1. Infection Control Update
Go Gators!
Annual infection control, bloodborne pathogen, and TB education is required by JCAHO, AHCA, and OSHA. It is also important for you to review your role in infection control at this time.
Please read this module and complete the test.
Shands HealthCare Infection Control 2001

2. Learning Objectives
Upon completion of the self-study module, the learner will be able to:
Discuss key elements of the infection control program
Describe the Bloodborne Pathogen Exposure Control Plan
Describe the TB Control Plan
Describe key elements of the Biohazardous Waste Management Plan
Discuss their individual role in Infection Control
Many of the topics included in this self-study module are mandated by either licensing or accrediting agencies. The other topics are important for healthcare infection control and will clarify your role in Infection Control.

3. Infection Control is Everyone’s Business
Family/Visitors
Administrators
Physicians
Hospital
Ambulatory Care Center
Therapists
You are an important part of our Infection Control Program. Your commitment to following proper procedures, handwashing, and patient and family teaching can make the difference for you and your patient. If you have questions about infection control and patient management, talk to your supervisor or call Infection Control at (5-0BUG)
CNA/PCA/CMA
Environmental Services
Nurses
Clerks
Patients

4. Infection Control: Basic Elements
Prevention
Surveillance
The basic elements of an infection control program include: policies and procedures for preventing and controlling infections as well as surveillance activities to determine the effectiveness of those policies and procedures.
Control

5. The Infection Control Team
Hospital Epidemiologist:
Jennifer White Janelle, MD
Infection Control Committee Chairman:
Richard R. Gutekunst, Ph.D.
Infection Control Director:
Loretta L. Fauerbach, MS, CIC
Infection Control Practitioners:
Mary Ann Gross, MT, CIC
Robert Kelly, RN
Charlene Ruse, MT, ASCP
Kay Stauffer, RN, CIC
Shands Healthcare Staff
YOU!!
The Shands at UF Infection Control Staff is responsible for overseeing the infection control program for Shands at UF Hospital, Shands Rehab Hospital, University of Florida Physicians clinics, Florida Surgical Center, outpatient rehab facilities, and Shands HomeCare.
Additionally, you play a key role in infection control. Your knowledge of and adherence to infection control standards are the best ways to decrease the risk of infection in our patients, your co-workers, and you.

6. Infection Control Policy Manual: Location and Key Contents
Shands at UF Infection Control Policies (PM03)
Yellow Infection Control (IC) Manual
Department/Clinic-specific Infection Control Policies
in front of yellow IC manual
Biohazardous Waste Management Plan
PM Appendix L and Clinic IC Policy
Bloodborne Pathogen Exposure Control Plan
Clinic IC Policy and PM03-01, Appendix B
TB Control Plan
Clinic IC Policy and PM03-01, Appendix C
An Infection Control Manual is located in each department, clinic, and nursing unit. The policies in this manual provide the overall framework for infection control practice. Also in the manual, for areas of identified risk, you will find the infection control policy which has been written specifically for your department, unit, or clinic. The OSHA required Bloodborne Pathogen Exposure Control Plan and TB Control Plan are also located in this manual.

7. Variance Procedure (IC manual PM 03-01, Appendix A)
An Infection Control variance is any observation of an infraction of infection control policy or good infection control practice.
Please report to your supervisor any infection control variance. The supervisor should investigate and help to resolve the problem. Infection Control and the Hospital Epidemiologist will also work to resolve issues identified in variances. PM03-01, Appendix A is the form that should be used to document variances. This form should be promptly sent (within 24 hours), or a report of the variance called to the Shands at UF Infection Control office ( ) for additional follow up and tracking.

8. Your Infection Control Responsibilities
Know and comply with infection control policies and procedures
Recognize potential infection problems
Report variances
Communicate! Document!
Teach patient and care givers
Every person is responsible for assuring their own compliance with infection control policies.
Remember that teaching the patient and family the important steps to prevent infection is also an important part of your duties.
Finally, the job is not done until every sign and symptom of infection is documented in the patient’s medical record. Remember also to document all patient/family education activities.

