1. Everyone Sign Roster Sign-In Rosters Required for all CCVESA Providers. Please Print Name, MIEMSS I.D. #, and Company Affiliation All completed rosters must be sent back to the EMS Training Coordinator.

2. Carroll County Volunteer Emergency Services Association Bloodborne Pathogen Exposure Control Plan Bloodborne Pathogen 2014 Update

3. Training Objectives The purpose of this training is to – Review OSHA Bloodborne Pathogen Standard. – Using Case Studies to Review BBP diseases that you could come in contact with – Review PPE needed to minimize exposure – Review what constitutes an exposure incident – Review Needle Stick exposures – Review the appropriate actions to take and persons to contact in an emergency involving an Exposure – Review procedures to follow if an exposure incident occurs – Review of required documentation that MUST be completed following an exposure – Review the post-exposure evaluation and follow up procedures

4. OSHA Standard Occupational Safety and Health Administration OSHA Standard 19 CFR 1910.1030 “Occupational Exposure to Bloodborne Pathogens” Applies to all occupational exposure to blood or other potentially infectious materials.

5. OSHA Standard 19 CFR 1910.1030 Each employer having employee(s) with the potential of exposure shall establish a written Exposure Control Plan Establish Exposure Determination Provide Personal Protective Equipment Establish good housekeeping procedures Provide Hepatitis B Vaccinations Establish Post-exposure Evaluation & Follow-up procedures Communication of hazards to employees with appropriate Labels and Signs Provide Information and Training Recordkeeping

6. Annual BBP Training Records OSHA requires annual BBP training for all volunteer and employees Training records are to completed for each volunteer or employee upon completion of training These documents must be kept for at least three (3) years at the office of the EMS Training Coordinator

7. Annual BBP Training Records Training Records should include – The dates of the training sessions – The contents or a summary of the training sessions – The names and qualifications of the persons conducting the training – The names and job titles of all persons attending the training sessions

8. Bloodborne Pathogens of Special Concern To Health Care Providers – HBV: Hepatitis B virus – HCV: Hepatitis C virus – HIV: Human Immunodeficiency virus – Influenza…H1N1 – Meningitis – MRSA Staphylococcus Aureus (Staph) – Tuberculosis

9. BloodBorne Pathogens Every patient is a threat to our safety Most common BBP are Hepatitis B/C and HIV Most common type of BBP exposure in EMS are a result of needlesticks. There are approximately 600-800k reported needlesticks of healthcare workers every year.

10. Types of BBP Exposures Percutaneous Exposures Occur Through Broken Skin and include – needle stick with contaminated needle – cut with a contaminated sharp object – direct contact of contaminated blood or other infectious material with non-intact skin (skin that is chapped, abraded, afflicted with dermatitis, etc.) Mucotaneous Exposures Occur when infectious material contacts mucous membranes of the mouth or nose

11. What constitutes a BBP exposure? The transfer of a patient’s blood, other bodily fluids containing blood, or other potentially infectious material, to the provider’s bloodstream by direct transfer, via mucous membrane inoculations, or through openings in the skin. Simple handling of a patient does NOT constitute an exposure Small amounts of blood or other infectious material on intact skin do not constitute an exposure.

12. Important things to keep in mind… Patient contact does not equal exposure It is NOT in your best interest to “upgrade” a near miss (for example, blood on intact skin or blood near but not on mucus membranes) to an actual exposure Exposure to blood does not necessarily (or even usually) result in exposure to disease Most exposures to disease do NOT result in infection You can greatly decrease your risk of occupationally acquired disease by following the guidance in this presentation.

13. CASE STUDY 1 November 21….1930 Hrs Your unit is dispatched to a 1624 Main Street for a “sick female patient”

14. ARRIVAL ON SCENE Upon arrival you find a 42 year old female patient lying supine in bed. She thinks she may have the “flu” Patient c/o fever, some upper abdominal pain, and nauseated. Patient states she has felt extremely tired and has no desire to eat.

15. INITIAL ASSESSMENT Airway: Patent Breathing: Regular, RR 18 Circulation: HR 100, skin warm & diaphortic and her skin has a yellowish discoloring

16. PHYSICAL EXAM Head/Neck – Pupils - PERRL – Eyes – slight jaundice in her eyes Chest – Equal lung sounds and expansion Abdomen – Soft, non-tender – Dull pain across both upper quadrants

17. PHYSICAL EXAM Pelvis – Stable Extremities – PMS present all extremities Posterior – No evidence of trauma

18. VITAL SIGNS BP: 114/88 HR: 100 regular RR: 18 SpO2: 96% Room Air

19. PATIENT HISTORY A: NKDA M: Tylenol for the fever P: IV Drug Abuser 10 years ago L: Not eating due to loss of appetite E: Not feeling well for past couple of days

20. What would you consider to be this patient’s chief medical problem?

21. PATIENT DIAGNOSIS Hepatitis B

22. What should you have done prior to & while in contact with this patient?

23. Hepatitis B -- Attempt to Avoid exposure – Assume every patient is infected – Prevention with use of universal precautions against Hepatitis B – Use appropriate PPE/Gloves – Follow all policies and procedure – Get Hepatitis B Vaccination

24. Personal Protective Equipment (PPE) Gloves – MINIMUM required PPE for all patients – shall be worn at all times when participating directly or indirectly in patient care – Shall also be worn during clean up activities, when handling any potentially contaminated items, and at any other time exposure to blood or other bodily fluids is possible. – Remove contaminated gloves before touching equipment (e.g. portable radios), vehicle door handles, or anything else that may lead to further contamination. If this practically cannot be done, be certain to decontaminate as soon as possible. – NEVER wear contaminated gloves in the front (driver/passenger) compartment of the medic unit.

