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Occupational Health and Administration (OSHA) Infection Control Back to Course Index

 

OSHA is responsible to ensure the safety of employees

in the workplace by the establishment and enforcement

of safety and health standards.

Infection Control

 

There are numerous health and safety issues associated with healthcare facilities. They include bloodborne pathogens and biological hazards, potential chemical and drug exposures, waste anesthetic gas exposures, respiratory hazards, ergonomic hazards from lifting and repetitive tasks, laser hazards, hazards associated with laboratories, and radioactive material and x-ray hazards. Some of the potential chemical exposures include formaldehyde, used for preservation of specimens for pathology; ethylene oxide, glutaraldehyde, and paracetic acid used for sterilization; and numerous other chemicals used in health care laboratories.

In addition to the medical staff, large healthcare facilities employ a wide variety of trades that have health and safety hazards associated with them. These include mechanical
maintenance, medical equipment maintenance, housekeeping, food service, building and grounds maintenance, laundry, and administrative staff

 

 

Background

The concept of Universal precautions was developed in the mid 1980’s as a result of the human immunodeficiency virus (HIV) epidemic. The Center for Disease Control and Prevention (CDC) recognized that there was an urgent need to create strategies to protect healthcare personnel from infections carried in blood. Why? Because personnel were experiencing needle sticks and skin contamination with patients blood, and, there were reports of hospital personnel becoming infected with HIV from such events. Researchers were also learning that many patients with bloodborne infections are symptom free and are not recognized as infectious.

In 1985 the CDC officially introduced the application of Universal Precautions to all persons regardless of their presumed infection status. In 1991, The Occupational Safety and Health Administration (OSHA) published the Final Rule to improve working conditions and promote safety for you, the healthcare worker (HCW), when caring for patients infected with bloodborne pathogens. The new law required compliance to the published federal guidelines by all healthcare facilities. This law is a very important part of our approach to healthcare today. All healthcare workers should be familiar with the requirements in order to comply and to carry out safe practices for themselves and all co-workers (either present or downstream).

 

Exactly what are these bloodborne pathogens?

Bloodborne pathogens are pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

 

Current definition

In 1996 the definition and recommendations for Universal Precautions was revised and given the new name of Standard Precautions. Today, Standard Precautions is the primary strategy to be used to reduce the risk of transmission of pathogens from moist body substances and applies to all patients regardless of their diagnosis or presumed infection status. Healthcare workers must avoid all contact with moist body substances by the use of Personal Protective Equipment (PPE), work practices and engineering controls.

 

Standard Precautions apply to:

1. Blood

2. All body fluids, secretions, and excretions (except sweat) regardless of whether or not they contain visible blood

3. Non-intact skin

4. Mucous membranes

 

What are the requirements for Standard Precautions in everyday nursing practice?

1. Hand washing

a. All HCW’s should wash their hands thoroughly with soap and water when visibly soiled.

b. All HCW’s should wash their hands:

1. Before and after patient contact

2. After contact with any source of microorganism (all body fluids or moist surfaces and also inanimate objects found in the patient’s environment)

3. Immediately after removing gloves

c. How long should you wash?

The recommended time to wash hands is 10-15 seconds using soap, water, and friction.

d. Which soap should you use?

1. Plain non-antibacterial soap is best for general patient care preferably in liquid form. It is advisable to check the policy on hand washing in your facility. Note: As liquid dispensers have the potential to become contaminated when refilled or topped off, they should be used only once and discarded or be washed and thoroughly dried before refilling.

2. Alcohol based gels/rubs are acceptable when a sink is not readily available. The application of gels should not be used when there is visible or gross soilage.

3. Antimicrobial soaps are recommended for performing invasive procedures such as surgery or placement of IV catheters, indwelling urinary catheters or other invasive devices.

A special tip: today’s informed consumers (patients) want to see you washing your hands.

 

2. Personal Protective Equipment/Attire (PPE)

PPE is defined as Attire designed for HCWs that provides protection against exposure to bloodborne pathogens. PPE includes protective gowns, gloves, masks, eye protection, head covers, and footwear. The amount and extent of protective attire is related to the activity involved. For example:

To insert a routine Intravenous catheter (IV), protective attire would be a pair of unsterile gloves.