9. CHAIN OF INFECTION SOURCE HOST Vector Method of Transmission Vehicle
Airborne
Vector
AGE
PATIENT
Vehicle
Treatment
EMPLOYEE
Method of Transmission
Immunity
Nutrition
ENVIRONMENT
EQUIPMENT
DISEASE
Skin Injury
CONTACT
Sources of Infection: Patient, volunteer, visitor, or employee may have an infection or be colonized with an infectious organism.
Environment -- Bacteria and viruses are all around us.
Equipment -- If not cleaned, disinfected, or sterilized properly,
equipment can be a source of contamination which leads to colonization and/or infection.
Method of Transmission: Infections are spread from the source to the susceptible host in very specific ways. Standard Universal Precautions and isolation can help break the chain of infection.
Host Factors: Many things can lower a person’s resistance to infection.
For example:
Age: The very young and the very old have lowered immune
responses.
Disease: Certain diseases can alter the patient’s immune system
and lower resistance to infection. (e.g., diabetes, cancer, HIV)
Treatment: May affect immune system. For example,
chemotherapy, radiation therapy, certain medications.
Skin injury: Intact skin is the best barrier against infection. If that
barrier is broken, bacteria and viruses can enter the
bloodstream more easily. Burns, trauma and surgery
increase infection risk.
VISITORS
Life Style
Direct
Indirect
Socioeconomics
SOURCE
HOST

10. Health Care Associated Infections
Infections associated with hospitalization are called “nosocomial infections
“Iatrogenic infections are related to care provided in other health care settings, such as ambulatory surgery centers or clinics.
May not be preventable
Not present on admission to hospital or prior to treatment in ambulatory care
May be detected after discharge from hospital or after outpatient treatment
Examples: Surgical Site
Urinary Tract
Bloodstream
Infection control first started to track nosocomial (hospital-associated) infections in the 1970’s. Today, it is also important to track infections associated with care given in outpatient areas, home health, and other healthcare settings.

11. Unfortunate 5% Patients at high risk for NI Transplant patients
Chemotherapy patients
Other Immunocompromised patients
Nationally, approximately 5%-10% of people admitted to a hospital will develop a nosocomial infection. Certain patients are at an increased risk for developing a nosocomial or iatrogenic infection because they do not have a “normal” immune system capable of fighting infection.

12. Risk Factors: Devices Foley Catheters Ventilators Other tubes IVs/CVLs
Implants
Any invasive device increases risk of infection. When assessing a patient, be sure to document your patient’s risk factors.
It is very important to follow infection control protocols to reduce device-related risks. See PM03-04 for specific risk reduction strategies for foley catheters, ventilators, and central lines.

13. Consequences of Hospital Acquired Infections
Complicate Treatment
Cause Additional Suffering
Increased Costs ($4.5 billion/yr)
prolonged hospital stay
drug treatment
additional surgery
Cause Death
Treatment is complicated because many of these patients need to be placed on antibiotics. These drugs may interact with medications the patient is already receiving, and/or cause unpleasant side effects. Infection may cause the patient increased pain, require frequent, uncomfortable dressing changes, necessitate removal/reinsertion of urinary catheters or IV lines, increasing costs and patient suffering. Nosocomial infections can even lead to death!

14. Wash Your Hands!!
Studies have shown that healthcare worker compliance with handwashing recommendations is 42% ---- What is your percentage?

15. Proper handwashing is VITAL to infection prevention
Wash your hands, even if gloves have been worn
Before patient contact
After contact with anything contaminated
Between contact with different patients
During patient care (per procedures)
before and after invasive procedure
before and after contact with wound
between procedures on different body parts of the same patient
Between glove changes
Immediately, if skin is contaminated or an injury occurs

16. How should I wash my hands?
In non-patient care areas and activities, the hospital-approved lotion soap should be used.
For patient care activities, use hospital-approved antimicrobial soap (Hibiclens®, Cida-Stat®, or Endure 420®).
For best results when using soap and water, use friction and lather for seconds
For patient care activities, the use of an antimicrobial agent containing Chlorhexidine Gluconate (CHG) is recommended. CHG is active against a wide range of bacteria, fungi, and viruses. It also has been shown to leave a protective residual on the skin which helps to decrease the overall bacterial count found on the hands ….. That is good news for both you and your patients!
If you experience hand irritation, report to Occupational Health Services for evaluation and recommendations for alternative soap.
As a supplement to or in place of handwashing, use hospital-approved alcohol-based hand rinse.
Squeeze generous amount (at least a teaspoon) into cupped hands. Rub vigorously until dry - - about seconds.

