Bloodborne Pathogens, Infection Control, PPE, Exposure Control and Germicides 2011

Transcription

1 Bloodborne Pathogens, Infection Control, PPE, Exposure Control and Germicides 2011 Test Length: 90 Minutes The Occupational Safety and Health Administration (OSHA) estimates that 5.6 million workers in the health care industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). All occupational exposure to blood or other potentially infectious materials (OPIM) place workers at risk for infection with bloodborne pathogens. Exposure can occur through cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood if gloves are not worn. Bloodborne pathogens are pathogenic microorganisms that are present in human blood and can cause disease in humans. The term "other potentially infectious materials" (OPIM) means the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, body fluids that are visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; any unfixed tissue or organ (other than intact skin) from a human (living or dead); and HIVcontaining cells or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals with HIV or HBV. Under the OSHA standard each employer who has at least one employee with occupational exposure is required to prepare an exposure determination. This exposure determination is made without regard to the use of personal protective equipment and contains the following information: A list of all job classifications in which employees have occupational exposure Medical Service Technicians Equipment Cleaning Technicians A list of job classifications in which some employees have occupational exposure Customer Service Branch Managers

2 A list of all tasks and procedures or groups of closely related task and procedures in which occupational exposure occurs and that are performed by employees in the specified job classifications Picking up used equipment Cleaning used equipment Repairing used equipment The exposure determination will then be used in the development of an exposure control plan. Not wearing PPE properly Not disinfecting equipment properly Exposure Control Plan OSHA requires every business with employees that may be potentially exposed to harmful agents on the job to have a written Exposure Control Plan (ECP). The exposure control plan is National HME's written program that outlines the protective measures taken to eliminate or minimize employee exposure to blood and OPIM and must be accessible to all employees. The prevention of exposure to bloodborne pathogens and any actions that need to be taken in the event of an exposure must be included in the written ECP. This course is not intended to take the place of National HME's Exposure Control Plan. The Exposure Control Plan must be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. The review and update of such plans shall also reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens and document annual consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure. Employers must solicit input from non-managerial employees responsible for direct patient care regarding the identification, evaluation, and selection of effective engineering controls, including safer medical devices. Employees selected should represent the employees that use the devices being evaluated. Employers are required to document, in the Exposure Control Plan, how they received input from employees.

3 Universal Precautions Universal precautions, as defined by the CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodborne pathogens. Universal precautions may also be referred to as Standard Precautions. Universal precautions apply to blood and other body fluids containing visible blood, semen, and vaginal secretions. Universal precautions also apply to tissues and to the following fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. Universal precautions do not apply to saliva except when visibly contaminated with blood or in the dental setting where blood contamination of saliva is predictable. Universal precautions involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infective materials. In addition, under universal precautions, it is recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices. Work Practices Employees have the responsibility of following universal precautions and the guidelines specific to their job description and related tasks for preventing bloodborne pathogen exposure. All procedures involving blood or OPIM must be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. Specifically, when picking up, cleaning, and repairing used equipment. In any area (dirty equipment area, at a residence) that has a reasonable likelihood of occupational exposure to bloodborne pathogens, eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses is prohibited. Food and drinks must never be kept in refrigerators, freezers, shelves, and cabinets or on countertops or bench tops where blood or OPIM is present.

4 National HME must ensure that the worksite is maintained in a clean and sanitary condition. National HME must determine and implement an appropriate written schedule for cleaning and methods of decontamination for the appropriate spaces in each facility, e.g., type of surface to be cleaned, type of soil present, and tasks or procedures being performed. Specific cleaning methods are discussed later in this course. Personal Protective Equipment All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure during contact with any patient's blood or body fluids that require universal precautions. These items are referred to as Personal Protective Equipment (PPE) and may include, but are not limited to: Gloves Face shields or masks and eye protection Aprons Mouthpieces, resuscitation bags, pocket masks, or other ventilation devices When there is the risk of occupational exposure, National HME must provide, at no cost to the employee, appropriate PPE. When National HME is required to provide PPE, they must also make sure that it is being used in the appropriate manner. They are also required to clean, launder, and dispose of PPE as required. In addition, they must repair or replace PPE as needed to maintain its effectiveness, all of which must be at no cost to their employees. Eye and Face Protection Masks and protective eyewear or face shields should be worn by health care workers to prevent exposure of mucous membranes of the mouth, nose, and eyes during procedures that are likely to generate droplets of blood or body fluids requiring universal precautions. These should be used anytime there is a risk of splashing or vaporization of contaminated fluids. Splashing can occur while cleaning dirty equipment, during clinical procedures, or while providing first aid or medical assistance. Bloodborne pathogens can be transmitted through the thin membranes of the eyes so it is important to protect them. Face shields may be worn to protect the eyes and can be used in addition to goggles to provide additional face protections. A face shield will protect against splashes to the nose and mouth.

