nys2011 Infection control

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New York State Infection Control & Barrier Precautions Training

Copyright (C) 2011 VMD Health Care Training

}  Section 1: Introduction }  Section 2: Bloodborne Pathogens and OPIM }  Section 3: Safety and Prevention in the Workplace }  Section 4: Exposure Incidents and Follow Up


} OSHA estimates that 8 million workers in the health care industry and related occupations are at risk of occupational exposure to bloodborne pathogens. ◦  Occupational exposure to blood or other potentially

infectious materials (OPIM) puts you and your patients at risk for serious illness or death.


} In environments where workers are potentially exposed to blood or body fluids, the risks of infection are undeniable. ◦  Knowledge about how exposure occurs, the risk of

transmission and how to prevent it can help you work safely and without unnecessary fear or anxiety.


} Employers must: ◦  Make certain that all employees with an occupational

exposure to bloodborne disease participate in a training program ◦  Ensure that workers receive regular training that covers: �  The dangers of bloodborne pathogens to self and others �  Safety and prevention practices. �  Post-exposure procedures.


} Methods for compliance ◦  Participation in required infection prevention and control

training ◦  Adherence to accepted principles and practices of

infection prevention and control


} Knowledge of the consequences of failing to follow accepted standards of infection prevention and control: ◦  Increase risk of adverse health outcomes for patients

and health care workers ◦  Subject to charges of professional misconduct.

�  Mechanisms for reporting misconduct �  Complaint investigation �  Possible outcomes �  1) Disciplinary action �  2) Revocation of professional license �  3) Professional liability


} New York State: ◦  Rules of the Board of Regents, Part 29.2 (a)(13) ◦  Part 92 of Title 10 (Health) of the Official Compilation of

Codes, Rules and Regulations of New York


}  Section 1: Introduction }  Section 2: Bloodborne Pathogens and OPIM }  Section 3: Safety and Prevention in the Workplace }  Section 4: Exposure Incidents and Follow Up


} Pathogen or infectious agent: ◦  A biological, physical, or chemical entity capable of

causing disease. Biological agents may be bacteria, viruses, fungi, protozoa, helminthes, or prions.

} Portal of entry: ◦  The means by which an infectious agent enters the

susceptible host.


} Portal of exit: ◦  The path by which an infectious agent leaves the

reservoir

} Reservoir: ◦  Place in which an infectious agent can survive but may or

may not multiply. Healthcare workers may also be reservoirs for a number of nosocomial organisms.


} Standard precautions: ◦  A group of infection prevention and control strategies that

combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents.

} Susceptible host: ◦  A person or animal not possessing sufficient resistance to a

particular infectious agent to prevent contracting infection or disease when exposed to the agent.


} Healthcare-associated infections (HAIs): ◦  Infections associated with healthcare delivery in any

setting (e.g., hospitals, long-term care facilities, ambulatory settings, home care).

} Engineering controls: ◦  Controls (e.g., sharps disposal containers, self-sheathing

needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.


} Injection safety (or safe injection practices): ◦  A set of measures taken to perform injections in an optimally

safe manner for patients, healthcare personnel, and others. A safe injection does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous for the community. Injection safety includes practices intended to prevent transmission of bloodborne pathogens between one patient and another, or between a healthcare worker and a patient, and also to prevent harms such as needlestick injuries.


}  Single-use medication vial: ◦  A bottle of liquid medication that is given to a patient through a

needle and syringe. Single-use vials contain only one dose of medication and should only be used once for one patient, using a new needle and new syringe.

} Multi-dose medication vial: ◦  bottle of liquid medication that contains more than one dose of

medication and is often used by diabetic patients or for vaccinations.

} Work practice controls: ◦  Controls that reduce the likelihood of exposure to bloodborne

pathogens by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).