17. First remove gross debris and organic matter by cleaning
Key Points for Cleaning & Disinfection of Environmental Surfaces/Patient Care Equipment
First remove gross debris and organic matter by cleaning
If cleaning equipment in your unit or department, use designated cleaning area
Only use disinfectants approved by Infection Control - see PM03-10
Be sure to follow the manufacturer’s directions for use on the container’s label
Bleach is the cheapest & best disinfectant
For 1:10 dilution: make fresh daily
For 1:5 dilution: use for 30 days
Dirt and debris must first be removed by cleaning so the disinfectants can work.
For best results, check the product label for correct dilution instructions. If product is placed in container that is not the original container, the new container must be labeled with the product name, concentration, and date mixed.

18. Bloodborne Pathogens Exposure Control Plan
Purpose: To provide a safe working environment and reduce the risk of exposure to bloodborne pathogens
Location: Infection Control Manual -- PM03-01, Appendix B
OSHA requires annual education for all employees who have the potential for blood and body fluid exposure as part of their routine job tasks.
The Shands Bloodborne Pathogen Exposure Control Plan lists the components of our program to provide a safe working environment and to reduce the risk of exposure to bloodborne pathogens. Each employee should review the plan and know how to reduce their risk of exposure to bloodborne pathogens.

19. Bloodborne Pathogens Exposure Control Plan
Personal Protective Equipment
Job Task List
Engineering Controls
Work Practice Controls
Post Exposure Management
Biohazardous Labeling
Waste Management
Bloodborne Pathogen Training
The components of the Bloodborne Pathogen Exposure Control Plan are multi-faceted and provide information to the employee on how best to reduce their risk of exposure and how to comply with this OSHA regulation

20. Standard Universal Precautions
Consider all blood and body fluids potentially infectious.
Use Personal Protective Equipment (PPE) to prevent exposure.
If it is wet and sticky and not yours,
DO NOT touch it…
without gloves!

21. Standard Universal Precautions (cont’d)
Handwashing
Gloves
Eye and face protection
Gowns
Pt. Care equipment
Environmental controls
Linens
Occupational Health and bloodborne pathogens exposure reduction
These are the components that comprise Standard Universal Precautions. They are explained in more detail throughout this module.

22. Types of Isolation (in addition to Standard Universal Precautions)
Airborne Transmission (requires negative air pressure room)
Strict (disease spread by both airborne and contact routes)
Respiratory
Droplet Transmission:
Droplet/Pediatric Respiratory
Contact Transmission:
Contact
Enteric
Vancomycin Resistant
Types of isolation are based on how the disease/infectious organism is spread from person to person. Read the isolation signs on the outside of the patient’s door or above the head of the patient’s bed. The signs will tell you what personal protective equipment to put on before entering the room or before initiating any patient care task.

23. Communication of Isolation
Notify departments receiving patient for testing, unit to which patient is being transferred, clinics where patient is to be seen (clinics notify inpatient unit when patient being admitted].
If MRSA/VRE, “Resistant Organism” sticker will be placed on chart
Appropriate isolation/precaution sign on door and/or above patient’s bed.
Enter isolation code in “enter/revise patient factors” screen
Good communication is vital to assure that precautions are continuously carried out in all areas of the facility. This is important to protect other patients and/or staff.

24. Personal Protective Equipment (PPE)
Gloves
Gown
Protective Eye and Face Shield
Masks
Others
Boots, shoe covers
CPR shield
In order to protect yourself, PPE must be worn appropriately. Health care workers may think that wearing the appropriate PPE is too cumbersome or time consuming ---- until an exposure occurs.
Be prepared for care. Anticipate the type of PPE that will be needed and make sure it is readily available.

25. Job Task List Know what PPE you should wear for each task you perform.
Review the Job Task List for your department/unit. It can be found in the Infection Control Manual, Section PM03-01, under the divider labeled “PPE - Job Task List”. It is the employee’s responsibility to utilize PPE appropriately and the supervisor/manager’s responsibility to enforce adherence to these precautions.