25. Infection of liver caused by Hepatitis B virus (HBV) Transmitted by contact with bodily fluids such as blood, saliva, and semen NOT transmitted by food or water, breastfeeding, sharing eating utensils, hugs or kisses Hepatitis B

26. Hepatitis B… – can be fatal – is very easy to catch compared to other diseases spread by BBP Hepatitis B can survive outside the body up to one week! Is preventable through vaccination

27. Hepatitis B Symptoms Initial symptoms may be mild or absent! – Tiredness – Loss of appetite – Fever – Vomiting – Yellow skin & eyes (jaundice) – Dark-colored urine. – Light colored stool

28. Hepatitis B There are 1.4 million chronically infected Approximately 73K new cases each year 15-25% mortality

29. Highest risk of contracting Hepatitis B Those with multiple sexual partners (unprotected) IV drug abusers Infants born to infected mothers Regular household contact with chronically infected persons Hemodialysis patients

30. Hepatitis B – Prevention Vaccine is the best prevention – vaccine is 95% effective and in most cases, provides lifelong immunity to the person receiving it – vaccine comes as a series of three shots. – after the 1 st IM shot is administered, a 2 nd shot will be given 30 days later, and the 3 rd dose is administered 6 months after the 2 nd dose. – Lab titers may be necessary to ensure that the vaccine is still working, and occasionally a person may need a booster shot to bring the number of antibodies in the body up to necessary levels. Safe handling of sharps and other potentially infected products

31. Hepatitis B Prevention Make sure you are vaccinated against Hepatitis B – Vaccination (or formal declination) is mandatory – The vaccine is safe. It is NOT a live virus vaccine, and cannot give you hepatitis B – The protection is permanent and highly effective – Vaccination requires 3 doses of vaccine over 4-6 months and then a blood titer – The titer is essential to verify you have responded to the vaccine & are protected! Avoid exposure - prevention with universal precautions remains your best protection against Hepatitis B and all other BBP – Assume every patient is infected – Use appropriate PPE – Follow all policies and procedures

32. Hepatitis B Vaccination Volunteer Members or Employees – Hepatitis B vaccines are available at no cost to you within 10 days of initial assignment – Vaccination will be provided by the CCVESA Physician

33. Hepatitis B Vaccination is encouraged unless… Documentation exists that the volunteer or employee has previously received the series Antibody testing reveals that the volunteer or employee is immune Medical evaluation shows that vaccination is contraindicated

34. Hepatitis B Vaccination is declined by a volunteer or employee… They must sign a declination form Documentation of refusal of the vaccination is kept at the CCVESA Physician’s facility Volunteers or employees who decline may request and obtain the vaccination at a later date at no cost.

35. HEPATITIS B VACCINE DECLINATION FORM HEPATITIS B VACCINE DECLINATION (MANDATORY) I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. Signed: __________________Date: _________________

36. CASE STUDY 2 October 15….2200 Hrs Your unit is dispatched to a Nursing Home @ 1122 Pepper Lane for a “sick male patient”

37. ARRIVAL ON SCENE Upon arrival you are met by a staff member of the nursing, who directs you to the patient’s room and provides you with an appropriate MOLST form. She advises that he had fell and injured his right wrist and his attending physician wants him evaluated at the ER.

38. ARRIVAL ON SCENE Patient is a 88 year old male sitting up in a chair c/o injury to his right wrist You note that there is some deformity of the right wrist. Patient states he fell on to his right hand as he went down Patient has no other obvious injuries

39. INITIAL ASSESSMENT Airway: Patent Breathing: Regular, RR 22 Circulation: HR 110, skin is hot and dry, You notice a rash on his skin, with multiple boils/pimples and several pus-filled abscesses

40. PHYSICAL EXAM Head/Neck – Pupils - PERRL Chest – Equal lung sounds and expansion – No bruising or deformities Abdomen – Soft, non-tender – No discoloration

41. PHYSICAL EXAM Pelvis – Stable Extremities – Deformity to right wrist – Good PMS in all extremities Posterior – No evidence of trauma

42. VITAL SIGNS BP: 150/90 HR: 110 RR: 22 SpO2: 93%

43. PATIENT HISTORY A: Penicillin M: Synthroid P: Hypothyroid L: Supper E: Walking back to his room and lost his balance and fell to the floor

44. What would you consider to be this patient’s chief medical problem?

45. FINAL DIAGNOSIS MRSA

46. What should you have done prior to & while in contact with this patient?

47. MRSA --Attempt to avoid exposure – Assume every patient is infected – Prevention with use of universal precautions against MRSA – Use appropriate PPE/Gloves – Follow all policies and procedure

48. MRSA MRSA was first discovered in 1961 in the United Kingdom. The first major outbreak in the US was in 1981 and was noted in a large population of IV drug users. Since then, approximately 94k Americans are infected every year. More than 18k people will die in the hospital as a result of this organism.