} Transmission: ◦  Any mechanism by which a pathogen is spread by a

source or reservoir to a person } Common vehicle: ◦  Contaminated material, product, or substance that serves

as an intermediate means by which an infectious agent is introduced into a susceptible host through a suitable portal of entry


} Concept of "The Chain of Infection" ◦  1. Pathogen or infectious agent ◦  2. Reservoir (human, animal, environmental) ◦  3. Portal of exit �  a. Sites (respiratory tract, gastrointestinal tract, genitourinary tract,

skin/mucous membrane, transplacental, blood) �  b. Mechanisms (drainage, excretions, secretions) ◦  4. Portal of entry �  a. Sites (respiratory tract, gastrointestinal tract, genitourinary tract,

skin/mucous membrane, transplacental, parenteral) �  b. Mechanisms (percutaneous injury, invasive devices/procedures

(e.g., vascular access), surgical incision


} Concept of "The Chain of Infection" ◦  5. Mode of transmission �  a. Contact with pathogen

�  1) Direct �  2) Indirect �  3) Droplet �  4) Airborne

�  b. Common vehicle (e.g., food, water) �  c. Vectorborne ◦  6. Susceptible host


} Factor influencing the outcome of exposures ◦  1. Host factors �  a. Natural barriers (e.g., intact skin, respiratory cilia, gastric acid

and motility, tears, normal flora) �  b. Host immunity (e.g., inflammatory response, humoral immunity,

cell-mediated immunity, immune memory) ◦  2. Pathogen or infectious agent factors �  a. Infectivity �  b. Pathogenicity �  c. Virulence �  d. Size of innoculum �  e. Route of exposure �  f. Duration of exposure


} Factor influencing the outcome of exposures ◦  3. Environmental factors �  Contamination of environment �  Contamination of equipment


} Standard precautions ◦  Respiratory hygiene/cough etiquette ◦  Safe injection practices (see Element III) ◦  Use of masks during spinal/epidural access procedures

} For patients infected with organisms other than bloodborne pathogens ◦  Early identification ◦  Prompt isolation ◦  Appropriate treatment


} Control of routes of transmission ◦  1. Hand hygiene �  Appropriate selection and use of agents (e.g., soap and

water, alcohol based hand sanitizers) �  Factors influencing hand hygiene efficacy �  Sources of potential contamination or cross-contamination of

hand hygiene materials ◦  2. Use of appropriate barriers �  Appropriate selection, donning, doffing, and disposal of

personal protective equipment (PPE)


} Control of routes of transmission ◦  3. Appropriate isolation/cohorting of patients infected with

communicable diseases �  Standard precautions for all patients �  Transmission based precautions for other pathogens

�  1) Contact (direct, indirect) �  2) Droplet �  3) Airborne

�  Host support and protection �  1) Vaccination �  2) Pre-and post-exposure prophylaxis �  3) Protecting skin and immune system integrity


} Control of routes of transmission �  Environmental control measures

�  1) Cleaning, disinfection, and sterilization of patient care equipment

�  2) Environmental cleaning (housekeeping) �  3) Appropriate ventilation �  4) Waste management �  5) Linen and laundry management �  6) Food services

�  Engineering and work practice controls �  Training and education of healthcare workers


} Both blood and other potentially infectious materials (OPIM) may contain bloodborne pathogens. ◦  Bloodborne pathogens are bacteria and viruses present

in the blood and body fluids of an infected person that can cause disease to others.


} Bloodborne pathogens include, but are not limited to: ◦  Hepatitis B Virus (HBV) ◦  Hepatitis C Virus (HCV) ◦  Human Immunodeficiency Virus (HIV).


} Other potentially infectious materials (OPIM) include: ◦  Human body fluids: ◦  Seminal ◦  Vaginal ◦  Cerebrospinal ◦  Synovial ◦  Pleural ◦  Pericardial ◦  Peritoneal ◦  Amniotic

◦  All body fluids in situations where it is difficult or impossible to differentiate between body fluids.


