Bloodborne Pathogens Prevention of Spread of Infectious Diseases OSHA Long Term Care Worker Protection Program

 Define bloodborne pathogens.  Recognize OSHA standards related to bloodborne pathogens.  Identify employer responsibilities related to compliance with OSHA standards.  Recognize key strategies to control the spread of infectious diseases.

 Bloodborne Pathogens  Pathogens include but are not limited to: Hepatitis B HIV – human immunodeficiency virus Pathogenic microorganisms that are present in human blood or other potentially infectious materials and can cause disease in humans.

 29 CFR , Occupational Exposure to Bloodborne Pathogens  Published December 1991  Effective March 1992  Scope ◦ ALL occupational exposure to blood and other potentially infectious material (OPIM)

Hepatitis B HIV/AIDS

What would you do? and what would other employees do?

 …reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.  Duties may include: ◦ Direct Patient Care ◦ Phlebotomy/Laboratory ◦ Environmental Services ◦ Waste Management ◦ Other?

◦ Exposure Determination  all job classifications in which all employees in those job classifications have occupational exposure.  job classifications in which some employees have occupational exposure.  all tasks and procedures…in which occupational exposure occurs and that are performed by the above listed employees.

 The schedule and method of implementation for: ◦ Methods of compliance. ◦ Hepatitis B vaccination and post-exposure evaluation and follow-up for any exposure. ◦ Communication of hazards to employees. ◦ Recordkeeping.

 The procedure for the evaluation of circumstances surrounding exposure incidents: ◦ Immediate availability for exposed employees to confidential medical evaluation and follow- up. ◦ Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred.

 Standard (universal) Precautions ◦ … shall be observed to prevent contact with blood or other potentially infectious materials. ◦ … all body fluids shall be considered potentially infectious materials.

Purpose - to eliminate or minimize employee exposure: ◦ Readily accessible hand washing facilities. ◦ Contaminated sharps management. ◦ Keeping food and drink out of the work area. ◦ Procedures involving blood handling. ◦ Transport of specimens. ◦ Contaminated equipment. ◦ CFR (d)(2)

 Teaching appropriate technique, make no assumptions!  Availability of materials.  Reinforcing and reminding.  Monitoring.

 Provide alcohol-based hand cleansers in multiple locations.  Monitor use by volume replacement and observation.  When they should be used: if hands are not visibly dirty, if soap and water are not available.  Frequent use is recommended, good amount, rubbing into all surfaces of hands until dry.  Washing with soap and water: careful technique, seconds, if hands are dirty, and after direct contact with potentially infectious material, after toileting, and when caring for a patient with a C. Difficile infection.

Let’s Take on the Challenge!

 Shall be used where exposure remains after institution of engineering and work practice controls.  Employer shall provide appropriate PPE at no cost to employee.  May include: gloves, gowns, laboratory coats, face shields or masks, eye protection, mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.

 Use  Accessibility  Cleaning, laundering, and disposal  Repair and replacement  Garment penetration  PPE removal prior to leaving work area

 Worksite maintained in clean and sanitary condition.  Cleaning and decontamination of items.  Safe disposal.

 Contaminated sharps discarding and containment: ◦ Approved sharp containers  Easily accessible  Upright  Not allowed to overfill ◦ Container removal  Close immediately prior to removal  Place in secondary container if leakage is possible ◦ Reusable containers  Should NOT be opened, emptied, or cleaned manually

 Other regulated waste containment: ◦ Closeable, constructed to contain all contents, labeled or color-coded, closed prior to removal. ◦ If outside contamination of the container occurs, it shall be placed in a second container.  Disposal of all regulated waste shall be in accordance with applicable regulations.

 Public Law  Signed into law November 2000 – enacted in 2001 – part of OSHA standards  “Needlestick Safety and Prevention Act”  Why? In 2000, it was estimated that over 300,000 percutaneous injuries would occur involving contaminated sharps.

 Requires that organizations use safer medical devices with injury protection or needleless systems.  Need to reflect the changes in technology that can eliminate or reduce exposure to blood borne pathogens.  Must document annually the consideration and implementation of safer devices.

