Using bottleneck analysis to examine the implementation of standard precautions in hospitals

Published:January 18, 2020DOI:


      • Bottleneck analysis was used to examine hospitals’ standard precaution implementation.
      • Service providers’ improper use of protection equipment was the primary bottleneck.
      • High workload and misperceptions contributed to incompliance of standard precaution.
      • Secondary bottlenecks included difficulties in finance, recycling, and procurement.


      Service providers are often inadequately compliant with standard precaution protocols. This study used bottleneck analysis to identify the weakest link in standard precaution implementation and its associated challenges in hospitals.


      Bottleneck analysis was conducted in 12 hospitals in Fujian Province, China. In each hospital, a focus group was organized among the key informants to illustrate the sequential steps of standard precaution implementation graphically. The level of difficulty and the specific challenges associated with each step were discussed.


      The sequential activities of standard precaution implementation generally start with making budget for personal protection equipment (PPE), followed by procurement, storage/inventory, in-hospital distribution, in-department distribution, usage/monitoring, and recycling of PPE. Service providers’ improper use of PPE was the primary bottleneck. The reasons for improper use of PPE included high workload, time constraints, the sense of wearing PPE would interfere with clinical judgment, and various misconceptions. Making financial planning, recycling, and procurement of PPE were the secondary bottlenecks.