To participate as the scrub nurse during a Cesarean Section, full coverage with protective attire is required.

Also included in protective attire are mouthpieces, pocket masks, and other ventilation devices.

Your employer should provide the appropriate attire for the task and also ensure that you (the HCW) Use the equipment provided!!! Appropriate sizes and alternate supplies are to be readily available for persons with special needs (allergies, dermatitis, etc.)

 

3. Engineering And Work Practice Controls

Tasks performed by HCW’s that require the handling of contaminated devices are to be evaluated and altered to reduce the likelihood of exposures. Examples include the puncture resistant and leak proof sharps disposal containers and the prohibition of two handed recapping of needles.

New products appearing in the work place such as safety syringes and needles should be used when provided. Clinicians must be conscious of new safety products and be willing to learn to alter or to use new techniques in order to adapt the safety devices into everyday use. The goal, of course, is to ensure HCW safety. By federal law, each healthcare facility MUST provide employees with safety products if they are available on the market. (The OSHA Directive emphasizing safety devices was published in November 1999 and became effective immediately)

 

4. Education

Any employee in a healthcare facility whose job has been identified as one potentially subject to occupational exposure must receive education upon employment and annually thereafter. In addition, employers must provide education/training when new procedures are introduced or new devices are implemented.

The training content includes precisely the information you are learning in this module plus information regarding the identity and symptoms of bloodborne diseases. The records of employee training sessions and the topics presented are to be kept for three years. Training is to be conducted by a qualified person. All persons attending the training must sign their name and job title. Employees should have the opportunity to ask questions of the person conducting the training session.

 

5. Housekeeping/Waste Disposal/Laundry

(Say, is all this information in the OSHA standard? -You bet it is!!)

The HCW should expect to work in a clean and sanitary environment. Employers are responsible to ensure that all equipment and environmental surfaces within the work site are cleaned and decontaminated according to a written schedule and as necessary when areas are contaminated between routine cleaning times. Cleaning is to be done with appropriate detergents and disinfectants selected to address the nature of the soilage.

Regulated waste (defined as containing liquid or semi liquid blood or body fluids) is to be placed in containers that are labeled or color coded red to indicate a biohazard. Clinicians are responsible for placing such waste in the appropriate containers when a procedure or activity has generated it where it has been produced. Sharps, which include scalpels, suture needles, syringes, IV catheters, etc. are to be handled (as mentioned in engineering controls) by placing in sharps disposal boxes. ALL regulated waste is subject to State and National regulations regarding types of containers, proper labeling, storage and transporting.

Soiled and contaminated laundry is to be handled as little as possible and with a minimum amount of agitation. Always bag linen at the location where it was used. Laundry bags are to be fluid resistant and are to be transported in solid containers to prevent leakage of fluids. HCW’s should avoid holding soiled linens against their uniforms. Your employer is responsible for the laundering of uniforms, lab coats and other work attire in the event that they are soiled with blood or body fluids.

 

6. Hepatitis B Vaccine

All employees whose job duties may involve exposure to blood or body fluids are to be offered the hepatitis B vaccination series at no cost.

Employees have the option to decline the vaccination by signing a statement, which is then to be kept in the workers employee health file. The same worker may later decide to accept the vaccination series. If so, the employer must provide it when requested.

 

7. Employee Exposure Protocol

Each institution/employer must have an exposure protocol set up in the event of an employee exposure (needle stick, mucous membrane splash, or exposure to non-intact skin). The protocol should go into effect immediately after the employee makes it known that there was an exposure. Please Take Note: the recommendations from the CDC state that the injured employee should be seen, evaluated, and treated within a two hour period of time- beginning from the time of the exposure. You, the HCW, need to report the injury at once to the designated person in your facility (supervisor, manager, or similar title). Protocol should then be followed to ensure an immediate and confidential medical evaluation with appropriate testing of the employee and the source patient (if known). If HIV testing is indicated and requested by the employee, all State and Federal laws must be observed to protect both employee and patient’s rights.

 

8. Records And Written Plans

Employee medical records are confidential and are not to be disclosed to any person without the employees written consent except as required by law. HCW medical records are to be maintained by the employer for the duration of employment plus 30 years.