49. MRSA Multiple drug-resistant strain of staph aureus Resistant to several common antibiotics and even antibiotics that have been developed within the past few years, making it extremely dangerous and difficult to treat. Grows on every single surface Survives outside the host for several months

50. MRSA – Risks Outbreaks IV Drug users Athletes Nursing homes Prisons Race/Population Age 65+ years African Americans Males

51. MRSA- Complications Develops drug resistance within 72 hours of host invasion – most common portals of entry include wounds, IV catheters, and the urinary tract. 75% all infections involve skin – Boils/Pimples – Fever – Rashes – Pus-filled abscesses

52. CASE STUDY 3 January 5….1430 Hrs Your unit is dispatched to a 2750 North Avenue for a “sick male patient”

53. ARRIVAL ON SCENE Upon arrival you find a 34 year old male patient in bed who states “I think I have the Flu” Patient c/o runny nose, coughing, headache, chills and body aches all over. Patient also states “I have been having some trouble breathing”

54. INITIAL ASSESSMENT Airway: Patent Breathing: Regular, RR 24 Circulation: HR 90, skin is warm & dry

55. PHYSICAL EXAM Head/Neck – Pupils - PERRL Chest – Equal lung sounds and expansion Abdomen – Soft, non-tender

56. PHYSICAL EXAM Pelvis – Stable Extremities – Good PMS in all four extremities Posterior – No evidence of trauma

57. VITAL SIGNS BP: 114/88 HR: 90 RR: 24 SpO2: 98%

58. PATIENT HISTORY A: NKDA M: Tyelnol as needed P: None L: Lunch, attempt a bowl of soup, but that was vomited back up E: Has felt sick with Flu like symptoms for past 24 hours

59. What would you consider to be this patient’s chief medical problem?

60. FINAL DIAGNOSIS H1N1 VIRUS

61. What should you have done prior to & while in contact with this patient?

62. H1N1 Virus --Attempt to avoid exposure – Assume every patient is infected – Prevention with use of universal precautions against H1N1 Virus – Use appropriate PPE/Gloves/mask – Follow all policies and procedure – Get Influenza/H1N1 Vaccination

63. Surgical Masks – Protect against large droplets produced by coughing or sneezing Most respiratory illness spread in this way Follow respiratory hygiene/cough etiquette – Protect against splashes or sprays of blood or other body fluids when worn in combination with eye protection (mask plus shield or goggles) Wear during patient care activities or procedures where splashes or sprays are possible This includes all persons in vicinity of patient during bag-mouth ventilation, intubation or suctioning Effective use of face and eye protection dramatically reduces mucus membrane exposures.

64. Cough hygiene/respiratory etiquette Put a mask on all patients with cough, or other signs/symptoms of respiratory illness – Non-rebreather – if O2 by non-rebreather mask is indicated – Nasal cannula with surgical mask - If O2 via nasal cannula is indicated – Surgical mask alone – for stable, alert patients with cough or S/S of respiratory illness when O2 is not indicated, AND Put a mask on ALL providers (surgical or N95) within 3 feet of the patient when a mask also is indicated for the patient with cough or S/S of respiratory illness – THIS IS MANDATORY FOR YOUR PROTECTION!

65. H1N1 Virus The H1N1 Virus is also referred to as “Swine flu.” It is called this because it has similar genes to the virus that infects pigs. Pandemic- thousands of patients affected worldwide 1st US case: April 2009 Similar to seasonal flu Human to Human transmission

66. H1N1 Risk Factors Age (Over 65 or under 5) Pregnant Chronic Medical Conditions Immunosuppressed Asthma

67. H1N1 Flu Virus Signs/Symptoms Stuffy or runny nose Sore throat Cough Fever Chills Headache Fatigue Body aches Vomiting Diarrhea Respiratory symptoms without a fever

68. Influenza/H1N1 Vaccination Why should health care providers - including “first responders” be vaccinated? – Protect Your Patients Influenza can be fatal for our frail, immunocompromised patients Per the CDC - “First responders” are a high priority group for immunization – Protect Yourself – Protect Your family Vaccination makes sense at least through March (flu season lasts into May)

69. Seasonal Flu Affects 5-20% of the US population every year Peak season: January and February 200K sick/hospitalized every year 36K Americans die annually

70. Seasonal Flu- Spread Airborne droplets – usually the result of a cough or sneeze – droplets land on the recipient’s face and then are inhaled into the nostrils. Contagious one day prior to S/S appearing and for 5-7 days after sickness

71. Seasonal Flu- Risk Factors Children – Children are susceptible due to having immature immune systems. Usually in those less than age 5. Elderly – The elderly, usually considered over 65 years of age, are also at a higher risk due to many times having previous medical conditions. Pregnant Asthmatics Diabetics

72. Seasonal Flu- Signs/Symptoms Fever Headache Dry cough Sore throat Muscle aches Lethargy Runny nose Nausea* Vomiting* Diarrhea* * Occasional

73. CASE STUDY 4 September 15….O130 Hrs Your unit is dispatched to a 2900 South Bend Road for Motor Vehicle Collision

74. ARRIVAL ON SCENE Upon arrival you have a 28 year male patient, with multiple injuries from being ejected from the vehicle

75. You are assisting with stabilization of this patient, and as an IV is being established the patient becomes combative secondary to a head injury and the IV needle comes out of the patient and you accidently get stuck in your left hand