5 Aprons Aprons or gowns may be worn to protect clothing and to keep blood or other contaminated fluids from soaking through to the skin and should be worn during procedures that are likely to generate splashes of blood or body fluids requiring universal precautions. An important note, however, is that regular work clothing is not considered PPE. Mouthpieces and other Ventilation Devices Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouth- pieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. Gloves The effectiveness of gloves in preventing contamination to health care worker's hands has been confirmed by laboratory tests. One study identified that glove usage reduced the numbers of bacteria on the hands by greater than 80%. Wearing gloves will aid in preventing hand contamination, the acquisition of resistant organisms, and the reduction of the transmission of pathogens. It is essential that all health care workers understand that wearing gloves does not eliminate the need for appropriate hand hygiene. The following precautions must be understood when wearing gloves: Gloves cannot provide complete protection against bacterial contamination of hands. Wearing gloves cannot completely guard against acquiring infections. Cover all cuts and sores on the hand with a bandage or similar protection prior to donning gloves. Glove manufacturing guidelines are designed to eliminate most glove defects; however, a limited percentage of gloves will have small holes that could provide a passageway for microbial transfer. If gloves are not removed correctly they can be a source of hand contamination.

6 When removing gloves, it is critical to do so carefully. It is important to be sure that no part of the contaminated gloves comes in contact with bare skin, and they should be disposed of so that no one else will come in contact with them either. It is crucial that health care workers immediately wash their hands following glove removal when hands are visibly soiled. Hands should also be washed any time the integrity of the gloves is compromised during use. If there is no visible contamination of the hands, an alcohol handrub may be appropriate for use following glove removal. In addition, gloves should be changed after contact with each patient. Hands and other skin surfaces should be washed immediately or as soon as patient safety permits if contaminated with blood or body fluids requiring universal precautions. Gloves should reduce the incidence of blood contamination of hands during phlebotomy, but they cannot prevent penetrating injuries caused by needles or other sharp instruments. Institutions that believe routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health care workers who wish to use them for phlebotomy. In addition, the following general guidelines apply: Use gloves when touching blood and body fluids requiring universal precautions, mucous membranes, or non-intact skin of all patients. Use gloves for performing phlebotomy when the health care worker has cuts, scratches, or other breaks in his/her skin. Use gloves in situations where the health care worker judges that hand contamination with blood may occur, e.g., when performing phlebotomy on an uncooperative patient. Use gloves for performing finger and/or heel sticks on infants and children. Use gloves when persons are receiving training in phlebotomy. Use gloves for handling items or surfaces soiled with blood or body fluids to which universal precautions apply. Gloves worn in home care activities are typically made from natural rubber latex or synthetic non-latex materials. There is an increasing prevalence of latex allergies in both health care workers and patients. To reduce the incidence of latex allergy, National HME is required to provide alternative protective gloves, e.g. reduced powder or powder-free, low protein natural rubber latex, or latex-free synthetic gloves for those with latex allergies. Medical gloves should never be washed or reused (an exception may be heavier reusable gloves such as those used in housekeeping or cleaning). Some additional considerations for gloves are as follows: The correct size gloves should be selected.

7 Promote proper fingernail length (1/4 inch) to minimize glove tears and maintain glove integrity. Avoid the use of petroleum-based lotions or creams with latex gloves, as they may adversely affect the integrity of latex gloves. Storing near hot or cold extremes, sunlight, ultraviolet light, fluorescent lights, or x-rays may impact the integrity of gloves. Heavily fragranced lotions may precipitate hand irritation if worn under gloves. Consider health care personnel lotions that are compatible with hand hygiene products. If powdered gloves are used, followed by hand hygiene with certain alcohol handrubs, powder residue may interact with the alcohol producing a gritty feeling on hands. This is an essential issue to address, both when selecting gloves as well as when choosing alcohol products for hand hygiene. Gloves should always be changed between patients and during patient care if moving from a contaminated to a clean task. Select an appropriate glove for use when exposure to chemicals is anticipated. PPE must be removed prior to leaving the work area. The work area is generally considered to be an area where work involving occupational exposure occurs or where the contamination of surfaces may occur. The use of gloves along with other PPE items can significantly reduce the risk of exposure to bloodborne pathogens and should be used when appropriate. Hand Hygiene Hand hygiene is a general term that applies to handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis. Handwashing is the washing of the hands with plain (i.e., non-antimicrobial) soap and water. Since handwashing is the best way to prevent the spread of disease, National HME is required to provide handwashing facilities that are readily accessible to employees. When the provision of handwashing facilities is NOT feasible, National HME must provide either an appropriate antiseptic hand cleaner (alcohol-based hand rub) or antiseptic towelettes. An alcohol-based hand rub is an alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands. The majority of alcohol-based hand

