There are additional factors making it unlikely that every specimen and test receives the same attention, as required by universal precautions: the pressure to produce rapid test results for very sick patients (particularly in emergency situations), sensitivity to clinical needs, the demands from clinicians and relatives to get autopsy information quickly and the understandable desire that funeral arrangements not be delayed. All these situations require professional judgement. Precautions, if they are to be applied, should facilitate rather than hinder. There is a need for a detailed review of hospital activities to establish what aspects of universal precautions are not being followed and why. If any activities are shown to be impractical in the application of these precautions, consideration must be given as to what should be done. I thank Valerie Dalgetty for her help in the preparation of this letter and Dr. Ingrid Luchsinger for her challenging questions and for her criticisms. Matthew J. McQueen, MB, ChB, PhD, FCACB, FRCPC Chief Department of Laboratory Medicine Hamilton General Division Hamilton Civic Hospitals Hamilton, Ont.
References 1. Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MMWR 1988; 37: 377387 2. National Committee for Clinical Laboratory Standards: Protection of Laboratory Workers from Instrument Biohazards: Proposed Guideline (publ I 17-P), NCCLS, Villanova, Pa, 1991 3. Idem: Protection of Laboratory Workers from Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Tentative Guideline (publ M29-T2), NCCLS, Villanova, Pa, 1991 4. McQueen MJ: Conflicting rights of patients and health care workers exposed to blood-borne infection. Can Med Assoc J 1992; 147: 299-302 1116
CAN MED ASSOC J 1992; 147 (8)
Universal precautions not justified
Numerous policies and procedures are being subjected to an analysis of cost-effectivene-s. According to a 1990 study by Stock, I disagree with the conclusion Gafni and Bloch4 the economic of Dr. Marie Louie and asso- validity of universal precautions ciates in "Prevalence of is questionable, and there is minibloodborne infective agents mal documentation of their effecamong people admitted to a Can- tiveness. Therefore, the assumpadian hospital" (Can Med Assoc J tion made by Louie and associates 1992; 146: 1331-1334) that the perpetuates but does not substanuse of universal precautions is tiate the perception that universal justified by prevalence rates of precautions are justified. 2.1% for hepatitis B surface antigen and 0.6% and 0.5% for anti- John Hardie, BDS, FRCDC, FICDC bodies to the human immunodefi- Head of Dentistry ciency virus (HIV) and the hepati- Department British Columbia's Health Sciences Centre tis C virus (HCV) respectively. Vancouver, BC Such an inference would be possible if the use of universal precau- References tions were the only reason for infective agents not being trans- 1. National Surveillance of Occupational Exposure to the Human Immunodefimitted to health care workers. The ciencv Virus, Federal Centre for AIDS, investigation failed to show this. Ottawa, 1992 The surveillance study' of the 2. Kiyosawa K, Sodeyama T, Tanaka E et al: Hepatitis C in hospital employees Federal Centre for AIDS demonwith needlestick injuries. Ann Intern strated that health care workers Med 1991; 115: 367-369 were exposed to HIV-infected 3. Universal precautions for prevention of transmission of human immunodefiblood no matter what form of ciency virus, hepatitis B virus, and protection was worn but that such other bloodborne pathogens in healthexposure did not result in serocare settings. MMWR 1988; 37: 377conversion. This should not be 388 surprising, since HIV transmis- 4. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transsion does not occur through the mission to health care workers: an ecoroutes protected by barrier technomic analysis. Can Med Assoc J 1990; niques. These findings weaken 142: 937-946 rather than support the use of universal precautions to avoid the occupational spread of HIV. Inexperience with HCV explains the uncertainty regarding Program evaluation its transmission to health care in health care workers. However, gloves would not have protected the 1 10 workhis article by the Health ers mentioned by Louie and assServices Research Group ociates from exposure through (Can Med Assoc J 1992; needlestick injuries.2 146: 1301-1304) describes the Finally, the authors fail to field as it was about 25 years ago. indicate that the most effective Program evaluation continues method of avoiding occupational to be viewed by some of its practitransmission of the hepatitis B tioners as a method of systemativirus is vaccination. The Centers cally collecting and analysing data for Disease Control, Atlanta, do about a specific program in order not include this among their uni- to summarize or improve its overversal precautions3 but consider it all performance. Over the past few to be an important adjunct to decades, however, this insular persuch preventive techniques. spective on the purposes of evaluLE