76. What action needs to be taken?

77. POST-EXPOSURE EVALUATION AND FOLLOW-UP Exposed provider should contact Member Company Exposure/Infection Control Officer Contact should be made immediately if not involved in an emergency response or immediately upon completion of the call of an emergency incident The Member Company Exposure/Infection Control Officer will contact the CCVESA Exposure Control Officer or designee Contact The CCVESA Exposure Control Officer or designee will contact – Carroll Hospital Center – Carroll Occupational Health - Carroll County Health Department

78. POST-EXPOSURE EVALUATION AND FOLLOW-UP Carroll Hospital Center, Carroll Occupational Health and/or County Health Department will report back the follow up procedures to the CCVESA Exposure Control Officer or designee The CCVESA Exposure Control Officer or designee will report back to the Member Company Exposure/Infection Control Officer The Member Company Exposure/Infection Control Officer will report back to the Exposed provider

79. POST-EXPOSURE EVALUATION AND FOLLOW-UP The exposed provider should receive an immediate confidential medical evaluation and follow-up conducted by Carroll Occupational Health if open …. or at Carroll Hospital Center if Carroll Occupational Health is closed

80. CCVESA Exposure Control Officer Will ensure that the Health care professional evaluating the volunteer or employee after an exposure incident receives – Description of volunteer’s or employee’s job duties relevant to the exposure incident – Route(s) of exposure – Circumstances of exposure – If possible, results of source individual’s blood test – Relevant volunteer/employee medical records, including vaccination status

81. POST-EXPOSURE EVALUATION AND FOLLOW-UP If actual exposure did occur – Clean, irrigate and dress area as appropriate – Allow puncture wounds to bleed – Irrigate mucus membranes copiously with water – Ringers also is appropriate

82. POST-EXPOSURE EVALUATION AND FOLLOW-UP If provider and Source patient are transported to Carroll Hospital Center – Advise Charge Nurse upon arrival that there has been an exposure and you would like the source patient’s blood tested. – Carroll Hospital Center will obtain the source patient’s blood and have it tested

83. POST-EXPOSURE EVALUATION AND FOLLOW-UP If provider and source patient are transported to another hospital – Advise Charge Nurse upon arrival that there has been an exposure and you would like the source patient’s blood tested. – The Hospital will obtain the source patient’s blood and have it tested – Results of the source patient’s blood test should be sent to Carroll Occupational Health – If Carroll Occupational Health is Closed have the results sent to Carroll Hospital Center

84. POST-EXPOSURE EVALUATION AND FOLLOW-UP The member infection/exposure control officer should transport the exposed provider to Carroll Occupational Health for initial evaluation and treatment The member infection/exposure control officer should Advise the Charge Nurse upon arrival that you have provider that an exposure has occurred and the source patient’s blood is being tested at the receiving hospital

85. POST-EXPOSURE EVALUATION AND FOLLOW-UP In the event that Carroll Occupational Health is closed and the Source patient was transported to Carroll Hospital Center then… The exposed provider will receive the initial evaluation and treatment at Carroll Hospital Center Results of the source patient and the provider will be sent to Carroll Occupational Health

86. POST-EXPOSURE EVALUATION AND FOLLOW-UP In the event that Carroll Occupational Health is closed and the Source patient was transported to another Hospital then… The exposed provider should be transported to Carroll Hospital Center The member infection/exposure control officer should Advise the Charge Nurse upon arrival that you have provider that an exposure has occurred and the source patient’s blood is being tested at the receiving hospital The exposed provider will receive the initial evaluation and treatment at Carroll Hospital Center Results of the source patient and the provider will be sent to Carroll Occupational Health

87. Treatment for Providers’ possible BBP exposure – Prompt evaluation and treatment – Source patient blood testing – PEP antiviral medications if indicated – Baseline and serial blood tests for six months after the exposure for our provider – Any other appropriate support, counseling or treatment The exposed provider must complete the exposure survey provided by the CCVESA Exposure Control Officer (required by federal regulation) Exposure Policy and Procedures

88. Remember: If treatment with HIV antiviral medications (postexposure prophylaxis) is indicated following an exposure, they should be started as soon as possible… “within hours” according to the CDC. All Carroll County EMS providers with suspected BBP exposure will receive initial treatment and evaluation at Carroll Hospital Center – This applies only to BBP exposures – The member infection/exposure control Officer will confer with the Exposure Control Officer and provide guidance Exposure Policy and Procedures

89. Carroll County Volunteer Emergency Services Association Exposure Survey Must be Completed for Any Type of Exposure and must be completed by the exposed provider POST-EXPOSURE DOCUMENTATION

90. Carroll County Volunteer Emergency Services Association Exposure Survey Complete for Any Type of Exposure Exposed Provider: Please complete carefully and include all requested information. Member Company infection Control Officer : Please review for accuracy and completeness prior to submitting. This form is to be completed by the provider at the time of the incident and submit the required paperwork to CCVESA Exposure Control Officer. 1. ID#: ____________________Unit/Shift ____________ 2. Date of this Report:__________ 3. Date of exposure: __________ Time_____ 4. If this exposure occurred outside: (Leave section 4 blank if the exposure was indoors) Ambient Conditions: Cold_____ Warm _____ Hot _____ Wet _____ Dry _____ 5. If Inside or Outside: (Fill in regardless if indoors or outdoors) Lighting Conditions: Good_____ Fair _____ Poor _____ 6. Type of Exposure: _____ Blood _____ Other (Describe)______ 7. Type of contact: _____Splash/Spill/Spray _____Droplet/Inhalation Area of body exposed_____________ If Skin exposed, any wounds, sores or abrasions? ____ _____ Dirty Needle Stick _____ Dirty IV Needle Self-Sheathing? ___Y ___N _____ Dirty Vacutainer Needle Self-Sheathing? ___Y ___N _____ Dirty Lancette Needle Self-Sheathing? ___Y ___N _____ Dirty Needle Attached to Syringe Self-Sheathing? ___Y ___N _____ Dirty Needle as part of a Pre-loaded drug Self-Sheathing? ___Y ___N CCVESA Exposure Survey Page 1 of 4 04-01-10