26. BE CAREFUL WITH SHARPS Do not recap by hand
Use one-hand technique or a recapping device--only if recapping is unavoidable.
Use safety syringes, needle-less IV system and other safety products whenever possible.
Replace sharps containers when 3/4 full
Immediately dispose of sharps in sharps container
Contaminated sharps are lethal weapons! Handle with great caution.
Make sure that the sharps container is not overfilled. Replacing sharps container when it is 3/4 full reduces the risk of getting stuck from needle protruding from overfilled box.

27. ENGINEERING CONTROLS Sharps containers
Safety needles (self - sheathing)
Needle-less IV system
Safety “butterfly”
Plastic page protectors
CPR face shields
PEVCO tube system
Engineering controls are continually evolving to lower the exposure risk for healthcare workers. The safety devices must be used by the worker to protect themselves and others.
If paperwork that is part of the chart is accidentally contaminated, it should be placed in a plastic sheet protector since this paperwork can not be discarded.
Using a CPR shield while performing mouth to mouth resuscitation reduces the risk of exposure to a host of pathogens.
When using the Pevco® tube system to transport specimens to the lab, make sure tops are secure. Also, samples are to be placed in sealed plastic bags before being sent.

28. Work Practice Controls
Handwashing
Do not recap needles by hand
No food/drink in refrigerators with blood or other infectious materials
Do not drink, eat, apply cosmetics/lip balm, or handle contact lenses in areas where blood/body fluids may be present
Keep work area clean and decontaminated
Use proper cleaning/disinfecting/sterilization practices for equipment and work areas
Adhering to good infection control practice standards, i.e. work practice controls, will also help to protect the employee from exposure.

29. Waste Management Biohazardous vs. Regular
The US Department of Transportation (DOT) and Agency for Health Care Administration (AHCA) regulate the handling and transportation of biomedical waste in Florida. Local county landfills can also determine what trash they will accept.
For the Biohazardous Waste Management Plan, see Infection Control Manual, PM03-04 Appendix L
Biohazardous waste (sometimes also called biomedical or infectious waste) is defined as any solid or liquid waste which may present a threat of infection to humans.

30. Method for sealing boxes  
Twist excess bag from the top of the waste to the end of the bag
Remove excess air
from bag
Tape the twisted part of the bag
The DOT regulates how biomedical waste bags and boxes must be closed. Pictures and instructions above, demonstrate the correct method for securing the biomedical waste bag/box.  
Tape the flaps to form a “H” design
Loop the twisted and taped end of bag over itself and tape again

31. Labeling - DOT Regulations for biomedical waste
Sharps containers
Red bags
Cardboard biomedical waste disposal boxes
Must be labeled with the name and location of the facility generating the waste

32. Bloodborne Pathogens Hepatitis B Hepatitis C HIV Malaria Syphilis
Babesiosis
Brucellosis
Leptospirosis
Arboviruses
Relapsing fever
CJD
HTLV - I & II
Viral hemorrhagic fever
Many pathogens may be transmitted to health care workers through contact with infected blood. The primary bloodborne diseases that affect health care workers are hepatitis B, hepatitis C, and HIV. OSHA* regulations require that you review these diseases.
* OSHA = Occupational Safety and Health Administration

33. Hepatitis B Incubation period = 6 weeks-6 months
May shorten life span years
Reported cases of acute Hepatitis B in US decreased 50% in last decade (21,102 in 1990 to 10,258 in 1998)
Hepatitis B is a serious disease. Similar to other hepatitis viruses, it can cause jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea, and vomiting. It can lead to cirrhosis and liver cancer. One in twenty cases remains chronically infected.
The incidence of Hepatitis B increased through 1985 but has now decreased because of wider use of the Hepatitis B vaccine. The downtrend in new cases is expected to continue with a national strategy for vaccination of children.
Since 1993, increased cases have been observed in only three major risk groups: sexually active heterosexuals with multiple partners, men who have sex with men, and injection drug users.