15 OCTOBRE 1992
ation has evolved into a more global one, particularly in the field of health care. Since the 1 980s, health program evaluation has become a key component of health services research. In part this is because of improvements in methods, but the field has also attracted practitioners with expertise in scientifically analysing interventions so that health program developers, researchers and policymakers have access to growing empiric evidence. No longer do evaluators have to tiptoe behind program developers and funders hoping for permission to collect data. Evaluation has proved its usefulness to the extent that most US federal and state programs require evaluations of new initiatives, and some health foundations have doctoral-level personnel specifically assigned to oversee evaluation activities. In addition, evaluations have been accepted as newsworthy: on a single day (Apr. 23, 1992), page 1 of the New York Times featured two evaluations: one of a US program linking welfare payments to job training and the other of the impact that current events broadcasts on a commercial in-school television channel had on children's knowledge. Despite the maturation of evaluation methods and uses some evaluation practitioners continue to assert that their discipline is only rarely a form of research, or they skim over this primary evaluation function. They claim that at certain stages of program development, research of any kind is not practical or even desirable. The example usually given to defend this view is that of a newly organized program that needs time to grow and train its staff and whose goals and objectives are evolving. At the beginning evaluators may be called in to help reformulate the goals and reassess the validity of the original standards, but research is irreleOCTOBER 15, 1992
vant. Further, the argument continues, evaluators are sometimes asked to conduct, for purposes of comparison, "summative" evaluations - historical reviews that take place after programs have been in operation for some time. The example given to defend evaluation against research is flawed, because it assumes that evaluators are program developers at the mercy of a "real" world that is inimical to research. It is true that some trained evaluators have the skills to participate in program development, monitoring and review and that practical concerns sometimes render research difficult to pursue. However, it is more likely that graduates of disciplines more directly concerned with institutional organization and management are better trained in program development than are evaluators. Evaluators are likely to be most helpful and influential in providing scientific data that are applicable beyond the needs of a single intervention. Evaluation is useful to policymakers only if it is a scientific endeavour with generalizable results. Policymakers regulate education in, access to, delivery of and reimbursement for health care. They may be legislators, insurers, philanthropic foundation leaders or medical educators. They have little use for data on the specific issues pertaining to a single program. Health researchers, too, benefit little if evaluators focus on developmental efforts and single programs. Researchers want to learn more about high-quality health care and how to deliver and appraise it. The most constructive way of providing valid data on quality, effectiveness, efficiency and methods is to use scientific procedures to investigate programs. The ability to do this is the unique province of the program evaluator. It is ironic that the CMAJ article has the section flag "Health
Services Research" when the authors give minimal attention to evaluation as research - just about one sentence, in fact. The example they give of outcome evaluation is the most inadequate they could have concocted. The example focuses on retrospective designs and comparisons with historical data, the sort of thing evaluators relied on more than a decade ago. It is definitely time to move on. Arlene Fink, PhD Professor of medicine and public health University of California at Los Angeles Los Angeles, Calif.