91. _____ Glass _____ Broken Drug _____ Opening glass vial _____ Other Glass on scene _____ Other – Describe: For all sharps exposures the following MUST be completed: Type of Device (IV cath, etc): __________________________ Brand or Model of Device (Protectiv, etc.): __________________________ Manufacturer of Device (Johnson & Johnson, etc.): __________________________ Did the design of the device or any other engineering control factor play a role in this exposure? If yes, in what way? 8. Information regarding the type of scene to which you responded: _____ Private Residence (House, any type) _____ Private Residence (Apartment, house divided into apartments) _____ Store or Business (Type___________) _____ Nursing Home or Assisted Living Facility _____ Public area (Pedestrian) ie mall, sidewalk _____ Road, Roadside etc. 9. Information regarding Location where exposure actually occurred: _____ Private Residence (House, any type) _____ Private Residence (Apartment, house divided into apartments) _____ Store or Business (Type______) _____ Nursing Home or Assisted Living Facility _____ Public Area (Pedestrian I.E. outdoor mall or sidewalk) _____ Road or Roadside _____ Inside of the Medic Unit If the actual exposure occurred inside the unit, how many people were in the patient compartment at the time of the exposure, NOT including the patient? _____ CCVESA Exposure Survey Page 2 of 4 04-01-10

92. 10. Patient Description at time of the exposure: (Check all that apply) _____ Medical Patient _____ Trauma Patient _____ Alert/Cooperative _____ Alert/Uncooperative or combative _____ Disoriented or Confused, cooperative _____ Disoriented or Confused, combative _____ Unconscious _____ Seizure Activity _____ flaccid _____ Other (Describe)__________ 11. Your activity at the time of the exposure: (Check all that apply) _____ Airway Management (Direct or invasive) _____ Using a Sharp _____ Preparing/Setting up the needle or device _____ Restraining/Holding the patient, not controlling the needle _____ Finger Stick _____ Transferring blood for Glucometer Reading _____ Transferring blood to vacutainer _____ Controlling the needle, disposing of sharp _____ Not controlling needle, assisting with disposal: _____ Passing or Holding Sharps Disposal Box _____ Other (Describe) __________ _____ Not engaged in Patient contact (injured during clean up, exchanging sharps box etc, describe_______________ 12. PPE in use at time of exposure: _____ Eye protection _____ Mask _____ Gloves: _____Standard _____Hi Risk Any comments of quality/feel/ease of use of glove? 13. Individual Training: Blood Borne Pathogen: ______Initial Blood Borne Pathogen Training? Year of Training ________ ______Approx. Date of last Update? CCVESA Exposure Survey Page 3 of 4 04-01-10

93. 14. Provide a precise and complete explanation of the circumstances surrounding this exposure and describe exactly how and why this exposure occurred: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ___________________________________________ 15. Do you have any suggestions for preventing future exposures of this type? ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _______________________________________________________________ 16. Are there any additional comments, recommendations or clarifications you would like to make? (Use back of page if additional room is needed.) ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _________________________________________________________________ Thank you for taking the time to carefully complete this survey. This survey is used to evaluate how we do things and find ways we can make our work safer. It also is used to maintain a legally required record of exposures. Please go back and make sure that all applicable information has been provided before sending this to the CCVESA Exposure Control Officer. CCVESA Exposure Survey Page 4 of 4 04-01-10

94. POST-EXPOSURE DOCUMENTATION Exposed volunteer or employee must complete a Carroll County Volunteer Emergency Services Association Exposure Survey Form Exposed volunteer or employee will also be required to complete any Exposure forms that may required at any post exposure follow-up facility. Exposed volunteer or employee must complete a station’s “First Report of Injury” Workers Compensation First Report of Injury/Illness Form must be completed and submitted by the appropriate member company personnel

95. Evaluating the Circumstances Surrounding an Exposure Incident CCVESA Exposure Control Officer and member company Exposure/ Infection Control Officer will review the circumstances of all exposure incidents to determine – Engineering controls in use at the time – Work practices followed – Description of the device being used (including type and brand)

96. Evaluating the Circumstances Surrounding an Exposure Incident Determine….. – Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.) – Location of the incident (on the scene of an incident, inside a transport unit, in the station, etc. – Procedure being performed when the incident occurred – Volunteer’s or employee’s training level

97. Needle Sticks – Most Dangerous Type of Blood Exposures Some needle stick exposures are caused by needles sticking thru medical bags! – Make sure the needle goes in the sharps container, the sharps container is snapped closed, and the bag compartment is zipped shut. – Other needle sticks can be caused by not having sharps container at patient’s side and open ready to receive sharp. Protect yourself and your coworkers!