Each employer must have a written Exposure Control Plan outlining a specific plan to eliminate or minimize employee exposures to bloodborne pathogens. Employees must have access to the plan. Plans should be reviewed and updated annually.

 

CDC Isolation Recommendations

A. Background

The 1996 CDC guidelines supersede all previous recommendations for isolation precautions in hospitals. They were revised to be as simple and user friendly as possible and to use new terms to avoid confusing them with older systems. In addition, the guidelines are based on the latest epidemiologic information on transmission of infection in hospitals. NOTE: Since each hospital is unique, they have the option to modify the CDC guidelines to meet the needs of their institution. HCW’s will note some of these differences as they change places of employment.

 

B. Precautions categories

1. Tier I- Standard Precautions

In the care of all patients in hospitals, regardless of diagnosis or presumed infection status, Standard Precautions is the primary strategy. These precautions always come first and are the most important precaution the HCW can implement. (for more detail refer to part I of this course).

 

2. Tier II- Transmission Based Precautions

These precautions are designed for patients who are diagnosed or suspected to be infected with highly transmissible pathogens. In these situations additional precautions (beyond Standard Precautions) are needed to interrupt transmission in hospitals.

In order for transmission of infections to occur, these elements must be present: a Source, a Host, and a Route of Transmission.

a. Source –

Sources include patients and HCW’s with either acute disease, persons in a chronic carrier state, or persons colonized (without any apparent disease). Also, the source could be inanimate environmental objects such as medical equipment, medications or furniture.

b. Host –

A host is a person who becomes infected. Persons most susceptible to infections include the elderly, infants, persons with other underlying diseases (diabetes, HIV) , certain treatments with antibiotics , corticosteroids or other immunosuppressive agents, irradiation, surgical operations, anesthesia, and invasive devices such as IVs, central lines, chest tubes, and urinary catheters.

c. Route of transmission –

This describes the manner in which a microorganism is transmitted from a source to a susceptible host. The goal is to interrupt the route of transmission by implementing the appropriate isolation precautions as described in the Isolation Guidelines. The CDC provides an extensive list of selected infections and conditions and the recommended type of precautions to prevent transmission. This list should be available to HCWs in order to select or confirm the category needed for specific infections. Most hospitals provide such a list in their Infection Control Manual.

 

3. Isolation Categories

a. Contact Precautions

Contact precautions are designed to prevent or reduce transmission of microorganisms by direct or indirect contact.

1.) Direct is described as skin to skin contact and includes such patient care activities as bathing and turning patients (eg. by hand contact)

2.) Indirect includes contact with inanimate objects in the patients environment such as IV pumps, electronic thermometers, bedrails, telephones, and light switches used by the patient or by a caregiver after direct contact with the patient. The Contact mode of transmission encompasses a long list of diseases and should be one that HCW’s become familiar with for frequent use. In addition to Standard Precautions, patients should be placed in a private room or cohorted with another patient who has the same infection. Gloves should be worn when entering the room. Remove the gloves before leaving the room and immediately wash hands. NOTE: do not touch the patient or any equipment or surface as you exit the room. Wear a gown when entering the room if you anticipate your clothing will have contact with patient surfaces or items within the room. (Some hospitals require a gown for any entry to the room, so check your employer’s policies). Avoid sharing equipment between patients but if unavoidable, clean and disinfect before use on another patient. Limit patient movement from the isolation room to essential purposes only. Ensure that isolation precautions are maintained during transport and be certain to inform the receiving department of the isolation status.

 

b. Airborne Precautions

These precautions are designed to prevent or reduce the transmission of microorganisms that are airborne in very small droplet particles or in dust particles. The microorganisms can be scattered widely by air currents and may be inhaled by a susceptible host either in the same room or over a long distance such as through a ventilation system. The list of diseases in this category is small. The most important ones include pulmonary tuberculosis and the viruses that cause rubeola and varicella (Chicken Pox).

In addition to Standard Precautions, place the patient into a private room with monitored negative air pressure. Keep doors and windows closed. All persons entering the room must wear approved and properly fitted respiratory protection. Limit patient movement from the room for essential purposes only. When necessary, place a surgical mask or an N95 respirator mask on the patient.