[Two of the authors respond.] We thank Dr. Fink for the vigorous statement of her view of program evaluation. She has highlighted two issues: the independence of evaluators from program developers and funders and the role of evaluators in developmental program evaluation efforts. Although we agree that program evaluators need not be involved in program development, monitoring and review, we believe that evaluators must, at the very least, have evidence that these activities have been undertaken and that appropriate evaluation standards have been met. The roles of evaluators may be different in the United States. In Canada, the provinces fund and administer programs for health and human services, as stipulated in the British North America Act. The federal government may share in the funding of programs and set national standards for access and coverage, but it does not have direct responsibility for either managing or evaluating these services. Even provincially the provision and the management of services are highly decentralized. Each provincial ministry of health is provided with patient discharge summary data and global hospital budgets for approval and funding. CAN MED ASSOC J 1992; 147 (8)
1117
References 1. Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other blood borne pathogens in health care settings. MMWR 1988; 37: 377387 2. National Committee for Clinical Laboratory Standards: Protection of Laboratory Workers from Instrument Biohazards: Proposed Guideline (publ I 17-P), NCCLS, Villanova, Pa, 1991 3. Idem: Protection of Laboratory Workers from Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Tentative Guideline (publ M29-T2), NCCLS, Villanova, Pa, 1991 4. McQueen MJ: Conflicting rights of patients and health care workers exposed to blood-borne infection. Can Med Assoc J 1992; 147: 299-302 1116
CAN MED ASSOC J 1992; 147 (8)
Universal precautions not justified
Numerous policies and procedures are being subjected to an analysis of cost-effectivene-s. According to a 1990 study by Stock, I disagree with the conclusion Gafni and Bloch4 the economic of Dr. Marie Louie and asso- validity of universal precautions ciates in "Prevalence of is questionable, and there is minibloodborne infective agents mal documentation of their effecamong people admitted to a Can- tiveness. Therefore, the assumpadian hospital" (Can Med Assoc J tion made by Louie and associates 1992; 146: 1331-1334) that the perpetuates but does not substanuse of universal precautions is tiate the perception that universal justified by prevalence rates of precautions are justified. 2.1% for hepatitis B surface antigen and 0.6% and 0.5% for anti- John Hardie, BDS, FRCDC, FICDC bodies to the human immunodefi- Head of Dentistry ciency virus (HIV) and the hepati- Department British Columbia's Health Sciences Centre tis C virus (HCV) respectively. Vancouver, BC Such an inference would be possible if the use of universal precau- References tions were the only reason for infective agents not being trans- 1. National Surveillance of Occupational Exposure to the Human Immunodefimitted to health care workers. The ciencv Virus, Federal Centre for AIDS, investigation failed to show this. Ottawa, 1992 The surveillance study' of the 2. Kiyosawa K, Sodeyama T, Tanaka E et al: Hepatitis C in hospital employees Federal Centre for AIDS demonwith needlestick injuries. Ann Intern strated that health care workers Med 1991; 115: 367-369 were exposed to HIV-infected 3. Universal precautions for prevention of transmission of human immunodefiblood no matter what form of ciency virus, hepatitis B virus, and protection was worn but that such other bloodborne pathogens in healthexposure did not result in serocare settings. MMWR 1988; 37: 377conversion. This should not be 388 surprising, since HIV transmis- 4. Stock SR, Gafni A, Bloch RF: Universal precautions to prevent HIV transsion does not occur through the mission to health care workers: an ecoroutes protected by barrier technomic analysis. Can Med Assoc J 1990; niques. These findings weaken 142: 937-946 rather than support the use of universal precautions to avoid the occupational spread of HIV. Inexperience with HCV explains the uncertainty regarding Program evaluation its transmission to health care in health care workers. However, gloves would not have protected the 1 10 workhis article by the Health ers mentioned by Louie and assServices Research Group ociates from exposure through (Can Med Assoc J 1992; needlestick injuries.2 146: 1301-1304) describes the Finally, the authors fail to field as it was about 25 years ago. indicate that the most effective Program evaluation continues method of avoiding occupational to be viewed by some of its practitransmission of the hepatitis B tioners as a method of systemativirus is vaccination. The Centers cally collecting and analysing data for Disease Control, Atlanta, do about a specific program in order not include this among their uni- to summarize or improve its overversal precautions3 but consider it all performance. Over the past few to be an important adjunct to decades, however, this insular persuch preventive techniques. spective on the purposes of evaluLE
15 OCTOBRE 1992