98. Most Needle Sticks Are Avoidable Protect yourself and your coworkers from preventable needle stick exposures by: Locking the protective sheath over the needle during withdrawal Making sure the IV catheter goes into the sharps container Snapping closed the sharps container after sharp is deposited, and zipping closed the medical bag’s compartment top

99. IV Catheters Use only self sheathing IV catheters. Use devices only if you have been instructed on their proper use. If you don’t know, ASK! IV Caths: If you don’t “click” ‘em, they are not safe!

100. Needle Sticks – Must be Reported & Documented Effect immediately all percutaneous injuries from contaminated sharps must be documented in a “Sharps Injury Log” as per 29 CFR 1904

101. “Sharps Injury Log” CCVESA Exposure Control Officer will record all percutaneous injuries from contaminated sharps in a “Sharps Injury Log” as per 29 CFR 1904 Incidences must include – Date of the injury – Type and brand of the device involved (syringe, IV needle, etc.) – Department or work area where incident occurred – Explanation of how the incident occured

102. “Sharps Injury Log” – This log is reviewed as part of the annual program evaluation – This log must be maintained for at least five (5) years following the end of the calendar year covered – If a copy is requested by anyone, it must have any personal identifiers removed from the report

103. CASE STUDY 5 April 29….1730 Hrs Your unit is dispatched to a 3520 Maple Road for a “sick female patient”

104. ARRIVAL ON SCENE Upon arrival you found a 85 year old female sitting in a chair c/o not feeling well She states that she has been very tired,has not felt like eating, has had some abdominal pains. When she did try to eat something, she got nausated and vomited

105. INITIAL ASSESSMENT Airway: Patent Breathing: Regular, RR 14 Circulation: HR 88, Exposed skin is warm/dry and slightly jaundice

106. PHYSICAL EXAM Head/Neck – Pupils - PERRL NOTE jaundice in her eyes Chest – Equal lung sounds and expansion Abdomen – Soft, non-tender

107. PHYSICAL EXAM Pelvis – Stable Extremities – Good PMS in all four extremities Posterior – No evidence of trauma

108. VITAL SIGNS BP: 150/92 HR: 88 RR: 14 SpO2: 94%

109. PATIENT HISTORY A: NKDA M: none P: Had hip replacement surgery in 1985, when she had to have a blood transfusion L: attempted lunch 5 hours ago E: Has had these symptoms for several days

110. What would you consider to be this patient’s chief medical problem?

111. FINAL DIAGNOSIS Hepatitis C

112. What should you have done prior to & while in contact with this patient?

113. Hepatitis C Virus --Attempt to avoid exposure – Assume every patient is infected – Prevention with use of universal precautions against Hepatitis C – Use appropriate PPE/Gloves – Follow all policies and procedure

114. Most common BBP infection in U.S. High rate among IV drug users. Mainly spread by exposure to blood and other bodily fluids containing blood Causes Infection of the liver, leads to high rate of chronic disease (75%) and cancer Before early 1990’s spread through blood transfusions Most infected people have no symptoms and do not know they are infected Hepatitis C

115. Hepatitis C (HCV) Signs/Symptoms Initial symptoms may be mild or absent! – Tiredness – Loss of appetite – Abdominal pain – Nausea – Vomiting – Yellow skin & eyes (jaundice) – Urine that is dark in color

116. Hepatitis C (HCV) Treatment No vaccine currently available Hepatitis B vaccine will not protect you from Hepatitis C No postexposure prophylaxis currently recommended Treatment with antiviral medications recommended for some patients with chronic disease Not all people respond to treatment

117. Hepatitis C Leading cause of liver transplant Accounts for 20% of all acute viral hepatitis cases 85% result in chronic infections 5% mortality 19K new cases/year 4.1 million Americans

118. Hepatitis C- Risk Factors Blood transfusions prior to 1992 Long-term kidney dialysis IV drug users Hepatitis C can survive outside the body for up to 16 days!

119. Hepatitis C- Signs/Symptoms Jaundice Dark Urine Fatigue Abdominal Pain Nausea Anorexia While these are common signs & symptoms, 80% of those infected may not exhibit any signs or symptoms until very late stages.

120. CASE STUDY 6 October 18….2230 Hrs Your unit is dispatched to a 13 East Landover Street for a “sick male patient”

121. ARRIVAL ON SCENE Upon arrival you find a 48 year old male patient sitting at the kitchen. The patient is c/o fever, chills and coughing for past three weeks The patient also c/o night sweats, loss of appetite and coughing up blood

122. INITIAL ASSESSMENT Airway: Patent Breathing: Regular, RR 30, coughing Circulation: HR 78, skin is warm & dry

123. PHYSICAL EXAM Head/Neck – Pupils - PERRL Chest – Equal lung sounds and expansion Abdomen – Soft, non-tender

124. PHYSICAL EXAM Pelvis – Stable Extremities – Good PMS in all four extremities Posterior – No evidence of trauma

125. VITAL SIGNS BP: 100/68 HR: 78 RR: 30 SpO2: 90 %

126. PATIENT HISTORY A: NKDA M: none P: none L: 5 hours ago E: Been feeling sick for past several weeks

127. What would you consider to be this patient’s chief medical problem?

128. FINAL DIAGNOSIS Tuberculosis

129. What should you have done prior to & while in contact with this patient?

130. TUBERCULOSIS --Attempt to avoid exposure – Assume every patient is infected – Prevention with use of universal precautions against Tuberculosis – Use N-95 mask – Provide flow through ventilation in the patient compartment during transport – Use appropriate PPE/Gloves/N-95 Mask – Follow all policies and procedure