34. Hepatitis B Transmission
Blood to Blood
Sexual contact
Persons at increased risk of acquiring Hepatitis B include:
injection drug users,
sexually active heterosexuals with multiple partners,
men who have sex with men,
infants/children of immigrants from disease-endemic areas,
low socioeconomic level,
sexual/household contacts of infected persons,
infants born to infected mothers,
healthcare workers, and
hemodialysis patients.
Perinatal transmission

35. Hepatitis B Prevention
Vaccination
Standard Universal Precautions
Safer Sex
No Sharing Needles
Hepatitis B vaccine prevents hepatitis B disease and its serious consequences. It has been called “the first anti-cancer vaccine” since it prevents the development of liver cancer following Hepatitis B infection.
It is recommended to screen pregnant women; to begin treatment of infants born to infected women within 24 hours of birth; to vaccinate infants and year olds, and to vaccinate high-risk groups of all ages.
Screening of blood/organ/tissue donors for Hepatitis B also helps prevent transmission.
Adherence to Standard Universal Precautions, not sharing needles, and safer sex practices are also key in disease prevention.

36. Hepatitis C 16% of viral hepatitis cases
Incubation Period = average 6-7 weeks
(Range 2-26 weeks)
3.9 million have been infected
2.7 million are chronically infected
70% of infected persons develop chronic liver disease
$600 million annually in medical and work loss expense - - not including transplantation.
Liver damage due to HCV is the primary reason for liver transplants in the U.S.

37. Hepatitis C Transmission Blood-to-Blood
May cause post transfusion hepatitis
50-60% of cases are associated with IV drug use
Only 30-40% of infected individuals report a clinical illness and only 20-30% have jaundice. The rest of the infected persons have no symptoms, but are still infectious.
Transfusion-associated cases most often occurred prior to Testing is now available to screen donated blood, so new transfusion-associated cases are rare.
Needlestick injuries have been associated with the majority of occupationally-acquired Hepatitis C cases.
*HCW = Health care worker
2% of cases are HCW* infected through occupational exposure to infected blood

38. Hepatitis C Prevention
Standard “Universal” Precautions
Reduce risk by personal choices
NO VACCINE
A vaccine to prevent Hepatitis C is not yet available. Therefore, it is important for healthcare workers to follow Standard Universal Precautions.
Personal choices to reduce risk of infection include:
avoid sharing of needles and/or illicit drugs
safer sex practices.

39. Epidemiology of AIDS As of December, 1999
World wide, an estimated 33.6 million people are living with AIDS
In US, there are 40,000 new AIDS cases reported annually.
Three million adolescents contract a sexually transmitted disease (STD) each year. STDs increase HIV infectivity and susceptibility.
743,534 reported cases in USA since 1980
43% of new cases are women

40. States/Territories Reporting Highest Number AIDS Cases in USA (Data as of December, 1999)
Florida has more cases than some countries!
In Florida, 25% of cases are under the age of 29
Approximately 1 in 156 Floridians are currently living with HIV infections:
1 in 286 Whites
1 in 50 Blacks
1 in 127 Hispanics

41. AIDS Epidemiology
Florida is SECOND in the US in reported cases of AIDS in women and children.
Pediatric cases-- USA = 11,643; Florida = 1,375
Women-- USA = 115,756; Florida = 16,319
Florida is challenged to provide care to many women and children who have AIDS. It also must provide assistance to children who are not infected but lose parental support due to the disease in their family.

42. HIV Transmission Sexual Contact Mother to Infant Blood Contact
IV needle sharing
Blood products including transfusion
Healthcare worker exposure to blood and body fluid
The news on transmission remains the same. It is transmitted by sexual contact, from mother to infant, and from contact with infected blood.
It is estimated that 1 in 500,000 units of blood may contain HIV.
HIV is NOT transmitted by casual contact, hugging, toilet seats, telephones, computer keyboards, etc.

43. Personal Prevention Measures
Abstain from sex with infected person
Discuss sexual history with partners
Reduce number of sexual partners
Always use latex male condoms or polyurethane female condoms
Use only water-soluble lubricants with condoms
Avoid illicit drug use and sharing of needles
Safer sex practices remain an important strategy to decrease the spread of HIV.
In addition to the traditional latex male condom, women now have another choice for protection. A female condom is available. A couple should either use a male condom or a female condom….not both at the same time, since the friction may tear and displace the condoms if both are worn.

