hospitals in Iowa and Virginia that training of at-risk personnel is uneven and that adherence to these precautions—despite the OSHA rule—is far from optimal.7 These authors provide insight into the following: (1) the occupational exposure rates in these community hospitals, giving the reader useful benchmarking data for similar institutions across the country; (2) the extent to which these institutions are investing in infection control programs as part of a comprehensive exposure-prevention strategy; (3) how these institutions are training their staff about exposure prevention; and (4) the unevenness of training for various categories of staff in many of these institutions. The article does provide some good news: the occupational exposure rates in these institutions appear to be slightly lower than those reported from larger centers over the past decade. A variety of factors, ranging from differences between community and academic centers, effective education of at-risk staff, and the use of safer devices, all may have contributed to this apparent reduction in exposure rates. One may postulate, however, that, with a minimum investment in aggressive exposure-prevention programs, these institutions could reduce their rates much further. In my own opinion, several of the findings in this manuscript are disquieting. Most of us working in the field of hospital epidemiology have been concerned with the “brain” and personnel drain that has occurred in our profession over the past 5 years. With hospitals scurrying to meet the challenges of leaner, meaner health-maintenance organizations and purchasers who have a careful eye on costs, hospital epidemiology programs have been vulnerable to what might be termed “creative downsizing.” The article by Beekmann et al demonstrates that the majority of