131. N-95 MASKS N95 Masks – Protect against very small particles – Wear whenever TB (tuberculosis), rubeola (measles), or varicella (chickenpox) is known or suspected – Fit testing required to ensure proper fit – If transporting a patient with suspected TB, use the exhaust fan AND by opening the windows to allow flow through ventilation

132. TUBERCULOSIS Bacterial disease caused by the infectious agent Mycobacterium tuberculosis Bacteria that cause TB are transmitted by infected airborne particles Infectious particles are produced when the infected person talks, coughs, or sneeze s

133. TUBERCULOSIS Latent TB – Person has a TB infection, but the bacteria remains in the body in an inactive state and causes no symptoms – This is not contagious Active TB – Person has TB with signs & symptoms – This person is contagious and can spread TB to others

134. ACTIVE TUBERCULOSIS Signs & Symptoms Unexplained weight loss Fatigue Fever Night sweats Chills Loss of appetite Coughing that lasts three or more weeks Coughing up blood Chest pain, or pain with breathing or coughing

135. TUBERCULOSIS Procedures performed that may increase the risk of exposure to TB – Endotracheal intubation – Suctioning – Use of bag valve masks – Administering aerosolized medications such as albuterol – Enclosed in the patient compartment of the ambulance

136. TUBERCULOSIS PREVENTION Avoid exposure - prevention with universal precautions remains your best protection against TB – Use appropriate PPE – Use N-95 mask – Provide flow through ventilation in the patient compartment during transport – Follow all policies and procedures

137. CASE STUDY 7 August 24….1930 Hrs Your unit is dispatched to a 2432 West Lighthouse Lane for a “sick male patient”

138. ARRIVAL ON SCENE Upon arrival you find a 34 year old male patient lying in bed. Patient c/o fever for several days, weight loss and feeling weak

139. INITIAL ASSESSMENT Airway: Patent Breathing: Regular, RR 20 Circulation: HR 84, skin is cool & dry, HR 84

140. PHYSICAL EXAM Head/Neck – Pupils - PERRL Chest – Equal lung sounds and expansion Abdomen – Soft, non-tender

141. PHYSICAL EXAM Pelvis – Stable Extremities – Good PMS in all 4 extremities Posterior – No evidence of trauma

142. VITAL SIGNS BP: 114/88 HR: 84 RR: 20 SpO2: 92%

143. PATIENT HISTORY A: NKDA M: none P: Pneumonia, Lymphomia, swollen lymp nodes L: Very light lunch at noon E: Sitting around the house and felt he should be transported to the ER Patient states that approximately 10 years ago he was IV drug abuser

144. What would you consider to be this patient’s chief medical problem?

145. FINAL DIAGNOSIS HIV – Human Immunodeficiency Virus

146. --Attempt to avoid exposure – Assume every patient is infected – Prevention with use of universal precautions against HIV – Human Immunodeficiency Virus – Use appropriate PPE/Gloves – Follow all policies and procedure

147. HIV – Human Immunodeficiency Virus Spread by blood and certain other bodily fluids 0.3% risk of seroconversion following percutaneous occupational exposure Risk may be higher for certain exposures – Hollow bore needle contaminated with visible blood – Other objects visibly contaminated with blood, especially deep punctures

148. AIDS – Acquired Immune Deficiency Syndrome Develops months to years after HIV infection Signs and symptoms of AIDS – Fever – Weight loss – Swollen lymph nodes – White patches in mouth (thrush) – Cancer - Kaposi’s sarcoma, certain lymphomas – Infections - pneumocystis pneumonia, TB NO CURE – drugs may slow the progress of the disease

149. HIV – Postexposure Prophylaxis Reduces the risk of infection up to 81% Four week regimen with 2 - 3 antiviral drugs If the source patient blood tests negative for HIV, PEP is not recommended by the CDC If the source patient HIV status is not yet known, PEP may be offered or recommended. If the source patient is HIV positive PEP will in most cases be recommended. – If indicated, PEP should be started as soon as possible after an exposure!

150. HIV/AIDS There are roughly 1.1 million Americans infected At least 21% are unaware or undiagnosed Spread by blood and bodily fluids Does not survive outside body Greatest risk factors are IV drug use and multiple unprotected sexual partners

151. HIV/AIDS Auto-immune disorder transmitted by blood and bodily fluids such as semen and vaginal secretions Almost always begins as HIV, but can progress into AIDS 21% of those with the disease are unaware and undiagnosed, therefore putting themselves and those they are in contact with at high risk

152. HIV/AIDS The virus does not survive outside the body for longer than 10 seconds Risks to EMS workers who come into contact with infection patient’s blood, most commonly from needle sticks Risk from needle stick is very low, only.3% of needle sticks result in HIV infections

153. Remember: If treatment with HIV antiviral medications (postexposure prophylaxis) is indicated following an exposure, they should be started as soon as possible… “within hours” according to the CDC. Exposure Policy and Procedures

154. CASE STUDY 8 August 4….0930 Hrs Your unit is dispatched to a 1624 Main Street for a “sick female patient”

155. ARRIVAL ON SCENE Upon arrival you find a 19 year old female patient lying in bed c/o severe headache, a high fever 105, nausated and vomiting. Patient also c/o has loss of appetite, cannot sleep and bright lights bother her