ation has evolved into a more global one, particularly in the field of health care. Since the 1 980s, health program evaluation has become a key component of health services research. In part this is because of improvements in methods, but the field has also attracted practitioners with expertise in scientifically analysing interventions so that health program developers, researchers and policymakers have access to growing empiric evidence. No longer do evaluators have to tiptoe behind program developers and funders hoping for permission to collect data. Evaluation has proved its usefulness to the extent that most US federal and state programs require evaluations of new initiatives, and some health foundations have doctoral-level personnel specifically assigned to oversee evaluation activities. In addition, evaluations have been accepted as newsworthy: on a single day (Apr. 23, 1992), page 1 of the New York Times featured two evaluations: one of a US program linking welfare payments to job training and the other of the impact that current events broadcasts on a commercial in-school television channel had on children's knowledge. Despite the maturation of evaluation methods and uses some evaluation practitioners continue to assert that their discipline is only rarely a form of research, or they skim over this primary evaluation function. They claim that at certain stages of program development, research of any kind is not practical or even desirable. The example usually given to defend this view is that of a newly organized program that needs time to grow and train its staff and whose goals and objectives are evolving. At the beginning evaluators may be called in to help reformulate the goals and reassess the validity of the original standards, but research is irreleOCTOBER 15, 1992
vant. Further, the argument continues, evaluators are sometimes asked to conduct, for purposes of comparison, "summative" evaluations - historical reviews that take place after programs have been in operation for some time. The example given to defend evaluation against research is flawed, because it assumes that evaluators are program developers at the mercy of a "real" world that is inimical to research. It is true that some trained evaluators have the skills to participate in program development, monitoring and review and that practical concerns sometimes render research difficult to pursue. However, it is more likely that graduates of disciplines more directly concerned with institutional organization and management are better trained in program development than are evaluators. Evaluators are likely to be most helpful and influential in providing scientific data that are applicable beyond the needs of a single intervention. Evaluation is useful to policymakers only if it is a scientific endeavour with generalizable results. Policymakers regulate education in, access to, delivery of and reimbursement for health care. They may be legislators, insurers, philanthropic foundation leaders or medical educators. They have little use for data on the specific issues pertaining to a single program. Health researchers, too, benefit little if evaluators focus on developmental efforts and single programs. Researchers want to learn more about high-quality health care and how to deliver and appraise it. The most constructive way of providing valid data on quality, effectiveness, efficiency and methods is to use scientific procedures to investigate programs. The ability to do this is the unique province of the program evaluator. It is ironic that the CMAJ article has the section flag "Health
Services Research" when the authors give minimal attention to evaluation as research - just about one sentence, in fact. The example they give of outcome evaluation is the most inadequate they could have concocted. The example focuses on retrospective designs and comparisons with historical data, the sort of thing evaluators relied on more than a decade ago. It is definitely time to move on. Arlene Fink, PhD Professor of medicine and public health University of California at Los Angeles Los Angeles, Calif.
[Two of the authors respond.] We thank Dr. Fink for the vigorous statement of her view of program evaluation. She has highlighted two issues: the independence of evaluators from program developers and funders and the role of evaluators in developmental program evaluation efforts. Although we agree that program evaluators need not be involved in program development, monitoring and review, we believe that evaluators must, at the very least, have evidence that these activities have been undertaken and that appropriate evaluation standards have been met. The roles of evaluators may be different in the United States. In Canada, the provinces fund and administer programs for health and human services, as stipulated in the British North America Act. The federal government may share in the funding of programs and set national standards for access and coverage, but it does not have direct responsibility for either managing or evaluating these services. Even provincially the provision and the management of services are highly decentralized. Each provincial ministry of health is provided with patient discharge summary data and global hospital budgets for approval and funding. CAN MED ASSOC J 1992; 147 (8)
1117