Hepatitis B Virus (HBV) }  Description: ◦  Serious disease caused by a virus that attacks and

causes inflammation of the liver. ◦  HBV can cause lifelong infection, scarring of the liver,

liver cancer, liver failure, and death.

Hepatitis B virus


HBV Incidence: }  Estimated 1.25 million chronically infected

Americans. ◦  20-30% acquired infection in childhood. ◦  Following widespread hepatitis B vaccination,

percentage of cases from occupational exposure to blood is now about 0.5%.


}  HBV Signs & Symptoms: ◦  Jaundice (yellowing of skin) ◦  Fatigue ◦  Abdominal pain ◦  Loss of appetite ◦  Nausea, vomiting ◦  Joint pain


HBV Transmission }  Occurs when blood from an infected person

enters the body of a person who is not infected. ◦  Sex with an infected person without a condom ◦  Injecting drugs with shared needles ◦  Needlesticks or sharps exposures on the job ◦  From an infected mother to her baby at birth


}  HBV is not transmitted by: ◦  Sneezing or coughing ◦  Kissing or hugging ◦  Sharing eating utensils or drinking glasses ◦  Breastfeeding ◦  Food or water ◦  Casual contact (such as an office setting)


HBV Prevention: }  Hepatitis B vaccine is the best protection. ◦  Proper use of condoms may reduce transmission. ◦  Do not inject drugs. Never share needles or syringes. ◦  Do not share personal care items that might have

blood on them (razors, toothbrushes).


HBV Prevention (continued): ◦  Consider the risks if you are thinking about getting a

tattoo or body piercing. ◦  If you are a designated first aid provider, health care

or public safety worker, assume that the blood and other body fluids from all patients/victims are potentially infectious.

◦  Always follow universal precautions and safely handle needles and other sharps.


Hepatitis B Vaccine }  Description: ◦  Used to prevent infection by the hepatitis B virus. ◦  Works by causing your body to produce its own protection

(antibodies) against the disease. ◦  Made without any human blood or blood products or any

other substances of human origin and cannot give you HBV.


Hepatitis B Vaccine }  Safety and Effectiveness: ◦  Medical, scientific, and public health communities

strongly endorse hepatitis B vaccine as safe and effective for infants, children, and adults.

◦  There is no evidence that hepatitis B vaccine can cause chronic illnesses.


Hepatitis B Vaccine }  Method of Administration: ◦  Injected.

�  Vaccine is available only from your doctor or other authorized health care professional.


Hepatitis B Vaccine }  Benefits: ◦  Vaccine prevents hepatitis B disease and its serious

consequences like liver cancer. ◦  Free.

�  OSHA requires employer to make the vaccine available at no cost to all employees who have potential occupational exposure.


Hepatitis B Vaccine }  Requirements: ◦  Employer must make vaccination available after

employee has received blood borne pathogens training.

◦  Must be done within 10 working days of when employee is assigned to a job with potential occupational exposure.

◦  An employee may decline the vaccination but decide to accept it at a later date.


If declined, the employee must sign a document with the following statement:

“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.”


Hepatitis C Virus (HCV) }  Description: ◦  HVC is a serious disease caused by a virus that

attacks the liver and causes inflammation. ◦  HCV can cause lifelong infection, scarring of the liver,

liver cancer, liver failure and death.


HCV Incidence: }  Number of new infections per year has declined from 240,000 (1980s) to

26,000 (2004). ◦  Most infections are due to illegal injection drug use. ◦  Transfusion-associated cases occur in less than one per 2 million transfused

units of blood. ◦  Estimated 3.9 million (1.6%) Americans have been infected with HCV, of whom

3.2 million are chronically infected.


}  HCV Signs & Symptoms: ◦  Jaundice (yellowing of skin) ◦  Fatigue ◦  Dark urine ◦  Abdominal pain ◦  Loss of appetite ◦  Nausea

�  Note: 80% of persons have no signs or symptoms


}  Transmission: ◦  Occurs when blood from an infected person enters the

body of a person who is not infected. ◦  HCV is spread by injecting drugs with shared needles,

through needlesticks or sharps exposures on the job, or from an infected mother to her baby during birth.