156. INITIAL ASSESSMENT Airway: Patent Breathing: Regular, RR 24 Circulation: HR 110, skin is hot & dry, and a skin rash noted

157. PHYSICAL EXAM Head/Neck – Pupils - PERRL – Signs indicating a stiff neck Chest – Equal lung sounds and expansion Abdomen – Soft, non-tender

158. PHYSICAL EXAM Pelvis – Stable Extremities – Good PMS in all 4 extremities Posterior – No evidence of trauma

159. VITAL SIGNS BP: 124/78 HR: 110 RR: 24 SpO2: 99%

160. PATIENT HISTORY A: NKDA M: None P: None L: Supper last night E: Has had a high fever for past two days

161. What would you consider to be this patient’s chief medical problem?

162. FINAL DIAGNOSIS Meningococcal Meningitis

163. What should you have done prior to & while in contact with this patient?

164. Meningococcal Meningitis --Attempt to avoid exposure – Assume every patient is infected – Prevention with use of universal precautions against Meningococcal Meningitis – Use N-95 mask – Provide flow through ventilation in the patient compartment during transport – Use appropriate PPE/Gloves/N-95 Mask – Follow all policies and procedure

165. Other Diseases - Meningitis An inflammation of the membranes covering the brain and spinal cord. Caused by several different organisms – Bacterial Neisseria meningitidis (Meningococcal) Streptococcus pneumoniae Haemophilus influenzae type B (Hib) – Viral Several different viruses Most cases of meningitis are viral Meningococcal meningitis is the type that poses the greatest risk of death or serious disease. Immediately report to the Infection Control Officer any patient determined by you or reported by a hospital to possibly have meningitis.

166. Meningococcal Meningitis Signs & Symptoms High fever Severe headache Stiff neck Vomiting or nausea Confusion or difficulty concentrating Seizures Sleepiness or difficulty waking up Sensitivity to light Lack of interest in drinking or eating Skin rash

167. Meningococcal Meningitis FACTS you should know to help you keep things in perspective: – "Health care personnel are rarely at risk when caring for infected patients; only intimate exposure to nasopharyngeal secretions (e.g. as in mouth to mouth resuscitation) warrants prophylaxis." (American Public Health Association) – “Fortunately, none of the bacteria that cause meningitis are as contagious as things like the common cold or the flu, and they are not spread by casual contact or by simply breathing the air where a person with meningitis has been.” (CDC) – "Despite the public fear, bordering on hysteria, that may follow a case of meningococcal disease, more than 95 percent of cases in the United States and other developed countries are sporadic. Thus, in the majority of instances, a second case does not follow a first one.” (New England Journal of Medicine) Meningococcal Meningitis

168. – At least 2%, and perhaps as many as 10%, of the population are carriers of this disease – Notification from hospital staff regarding meningitis Must be reported immediately to the on-call Exposure Control Officer Historically, in the vast majority of cases patients have not had meningococcal disease or anything else that requires treatment or follow-up for our personnel Will be promptly investigated in close cooperation with the Carroll County Health Department Rarely warrants prophylaxis before appropriate testing and evaluation is done In most cases, further testing shows prophylaxis is not indicated. – Prophylaxis will be provided if needed. – Use of proper PPE reduces the already low risk if you do come in contact with an infected person Meningococcal Meningitis

169. Four types of “cleaning” in the EMS setting 1. Cleaning: – This is the physical removal of obvious dirt, dust, and debris. – It is the necessary first step before any other measures can be taken 2. Decontamination: – This is the most common type of cleaning that happens in EMS. This process removes most disease- producing organisms to make equipment safe for handling. It has limited effectiveness against more serious pathogens

170. Four types of “cleaning” in the EMS setting 3 Disinfection: -This process destroys nearly all disease- producing organisms, however it does not work on bacterial spores. – Spores are bacteria that have protection against extreme types of environments and can become activated in the right setting.

171. Four types of “cleaning” in the EMS setting 4 Sterilization: -This is the complete elimination of microbial life. -It can be an expensive process and takes quite some time to complete. -Since disinfection covers most of the pathogens that are worrisome in EMS, this process is generally considered unnecessary

172. REMEMBER IN THE EVENT OF EXPOSURE TO AN INFECTIOUS DISEASE Exposed provider needs to contact Member Company Exposure/Infection Control Officer Contact should be made immediately if not involved in an emergency response or immediately upon completion of the call of an emergency incident The Member Company Exposure/Infection Control Officer will contact the CCVESA Exposure Control Officer or designee Contact The CCVESA Exposure Control Officer or designee will contact – Carroll Hospital Center – Carroll Occupational Health - Carroll County Health Department

173. Carroll Hospital Center, Carroll Occupational Health and/or County Health Department will report back the follow up procedures to the CCVESA Exposure Control Officer or designee The CCVESA Exposure Control Officer or designee will report back to the Member Company Exposure/Infection Control Officer The Member Company Exposure/Infection Control Officer will report back to the Exposed provider as to appropriate follow-up action should be taken All exposures must be reported!

174. Your time and attention during this training program has been appreciated. If you have any questions, comments, or concerns concerning bloodborne pathogens please contact the CCVESA Exposure Control Officer.