HIV, trauma, and infection control: universal precautions are universally ignored

The medical, legal, and ethical problems associated with routine HIV screening have led to the recommendation that all patients should be presumed to be seropositive and thus protective measures should be taken by all health care workers. This philosophy, termed "universal precautions," has been difficult to adhere to or enforce, however. Nevertheless, in some trauma population subsets, the prevalence of HIV seropositivity runs as high as 19%, and thus presents an occupational hazard to the trauma health care worker. The mainstays of universal precautions (UP) are barrier techniques against body fluid contact and protection from inadvertent needlestick. To judge compliance with a strict UP protocol, surgical residents engaged in trauma room resuscitations were observed on a random basis by trauma nurse coordinators. Previously, UP had been discussed in conferences and by memo. Over 2 months, 81 trauma rooms were observed, involving 18 house officers. Overall, there was only 16% compliance with strict UP. The most common protocol variations involved sharps technique. While glove use was nearly universal, protective eye wear, ankle and foot protection, and body protection such as gowns or aprons were commonly ignored. Even in the presence of invasive procedures such as endotracheal intubation or insertion of chest tubes, compliance was less than 40%. The reasons most commonly given by house officers for the lapse in UP were not knowing the protocol, forgetting the protocol, or not having time to implement the protocol. Even for the nine patients residents identified as suspected of being in a high-risk category, UP was strictly adhered to only once. Compliance with universal precautions is difficult to achieve under the best of circumstances. It cannot be assumed that passive informational measures can achieve this goal. Active infection control surveillance and ongoing housestaff inservice are required to minimize the risk of inadvertent injury or contamination.