8 antiseptics contain isopropanol, ethanol, n-propanol, or a combination of two of these products. Alcohol hand rubs are not appropriate when hands are visibly dirty or contaminated with proteinaceous materials. However, when relatively small amounts of proteinaceous material are present, ethanol and isopropanol may reduce viable bacterial counts on hands more than plain soap or antimicrobial soap. Alcohol-based products are more effective for standard handwashing or hand antisepsis by health care workers than soap or antimicrobial soaps. Many people who frequently perform hand hygiene may experience skin problems, including skin dryness and contact dermatitis. Irritation associated with antimicrobial soaps may be caused by the antimicrobial agent or by other ingredients in the formulation. Alcohol-based hand rubs cause less skin irritation. Allergic reactions to alcohol-based products may represent true allergy to alcohol, or allergy to another constituent of the product. Potential strategies for minimizing skin irritation include evaluation of the products used to select a less irritating product, and providing workers with moisturizing skin care products or barrier creams. There are alcohol-based hand rubs that contain various emollients that provide some skin protection. The CDC states that, "Routinely washing hands with soap and water immediately after using an alcohol hand rub may lead to dermatitis. Therefore, personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol hand rub." However, because personnel feel a "build-up" of emollients on their hands after repeated use of alcohol hand gels, washing hands with soap and water after 5-10 applications of a gel has been recommended by certain manufacturers. CDC Guidelines The CDC provides the following recommendations for handwashing and antisepsis: When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, they should be washed with either a non-antimicrobial soap and water or an antimicrobial soap and water. If hands are not visibly soiled, an alcohol-based hand rub may be appropriate. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations where appropriate. Decontaminate hands before having direct contact with patients Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter

9 Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient Decontaminate hands after removing gloves. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of health care workers, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores The following are CDC recommendations for performing hand hygiene techniques: When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's recommendations regarding the volume of product to use. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.

10 Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a nonantimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings. The CDC provides the following guidelines for selecting cleansers: Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift. This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel. To maximize acceptance of hand-hygiene products by health care workers, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand-hygiene products should not be the primary factor influencing product selection. When selecting non-antimicrobial soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit information from manufacturers regarding any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution. Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate volume of product. Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to bacterial contamination of soap. The following are CDC recommendations for providing skin care: Health care workers should be provided with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing Information should be solicited from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution.

11 If the hands become exposed to blood or other potentially infectious materials, they should immediately be washed with soap and water. Mucous membranes that are exposed should be flushed with water immediately or as soon as feasible. Decontamination and Sterilization It is necessary to decontaminate and sterilize any surface that has been compromised by blood or other infectious materials. The more commonly used public health antimicrobial products include the following: Sterilizers (Sporicides): These are used to destroy or eliminate all forms of microbial life including fungi, viruses, and all forms of bacteria and their spores. Spores are considered to be the most difficult form of microorganism to destroy. Therefore, the EPA considers the term Sporicide to be synonymous with "Sterilizer." Sterilization is the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial spores and is critical to infection control and is widely used in hospitals on medical and surgical, instruments and equipment. Types of sterilizers include steam under pressure (autoclaving), dry heat ovens, low temperature gas (ethylene oxide), and liquid chemical sterilants. Gaseous and dry heat sterilizers are used primarily for sterilization of medical instruments. Liquid sterilants are primarily used for delicate instruments which cannot withstand high temperature and gases. Disinfectants: Disinfection is the use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores) on inanimate objects. Disinfectant products are divided into two major types: hospital and general use. Hospital type disinfectants are the most critical to infection control and are used on medical and dental instruments, floors, walls, bed linens, toilet seats, and other surfaces. General disinfectants are the major source of products used in households, swimming pools, and water purifiers. There are three levels of Hospital type disinfection: high, intermediate, and low. High-level disinfection kills all organisms, except high levels of bacterial spores. The FDA recognizes these chemical germicides as sterilants. Intermediate-level disinfection kills mycobacteria, most viruses, and bacteria with a chemical germicide registered by the Environmental Protection Agency (EPA) as tuberculocides.