 Must maintain a Sharps Injury Log.  List for each incident the type and brand of device involved, department/work area, and how the incident happened.  Must “solicit input” from non-managerial staff in the identification, evaluation, and selection of effective engineering and work practice controls and shall document this input process in the Exposure Control Plan.

 Shall be handled as little as possible: ◦ Bagged or containerized at the location where it was used. ◦ Containers labeled or color-coded. ◦ Leak proof bags or containers.  Employer shall ensure that employees who have contact with contaminated laundry wear protective gloves and other appropriate PPE.  Shipping to an off-site facility.

 The employer shall make available the Hep B vaccine & appropriate medication…to all employees who have occupational exposure.  Post-exposure evaluation & follow-up care to all employees who have had an exposure incident: ◦ No cost to the employee ◦ At a reasonable time ◦ Licensed physician or healthcare professional ◦ According to recommendations of the US Public Health Service ◦ All lab tests are conducted by an accredited lab at no cost to employee

 Yes  Must have them complete the Declination Statement and keep that document Appendix A (mandatory) Individuals can change their mind at any time and receive the vaccinations.

 Documentation of the route(s) of exposure.  Identification and documentation of the source individual.  Collection and testing of blood for HBV and HIV.  Post-exposure prophylaxis and care.  Counseling.  Evaluation of reported illnesses.

Labels and Signs Information and Education At the time of initial assignment At least annually When changes occur Content and vocabulary appropriate to educational level, literacy, and language of employees

 Provided to all employees who may be at risk for exposure.  At no cost.  Minimum requirements ◦ CFR (g)(2)(vii) lists all training program requirements.

 Medical Records ◦ Shall be maintained for duration of employment plus 30 years.  Training Records ◦ Shall be maintained for 3 years from the date of training.

 Lack of training  Busy, hectic, rushing  Decreased awareness of hazards  “won’t happen to me….”

 What strategies can we use that are really effective?  What types of infectious diseases?  Who is accountable?

Engineering controls involve making changes to the work environment to reduce work-related hazards. Work practice controls are procedures for safe and proper work that are used to reduce the duration, frequency or intensity of exposure to a hazard. Administrative controls include controlling employees' exposure by scheduling their work tasks in ways that minimize their exposure levels. Personal Protective Equipment (PPE) includes all clothing and other work accessories designed to create a barrier against workplace hazards. 34

Keys to success with all of these strategies: * Consistency * Individual accountability 35

 Current challenge with this: improper and infrequent hand-washing or use of alcohol-based cleansers.  Strategies to encourage: * Demonstrate proper technique * Make the materials/supplies/facilities easy to access, close to all work areas. * Monitor compliance * Role modeling 36

 Encouraging this with all employees and customers, family members/visitors.  Consistent messages!  Providing adequate facilities and materials.  Monitor use and consistency of practices. *** We all need to practice this every day. 37

“ Specialized clothing or equipment, worn by an employee for protection against infectious or other hazardous materials/objects. Remember: PPE is the last resort to addressing worker hazard. (Hierarchy of Controls)

 PPE for eyes, face, hand, extremities, protective clothing, respiratory devices, protective shields and barriers: * Shall be provided, used, and maintained in a sanitary and reliable condition, * Wherever it is necessary by reason of hazards or processes or environment.

 Must provide PPE at no cost to employee.  Must assess all work environments for potential hazards.  Must provide training to any employee who uses any PPE.  Must pay for replacement of any required PPE, unless the employee has lost or intentionally damaged the item.

Chemical Radiological Thermal Mechanical Noise Blood and OPIM (other potential infectious material) Encountered by an employee in a manner capable of causing injury or impairment in any function/body part through absorption, inhalation, or physical contact.

 Employer shall assess the workplace to determine if hazards are present that require the use of PPE.  Communicate presence of hazards to employees.  Select the appropriate PPE – must fit each employee.

 Engage supervisors and employees in the process.  Assess in all work locations: support service areas, patient care areas, specialty areas, facility management areas, external areas, etc.  Need to have a written certification that identifies what was evaluated, who did it, the date.  Reassess when appropriate - if services change, locations change.