44. All positive HIV tests reported to Florida Department of Health
Exceptions to reporting:
tests performed at anonymous test sites
tests of patients performed because of employee blood/body fluid exposure
tests performed on employee following blood/body fluid exposure
certain HIV/AIDS research settings
Shands at UF Infection Control reports positive HIV results for the Shands laboratory, as required by law.
The Alachua County Public Health Department ( ) is an anonymous test site. Shands Occupational Health Services will perform HIV testing for employees using a confidential numbering system.

45. Informed Consent
Patient must give informed consent to be tested for HIV
Written informed consent is best
Place on chart
When obtaining informed consent, explain the law’s provision for a person’s right to confidentiality of the results of the test and any information which identifies him/her by name.
According to Florida Administrative Code, an explanation of the following information represents a sound and reasonable standard for informed consent:
An HIV test will determine if an individual is infected with the virus which causes AIDS
The potential uses and limitations of the test
The procedures to be followed
HIV testing is voluntary. Consent to be tested can be withdrawn at any time prior to the test being performed
Reportability of positive test.

46. When is informed consent not required?
A bona fide medical emergency that requires knowledge of the patient’s HIV status for medical management
If knowledge of testing would be detrimental to patient and is necessary for medical management purposes to provide appropriate care.
If consent is obtained for autopsy, specific HIV consent not required
If tissue/blood is being donated
HIV testing would need to be clearly indicated for the medical care and/or treatment of the patient - - and the patient must be unable to consent

47. Exception to Informed Consent Following a Healthcare Worker Exposure
Source patient may be tested without informed consent only when:
There has been a significant exposure
There is existing blood available
The exposed employee consents to be tested or has a documented HIV test within the previous 6 months
The source patient dies during emergency treatment.
The patient has been asked to consent and has refused. Patient must be told that testing will be done under Florida Law.
Results are not placed in patient’s medical record.
Be sure to work with patient’s physician and Occupational Health Services to make sure the law is followed for post exposure workups.
If a patient has been told of a healthcare worker’s significant exposure and refuses to be tested, the testing is performed on existing serum. The results of this testing are then entered in the employee’s medical record, not the source patient’s medical record. (A court order can be obtained if the patient refuses testing and there is no existing serum.)

48. Mandatory Offering of Testing to Pregnant Females
Providers of care to pregnant women must offer HIV testing and explain benefits of early treatment of HIV infection in decreasing transmission to infant
Emphasize education for high risk patients
Refer to substance abuse programs as needed
The transmission of the virus from mother to infant can be reduced from 30% to 8% through the administration of AZT/protease inhibitors to the mother during pregnancy and to the infant for 6 weeks after birth. Therefore, Florida Law requires that a health care provider who attends a pregnant woman for conditions relating to her pregnancy offer HIV testing and counsel her on the availability of treatment if she tests positive.
If the pregnant women objects to HIV testing, a reasonable attempt must be made to obtain a written statement of objection, signed by the patient, which shall be placed in her medical record.
Act as liaison with other services
Mother’s HIV test results may be noted in child’s medical record

49. United States Healthcare Workers with Documented Occupationally Acquired HIV -- 1980-1999
“Documented” cases are healthcare workers who have contracted HIV through work related injury. All other risk factors were ruled out and exposure on the job was documented.
The “possible” cases in healthcare workers have been investigated and are without identifiable behavioral or transfusion risks. Although each person had experienced exposure to blood or body fluids, or laboratory solutions containing HIV, a specific job-related incident resulting in a HIV positive blood test was not documented.

50. Occupationally Acquired HIV in US Healthcare Workers (through December ‘99)
56 confirmed cases
48 percutaneous
5 mucocutaneous
2 both
1 unknown route
Percutaneous injury = injury through needlestick or scalpel cut
Mucocutaneous exposure = splash in eyes or mouth or contact with non-intact skin

51. Occupationally Acquired HIV Infection in the US (1980-1999)
23 Nurses
16 Clinical lab techs
6 Non-surgical physicians
3 Nonclinical lab techs
2 Surgical tech
1 Dialysis tech
1 Embalmer/morgue tech
1 Home health aids
2 Housekeeper/ maintenance worker
1 Respiratory therapist
Healthcare workers who more frequently handle needles and draw blood have been more likely to have occupationally acquired HIV.
Housekeepers and others who do not perform hands-on patient care are generally exposed through the negligence of others -- such as needles left in patient’s linens or in the trash.