      Bottleneck analysis is useful to illustrate workflow in healthcare systems and pinpoint constraints in standard precaution implementation. Institutional changes, including targeted provider training, adjustment of providers’ workloads, and allocation of budget, are suggested strategies to address the identified bottlenecks in standard precaution.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Rao SB
        How “Universal” are universal precautions?.
        AMA J Ethics. 2009; 11: 949-952
        • Bierer BE
        Universal precautions: necessary safety procedures when handling human blood, body fluids, and specimens.
        Curr Protoc Immunol. 2017; 118: A-3P
        • Yasin J
        • Fisseha R
        • Mekonnen F
        • Yirdaw K
        Occupational exposure to blood and body fluids and associated factors among health care workers at the University of Gondar Hospital, Northwest Ethiopia.
        Environ Health Prev Med. 2019; 24: 18
        • Centers for Disease Control and Prevention
        Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.
        2007 (Available at:) (Accessed July 23, 2019)
        • Centers for Disease Control and Prevention
        NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings.
        1999 (Available at:) (Accessed July 23, 2019)
        • Occupational Safety and Health Administration
        Worker Protections Against Occupational Exposure to Infectious Diseases.
        2019 (Available at:) (Accessed July 23, 2019)
        • Bledsoe BE
        • Sweeney RJ
        • Berkeley RP
        • Cole KT
        • Forred WJ
        • Johnson LD
        EMS provider compliance with infection control recommendations is suboptimal.
        Prehosp Emerg Care. 2014; 18: 290-294
        • Haile TG
        • Engeda EH
        • Abdo AA
        Compliance with standard precautions and associated factors among Healthcare Workers in Gondar University comprehensive specialized hospital, Northwest Ethiopia.
        J Environ Public Health. 2017; 20172050635
        • Liu XN
        • Sun XY
        • Genugten L
        • et al.
        Occupational exposure to blood and compliance with standard precautions among health care workers in Beijing, China.
        Am J Infect Control. 2014; 42 (e37-8)
        • Porto JS
        • Marziale MH
        Reasons and consequences of low adherence to standard precautions by the nursing team.
        Rev Gaúcha Enferm. 2016; 37: e57395
        • Li L
        • Lin C
        • Wu Z
        • Guan J
        • Jia M
        • Yan Z
        HIV-related avoidance and universal precaution in medical settings: opportunities to intervene.
        Health Serv Res. 2011; 46: 617-631
        • Felix AM
        • Victor E
        • Malagutti SE
        • Gir E
        Individual, work-related and institutional factors associated with adherence to standard precautions.
        J Infect Control. 2013; 2 (106-1)
        • Punia S
        • Nair S
        • Shetty RS
        Health care workers and standard precautions: perceptions and determinants of compliance in the emergency and Trauma Triage of a Tertiary care hospital in South India.
        Int Sch Res Notices. 2014; 2014685072
        • Efstathiou G
        • Papastavrou E
        • Raftopoulos V
        • Merkouris A
        Factors influencing nurses' compliance with Standard Precautions in order to avoid occupational exposure to microorganisms: a focus group study.
        BMC Nurs. 2011; 10: 1
        • Oliveira AC
        • Cardoso CS
        • Mascarenhas D
        Contact precautions in intensive care units: facilitating and inhibiting factors for professionals' adherence.
        Rev Esc Enferm USP. 2010; 44: 161-165
        • Kinlay J
        • Flaherty K
        • Scanlon P
        • Mehrotra P
        • Potter-Bynoe G
        • Sandora TJ
        Barriers to the use of face protection for standard precautions by health care providers.
        Am J Infect Control. 2015; 43: 169-170
        • Quan M
        • Wang X
        • Wu H
        • et al.
        Influencing factors on use of standard precautions against occupational exposures to blood and body fluids among nurses in China.
        Int J Clin Exp Med. 2015; 8: 22450-22459
        • Adebimpe WO
        Knowledge, attitude, and practice of use of safety precautions among health care workers in a Nigerian Tertiary Hospital, 1 year after the Ebola virus disease epidemic.
        Ann Glob Health. 2016; 82: 897-902
        • Akagbo SE
        • Nortey P
        • Ackumey MM
        Knowledge of standard precautions and barriers to compliance among healthcare workers in the Lower Manya Krobo District, Ghana.
        BMC Res Notes. 2017; 10: 432
        • Rupani MP
        • Gaonkar NT
        • Bhatt GS
        Bottleneck analysis and strategic planning using Tanahashi model for childhood diarrhea management in Gujarat, Western India.
        Eval Program Plann. 2016; 58: 82-87
        • Moran J
        Process Bottleneck Analysis.
        2017 (Available at:) (Accessed July 23, 2019)
        • Kiwanuka Henriksson D
        • Fredriksson M
        • Waiswa P
        • Selling K
        • Swartling Peterson S
        Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda.
        Glob Health Action. 2017; 101327256
      1. Bryant A Charmaz K The SAGE Handbook of Grounded Theory. SAGE Publications, Thousand Oaks, CA2010: 165-290
        • Yawson AE
        • Awoonor-Williams JK
        • Sagoe-Moses I
        • et al.
        Bottleneck analysis approach to accelerate newborn care services in two regions in Ghana: implications for national newborn care.
        Public Health. 2016; 141: 245-254
        • Gammon J
        • Morgan-Samuel H
        • Gould D
        A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions.
        J Clin Nurs. 2008; 17: 157-167
        • Hedayati H
        • Marjadi B
        • Askarian M
        Barriers to standard precautions adherence in a dental school in Iran: a qualitative study.
        Am J Infect Control. 2014; 42: 750-754
        • Dick AW
        • Perencevich EN
        • Pogorzelska-Maziarz M
        • Zwanziger J
        • Larson EL
        • Stone PW
        A decade of investment in infection prevention: a cost-effectiveness analysis.
        Am J Infect Control. 2015; 43: 4-9
        • Muder RR
        • Cunningham C
        • McCray E
        • et al.
        Implementation of an industrial systems-engineering approach to reduce the incidence of methicillin-resistant Staphylococcus aureus infection.
        Infect Control Hosp Epidemiol. 2008; 29: 702-708
        • The Central People's Government of the People's Republic of China
        Medical Waste Regulation.
        2003 (Available at:) (Accessed July 23, 2019)
        • Ali M
        • Wang W
        • Chaudhry N
        • Geng Y
        Hospital waste management in developing countries: a mini review.
        Waste Manag Res. 2017; 35: 581-592