 Locations/situations in where this is needed?  Must ensure that each affected employee uses eye protection that provides front and side protection from flying objects/materials.  If they wear prescription lenses, the eye protection can incorporate the prescription in the design, or be worn over the prescription lenses – must not disturb the prescription lenses or the protective lenses.

 Does everyone who should wear this, do so, every time?  Are they fit properly?  Are they checked to be sure they are in good condition?  What could we do differently?

 First Priority: Engineering Controls.  Includes: enclosure or confinement, general or local ventilation, or substitution of less toxic materials.  When engineering controls are not adequate or feasible: Face masks or Respirators should be used! CFR

 Provided by the employer.  Must be applicable and suitable for the purpose and potential hazards involved.  Must establish and maintain a respiratory protection program.

 Identify when and where respiratory PPE needs to be used by employees and what type.  Provide Medical evaluations prior to fit-testing and use.  Follow standards on fit-testing procedure.  Documentation requirements!  N95 or higher NIOSH certified respirators.

 Employer must select and provide appropriate hand protection for employees that are exposed to hazards: * skin absorption of harmful substances * severe cuts, lacerations, or abrasions * punctures * chemical or thermal burns * harmful temperature extremes

 When and where: patient care, environmental services, engineering, other areas.  Glove material: vinyl, latex, nitrile, other.  Sterile and nonsterile.  Single use or reusable.  Critical to train employees on appropriate use, putting on, and taking off of gloves.

 Gown first  Mask or respirator  Goggles or face shield  Gloves  Combination of PPE will affect sequence – be practical !

Select a fit tested respirator Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with elastic Adjust to fit Perform a fit check – –Inhale – respirator should collapse –Exhale – check for leakage around face

 Gloves  Face Shield or goggles  Gown  Mask or respirator  And always wash hands thoroughly after removal of PPE!

 Must train before they use the PPE.  Need to know at least the following: * when PPE is necessary * what PPE is necessary * How to properly put on, take off, adjust, and wear PPE * the limitations of the PPE * proper care, maintenance, useful life, and disposal of PPE Resources available: OSHA and CDC/NIOSH

 Before using any PPE.  Document training.  Do not make assumptions about prior knowledge of the use of PPE!

 When do you want employees to use hand protection?  What are some of the most important “engineering controls” we need to provide?  Gloves/all PPE must be easily accessible, in good condition, good fit for every employee.  Monitoring practices.  Current state of our art?

 Monitoring  Reminders – examples?  Easy access  Good role models/teachers

 Careful housekeeping procedures.  Clear procedures for cleaning of items used by patients.  Control of waste materials.  Annual flu vaccinations for staff and patients. (now that is a challenge!)

 Encourage all employees to get the annual flu vaccine.  Encourage employees who are at risk for complications due to the flu such as those over 50 or with a chronic health condition such as asthma to get the pneumonia vaccine. 60

 Seasonal Influenza: 1. VACCINATION!! * This is the primary prevention strategy. * Developed each year with the best knowledge of circulating viral strains included. * Available in intranasal form (live attenuated) and injectable form (inactive attenuated). 2. Adherence to good daily hygiene practices. 61

 Seasonal Flu vaccine is widely available most years.  Many healthcare organizations offer it free or at minimal cost to employees.  Available at community clinics, pharmacies, doctor’s offices, etc.  Current statistics: approximately 30% of US citizens get the flu vaccine. And healthcare workers? 62

 History – I have never had the flu!  Beliefs in stories of the past.  One experience (misinterpreted) may decide the future for an individual!  I don’t like needles.  Availability – timing, access, simplicity of the process. 63

64 Flu.gov, April 20, 2010

 Sharing the facts.  Making the vaccine easily available.  Enlisting the aid of other employees, employee health staff to talk with employees.  Assuring that patients and visitors receive the factual information about the vaccine. 65

 Hazard awareness in healthcare.  Must control contact with blood and OPIM.  Provide hand, eye, face, full body protection – easily accessible and good fit.  Teach employees how to use, when to use, how to put on and take off, how to dispose.  Prevent the spread of infections whenever possible!

 To improve employee safety.  To enhance our care of patients, keeping them and their families safe.

 Definition and scope.  OSHA standards relating to Bloodborne Pathogens and Personal Protective Equipment.  Employer responsibilities.  Employee accountability.