52. HIV Post-exposure Conversion Factors
Hollow bore needle
Deep IM stick
HIV stage of source patient
Gloves not worn
Volume of exposure
Type of body fluid with blood
Lack of post-exposure prophylaxis
The risk of becoming HIV positive after an exposure to blood is dependent on the volume of blood present during exposure. More blood is present with a hollow bore needle and transferred during a deep injury. If a needlestick occurs through the glove, gloves can act as a “squeegee” and actually decrease the volume of blood encountered. Patients with a higher number of HIV virus in their blood are more likely to transmit disease.

53. What should I do if an exposure occurs?
Thoroughly wash exposed area
Contact supervisor/access Occupational Health
Optimal time for post-exposure prophylaxis (PEP) is 1-2 hours post exposure
Post-exposure prophylaxis (PEP) for HIV = AZT + 3TC + protease inhibitor
If an exposure occurs to your skin, wash with soap and water.
If an exposure occurs to your mucous membrane (eyes/mouth), flush with water or saline.
Occupational Health Services (OHS) will evaluate your exposure. If a significant exposure has occurred, PEP (i.e., preventive medications) should be started within 1-2 hours, since earliest therapy is generally most effective.
Note: If there has been a delay in reporting of an exposure, PEP will be evaluated at time of reporting
***During off-hours, contact Nursing Coordinator for evaluation of exposure and possible referral to Emergency Department. (Contact Paging Operator for beeper number.)
**See Post-Exposure checklist on next page.**

54. TB Exposure Control Plan
See PM03-01, Appendix C
Designed to reduce risk of transmission of tuberculosis
OSHA requires a TB Exposure Control Plan to reduce the risk of transmitting tuberculosis in the healthcare setting.

55. TB Exposure Control Plan
Early Recognition
Recognize signs and symptoms
Adequate specimen testing
Initiate and maintain appropriate isolation
Isolation: Respiratory Isolation
Masks: 95N respirator masks
Be sure to be fit tested for proper mask size before caring for TB patient.
Engineering Controls
Negative Air Pressure, air exchanges,outside exhaust, hepa filtration (in hospitals)
Post Exposure Management: PPD testing
TB control requires early recognition of persons with tuberculosis, and prompt isolation .
Before providing care to a patient with active TB, OSHA requires that all employees be fit tested to make sure they know the correct size of 95N particulate respirator mask to wear and how to properly fit it to their face.

56. Tuberculosis (TB)
Agent -- Mycobacterium tuberculosis (acid fast bacillus -- AFB)
Reservoir -- man
Transmission -- airborne droplet nuclei
Tuberculosis (TB) is a disease caused by a bacterium called Mycobacterium tuberculosis. Tuberculosis usually causes a chronic lung infection but it can also cause infection in other organs of the body.
Tuberculosis is spread when a patient with the disease in the lung coughs, sneezes, or otherwise expels the organism into the air. The TB bacteria is suspended in droplet nuclei that float in the air and can be inhaled by another person.

57. TB -- Pathogenesis & Transmission
4-12 weeks from infection to demonstrable tuberculin reaction
first 1-2 years after infection -- greatest risk for developing active disease
considered infectious until 3 negative sputum smears
The initial infection may go unnoticed, and it can take from 4-12 weeks after exposure to a person with TB for the PPD skin test to be positive. However, when a person develops active TB, the symptoms usually are chronic, meaning that they last longer than four weeks. Active disease is most likely to occur in the first two years after conversion from a negative to a positive PPD.
Once a person has been diagnosed with TB in the lung, they are considered infectious until their sputum no longer shows the TB organism (3 negative AFB smears, at least 24 hours apart).

58. TB -- Signs and Symptoms
Persistent cough
Abnormal chest
X-ray
Fever
Bloody sputum
Weight loss
Loss of appetite
Night sweats
THINK TB…..during patient assessment. It is important to consider TB if a patient has these signs and symptoms and has been ill for 4 weeks or more.

59. Active Tuberculosis Infection
Positive skin test
Abnormal chest x-ray
Symptomatic
Medications to treat disease
Isolation required
Infectious
Infection
Positive skin test
Normal chest x-ray
No symptoms
Medications to prevent active disease
No isolation
Not Infectious
Only people with active pulmonary TB can spread the infection.
Certain populations are at higher risk for developing tuberculosis.