The HCW needs to be properly educated about the requirements for this category. Federal OSHA has required that healthcare facilities provide a written TB plan. Information regarding TB and OSHA will be found in part III of this course.

 

c. Droplet Precautions

Droplet precautions are designed to prevent or reduce the transmission of large droplets containing microorganisms generated from an infected source during coughing, sneezing, talking, and during certain procedures such as suctioning, and bronchoscopy. Transmission occurs when infected droplets travel a short distance and are deposited on a hosts mucosa of eyes, nose or mouth. The large droplets do not remain suspended in the air. No special air handling and ventilation is required. Transmission requires close contact between source and host persons as droplets generally travel 3 feet or less through the air.

Among the more common diseases requiring Droplet Precautions are Meningococcal Meningitis, Rubella, Mumps, and some types of Influenza.

In addition to Standard Precautions, Droplet Precautions require a private room. HCWs must wear gloves and a surgical mask when working within 3 feet of the patient. Patient transport should be limited to essential purposes only and when necessary, place a surgical mask on the patient prior to transport.

 

d. Combination of Isolation Precautions

More than one type of Isolation Precautions may be required for diseases that have two routes of transmission. The most frequently seen use of combinations occur with Varicella (Chicken Pox) and Disseminated Herpes Zoster (or localized HZ in immunocompromised patients). For both of these situations use Contact and Airborne precautions.

 

4. Multi Drug Resistant Organisms

In some states and regions resistant bacteria may be judged by the Infection Control Committee to be of special clinical or epidemiological significance. As a result, special policies may be in place to identify persons with a history of infection or colonization for routine placement in Precautions. Examples of Multi-drug resistant organisms are:

MRSA- Methicillan Resistant Staphylococcus Aureus

VRE – Vancomycin Resistant Enterococcus

These two conditions require Contact Precautions. A special emphasis should be made to HCW’s regarding the transmission of microorganisms by both direct and indirect contact. Patients colonized with MRSA or VRE should be placed into Contact Precautions to prevent nosocomial spread to vulnerable patients.

 

5. Empiric, temporary precautions

Often the risk of transmission of infection may be highest before a definitive diagnosis can be made and before precautions can be put into place. Certain High Risk conditions may warrant placing patients in precautions prior to obtaining a definitive diagnosis. Examples include:

Escherichia Coli 0157:H7 – E.Coli
Neisseria Meningitidis – Meningitis
Mycobacterium tuberculosis – TB
Pertussis – Whooping Cough
Respiratory infections – RSV
Multi Drug Resistant – MRSA and VRE

Some hospitals may have policies in place for Empiric precautions

 

What are the important facts that Healthcare Workers need to know about Tuberculosis?

A. Background

Tuberculosis is an infectious disease caused by bacteria, which is spread from person to person through the air. The infected person (source) exhales germs into the air and another person (host) inhales them, usually after close and prolonged contact. The risk of TB increases with age and underlying diseases such as Diabetes, AIDS, and other diseases that cause immuno-suppression. TB is a curable disease. Health Care Workers are at risk when a patient with TB of the lung or larynx has not yet been identified and Infection Control Precautions are not in place.

B. Tuberculosis

1. Most common symptoms

Commonly seen symptoms include night sweats, weight loss, fever, fatigue, frequent coughing, and coughing up blood.

 

2. Diagnostic tests

Tests commonly used to diagnose TB include PPD skin testing, Chest X rays, and cultures from sputum specimens

 

3. TB treatment

Most people with TB must take anti TB medications for 6 to 12 months. They may need to take as many as 5 different anti TB drugs and some vitamins. The contagious period depends on the patient’s response to treatment. It may be as short as two weeks or may be longer based on the results of sputum tests, X rays, and decreasing symptoms.

 

C. Prevention of transmission of TB

1. Patients identified with suspected or confirmed TB must be placed in a private room with negative pressure ventilation according to the requirements for Airborne Precautions. Doors and windows must be kept closed and visitors should be limited to immediate family members.

2. Patients should be instructed to cover their nose and mouth with a tissue when coughing or sneezing.

3. Persons entering the room must wear an approved respirator (mask). NOTE: The recommended mask is rated N95 by NIOSH (National Institute for Occupational Safety)

4. Transport of the patient from the room should be limited to essential purposes only. Patients must wear a surgical mask or an N95 mask fitted snuggly over nose and mouth when leaving the room.