12 Low-level disinfection kills some viruses and bacteria with a chemical germicide registered by the EPA as hospital disinfectants. Sanitizers: Used to reduce, but not necessarily eliminate, microorganisms from the inanimate environment to levels considered safe as determined by public health codes or regulations. Sanitizers include food contact and non-food contact products. Sanitizing rinses for surfaces such as dishes and cooking utensils, as well as equipment and utensils found in dairies, food-processing plants, and eating and drinking establishments comprise the food contact Sanitizers. These products are important because they are used on sites where consumable food products are placed and stored. Non-food contact surface sanitizers include carpet sanitizers, air sanitizers, laundry additives, and in-tank toilet bowl sanitizers. Antiseptics and Germicides: These are used to prevent infection and decay by inhibiting the growth of microorganisms. Because these products are used in or on living humans or animals, they are considered drugs and are thus approved and regulated by the Food and Drug Administration (FDA). The CDC uses the Spaulding classification for medical and surgical equipment, which outlines three categories of equipment based on the potential for the device to transmit infection if the device is microbiologically contaminated before use. The categories are critical, semi-critical, and non-critical. In 1991 the CDC proposed an additional category designated environmental surfaces to represent surfaces that generally do not come into direct contact with patients during care. Critical Items Critical items are those that present a high risk of infection if contaminated with any microorganism. Most items in this category should be heat sterilized by steam under pressure. Chemical sterilants can be relied on to produce sterility only if adequate cleaning precedes treatment and if proper guidelines with regard to quantity of organic material, germicide contact time, temperature, and ph are met. Semicritical Items Semicritical items are those objects that come in contact with mucous membranes or skin that is not intact. Semicritical items generally require high-level disinfection with wet pasteurization or chemical

13 disinfectant. It is recommended that semicritical items be rinsed with sterile water after disinfection to prevent contamination with organisms that may be present in tap water. Noncritical Items Noncritical items are those that come in contact with intact skin, but not mucous membranes. There is generally little risk of transmitting infectious agents to patients by means of noncritical items. Most items in this category can be cleaned using low-level disinfectant. Selection of Cleansing Method National HME must identify which items need sterilization or disinfection based on their intended use and use the appropriate germicide. Medical devices that enter the blood stream or enter normally sterile tissue should be sterilized using heat-based methods. Reusable devices or items that touch mucus membranes should, at a minimum, receive high-level disinfection between patients. These devices include reusable flexible endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment. Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce organic or inorganic material before being exposed to the germicide and the germicide and the device manufacturer's instructions should be closely followed. Except on rare and special instances, items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients. These items include crutches, bed boards, blood pressure cuffs, and a variety of other medical accessories. Consequently, depending on the particular piece of equipment or item, washing with detergent or using a low-level disinfectant may be sufficient when decontamination is needed. When using a low-level disinfectant the contact time should be at least 10 minutes. To see listings of the EPA's registered antimicrobial products, select here. If you have any questions about low- or intermediate disinfectants and certain sterilants, contact the manufacturer, or the Antimicrobial Program Branch of the EPA hotline at (703) If you have questions about highlevel disinfectants, contact the FDA's Center for Devices and Radiological Health at (301)

14 Extraordinary attempts to disinfect walls, floors, or other environmental surfaces are not necessary. However, cleaning and removing of soil should be done routinely. An inexpensive environmental surface germicide effective against HIV is a solution of sodium hypochlorite (1 part household bleach to 99 parts water or ¼ cup bleach to 1 gallon of water) prepared daily. Of course, any materials you use to clean up a spill of blood or potentially infectious materials must be decontaminated immediately. This would include mops, sponges, reusable gloves, buckets, pails, etc. Communication of Hazards Warning labels need to be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material, and other containers used to store, transport, or ship blood or other potentially infectious materials. These labels are fluorescent orange, red, or orange-red. Bags used to dispose of regulated waste must be red or orange-red, and they, too, must have the biohazard symbol readily visible upon them. Regulated waste should be double-bagged to guard against the possibility of leakage if the first bag is punctured. Regulated waste refers to: Any liquid or semi-liquid blood or other potentially infectious materials. Contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed. Items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling. Contaminated sharps. Pathological and microbiological wastes containing blood or other potentially infectious materials. All regulated waste must be disposed in properly labeled containers or red biohazard bags. These must be disposed at an approved facility. Most departments or facilities that generate regulated waste will have some sort of contract with an outside disposal company that will pick up the waste and take it to an approved disposal facility.

15 Non-regulated waste (i.e., does not fit the definition of regulated waste provided above) that is not generated by a medical facility may be disposed in regular plastic trash bags if it has been decontaminated or sterilized prior to disposal.