60. PPD Testing Policy -- ALL Shands Employees
All employees with negative PPD history receive annual skin testing
All employees with history of positive PPD must fill out form annually, and report to OHS any time they experience prolonged symptoms
Persons who have received BCG vaccine for TB, should discuss skin testing with OHS
Post Exposure Follow-up
Report to OHS if exposed to patient with TB without wearing mask
PPD testing done when exposure reported and repeated weeks after exposure
A PPD skin test is used to determine if someone has been exposed to the TB bacteria. During testing, a Purified Protein Derivative (PPD) is injected just under the skin. The site of injection is examined 48 to 72 hours later. If there is a reaction, the site is measured. At Shands, a reading of >10 mm based on the induration (swelling or lump) is considered positive. Immunosuppressed individuals must be evaluated using other criteria and are often considered to be positive at 5mm of induration.
Annual PPD testing/screening is required as part of your annual performance evaluation. When your skin test is completed, you will receive documentation from Occupational Health.

61. Report These Conditions To Occupational Health
“Weeping” dermatitis and draining lesions
“Pink eye”/conjunctivitis
Rash (no known reason)
Fever/nausea/vomiting/
diarrhea
Blood/body fluid exposures
for post exposure prophylaxis
Other infectious disease exposures
It is important that you come to work healthy. Please do not put others at risk. If you have any of the above listed conditions, or other infectious illness, obtain “fitness for duty” clearance from Occupational Health before reporting to work

62. Influenza and Pneumonia
6th leading cause of death in USA
1998 deaths due to influenza and pneumonia
USA--91,871
Florida--4,080

63. Do your part to protect yourself against influenza
Get immunized against flu each fall
vaccination reduces
severity of disease
risk of complications
risk of death
Practice cough containment by covering nose and mouth with a tissue when you cough or sneeze. Discard tissues and wash your hands.

64. IMMUNIZATIONS Required: MMR Chicken Pox (Varicella) Recommended:
Hepatitis B
Influenza
Vaccinations help prevent disease. It is especially important for healthcare workers to be immune to these infectious diseases in order to protect patients and our own families as well as ourselves.
The mandatory varicella vaccination program initiated in June, 1998, has reduced varicella exposure incidents and significantly decreased non-immune employees’ risk of getting chickenpox. It has also reduced the use of administrative leave and overall exposure management costs.

65. Some general infection control practices when not at work
Prevent antibiotic resistance
Food/eating safety
Child and elder care considerations
To prevent antibiotic resistance, remember these points:
Don’t insist on a prescription for an antibiotic if you have a viral infection such as a cold or the flu.
Don’t stop taking antibiotics before you complete your prescription, even if your symptoms are gone.
Follow your doctor’s instructions carefully - - take doses on schedule until all of the pills are gone!
Never share your medication with anyone, and do not take someone else’s medicines.
Most food poisoning occurs after eating food prepared at home.
Thaw frozen food in the refrigerator - - not at room temperature
Keep cold food cold and hot food hot - - not at room temperature.
Wash your hands before, during, and after preparing food.
Use separate cutting boards for meat and fruit/vegetables
Cook meat until well done
Wash sponges and dish clothes frequently in washing machine or dishwasher, or use disposable cloths (use once and throw away).
Children immune systems have not fully developed the ability to fight off infections.
Day care centers, schools, and camps are settings where infections diseases (such as ear infections) may be spread among children.
Choose your day care carefully. Ask how and how often toys are cleaned, what is the procedure for diaper changes, and what is the policy regarding sick children and staff?
Do not send your child to day care if he/she has diarrhea or is running a fever.
Elderly persons need extra care also. As we age, our immune systems wear down.
Flu and pneumonia are leading causes of death among our older population. Encourage elders to get their flu and pneumonia vaccinations.

66. Remember: everything you touch has been touched by someone else
Thanks for washing your hands
Finally, please remember that handwashing is your most important means for preventing infection in YOU!

67. Any Questions????? Talk to your supervisor
Call Shands at UF Infection Control
For questions please talk to your supervisor. Please call Shands at UF infection control if you need additional clarification.

68. Host Characteristics: Influence susceptibility and severity of disease
Age
Socioeconomic status
Disease history
Life style
Nutritional status
Immunization