5. TB is a public health hazard and must be reported to the local or state health department for patient monitoring and follow up after discharge.

 

D. Healthcare Worker Safety

1. Possibility of acquiring active TB

If a HCW becomes infected after exposure to TB, he/she will develop a positive skin test result (PPD). This is identified as infection but is Not Active TB Disease. Preventive treatment may be recommended as a result of the positive skin test. Treatment decisions are made by a qualified physician and are based on the individual’s age, health status, and current recommendations for TB preventive therapy. Each individual is unique and treatment must be planned accordingly.

The risk of developing active disease after PPD conversion is 1% in the first year and only 10% over a lifetime.

 

E. TB Education

1. OSHA requires healthcare employers to provide TB education annually

The education is to include the nature, extent and hazards of TB in that institution, job risks for exposure to TB, possibility of acquiring active TB, treatment of TB, engineering controls in place (masks, negative pressure), the selection, fitting, testing, and policies for TB masks, and the OSHA requirements.

2. Patient and family education

Patients are taught techniques to control spread such as coughing into a tissue, wearing a snug fitting mask when out of the isolation room, taking medications exactly as instructed and for as long as instructed, reporting for checkups, and avoiding travel and crowds until declared noninfectious.

 

 Biomedical Waste

Biomedical waste is any solid or liquid waste which may present a threat of infection to humans.

If biomedical waste is in a liquid or semi-solid form and aerosol formation is minimal, the waste may be disposed into a sanitary sewer system or into another system approved to receive such waste by the Department of Environmental Protection or the DOH.

Sharps should be placed into sharps containers at the point of origin. Filled red bags and filled sharps containers should be sealed at the point of origin. Red bags, sharps containers, and outer containers of biomedical waste, when sealed, will not be reopened in this facility. Ruptured or leaking packages of biomedical waste should be placed into a larger container without disturbing the original seal.

All sealed biomedical waste red bags and sharps containers will be labeled with the facility’s name and address prior to offsite transport. Transport should be completed by a contracted provider of the DOH.  If a sealed red bag or sharps container is placed into a larger red bag prior to transport, placing the facility’s name and address only on the exterior bag is sufficient. Outer containers must be labeled with the transporter’s name, address, registration number, and 24-hour phone number.

When sealed, red bags, sharps containers, and outer containers will be stored in areas that are restricted through the use of locks, signs, or location. The 30-day storage time period will commence when the first non-sharps item of biomedical waste is placed into a red bag or sharps container, or when a sharps container that contains only sharps is sealed.

Indoor biomedical waste storage areas will be constructed of smooth, easily cleanable materials that are impervious to liquids. These areas will be regularly maintained in a sanitary condition. The storage area will be vermin/insect free. Outdoor storage areas also will be conspicuously marked with a six-inch international biological hazard symbol and will be secure from vandalism.

 

Blood Spill

Prevent
C
ontain
R
emove
D
ispose
D
iscard

Blood spills can happen in a moment’s notice in a hospital or other healthcare facility.  The first step in cleaning up a blood spill is prevention.  In order to prevent direct contact with the spill during the cleanup process and minimize the risk for infection, disposable protective clothing must be worn. This includes gloves, combo mask/safety shield and protective apron.

The next step in the process is contain and remove.  To efficiently contain and remove the spill, a solidifying agent and scoop/scraper are to be used and the spill contents are to be disposed in a red biohazard bag that is clearly labeled.

Once you have contained and removed the spill, you can now work on disinfecting the contaminated surface. You need to use a germicidal wipe. This process is critical for preventing any further contamination.

The fourth step in the process is dispose and discard the germicidal wipe, gloves, safety shield and apron into red biohazard bag and dispose of bag as required by your local, state and federal regulations.

Lastly, you will need to sanitize your hands and use soap and water once the immediate cleanup is complete.

 

Conclusion

In today’s complex health care world, it still remains essential to practice the simplest form of infection control: HAND WASHING. In addition, it is prudent to keep abreast of current literature regarding the scientific studies and recommendations for ways to prevent the transmission of infectious diseases. Learning, however, is just the beginning. We, as health care professionals need to apply our knowledge in daily practice.

 

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