◦  HCV can be spread by sex, but this is rare. ◦  Persons at risk for HCV infection might also be at risk

for infection with hepatitis B virus or HIV.


}  HCV is not transmitted by: ◦  Sneezing or coughing ◦  Kissing or hugging ◦  Sharing eating utensils or drinking glasses ◦  Breastfeeding ◦  Food or water ◦  Casual contact (such as an office setting)


}  HCV Prevention: ◦  There is no vaccine to prevent HCV.

�  Proper use of condoms may reduce transmission. �  If you are pregnant, you should get a blood test for

hepatitis C. �  Do not inject drugs. Never share drugs, needles, or

syringes. �  Do not share personal care items that might have blood

on them (for example, razor or, toothbrushes).


}  HCV Prevention (continued): ◦  Consider the risks if you are thinking about getting a

tattoo or body piercing. ◦  If you are a designated first aid provider, health care

or public safety worker, assume that the blood and other body fluids from all patients are potentially infectious.


◦  If you have or had hepatitis C, do not donate blood, organs, or tissue.


Human Immunodeficiency Virus (HIV) Acquired Immune Deficiency Syndrome (AIDS) }  Description: ◦  AIDS is a term used to apply to the most advanced

stages of HIV infection. ◦  HIV kills or damages cells of the body's immune

system.


AIDS Incidence: }  Has killed more than 25 million people since

1981 ◦  More than 3 million died in 2005 - 570,000 of them -

children. ◦  More than 900,000 cases of AIDS have been reported

in the US since 1981. ◦  As many as 950,000 Americans may be infected. ◦  More than 230,000 are unaware of their infection.


AIDS Incidence (continued): }  Growing most rapidly among minority

populations. ◦  Leading killer of African-American males ages 25 to 44. ◦  Almost 5 million people newly infected in 2005 (worldwide). ◦  Risk of health care workers being exposed to HIV on the job is very

low. �  Average risk of HIV transmission after a needle-puncture of the skin with

HIV-infected blood is about 0.3% and after a mucous membrane exposure (eyes/mouth) about 0.09%.


Early Signs & Symptoms. }  Within a month or two after exposure to the

virus, symptoms may imitate a flu-like illness: ◦  Fever ◦  Headache ◦  Tiredness ◦  Enlarged ◦  Large lymph nodes or "swollen glands"


}  Other symptoms often experienced months to years before the onset of AIDS include: ◦  Lack of energy. ◦  Weight loss. ◦  Frequent fevers and sweats. ◦  Persistent or frequent yeast infections (oral or vaginal). ◦  Persistent skin rashes or flaky skin. ◦  Pelvic inflammatory disease in women that does not

respond to treatment. ◦  Short-term memory loss.


}  AIDS Transmission: ◦  Having sex with infected person. ◦  Sharing needles and syringes with infected person. ◦  Infants: Exposure to HIV before or during birth, or

through breast feeding.

Cell infected with HIV and covered with virus particles

Berkeley National Laboratory Copyright (C) 2011 VMD Health Care Training

}  HIV is not transmitted by: ◦  Shaking hands ◦  Hugging or a casual kiss ◦  Toilet seats ◦  Drinking fountains ◦  Door knobs ◦  Dishes ◦  Drinking glasses ◦  Food ◦  Pets, Mosquitoes, or bedbugs


Prevention: }  There is no vaccine to prevent HIV ◦  Abstain from having sex or use condoms. Proper use

may reduce transmission. ◦  Do not inject drugs. Never share drugs, needles, or

syringes. ◦  Consider the risks if you are thinking about getting a

tattoo or body piercing.


Prevention (continued): ◦  If you are a designated first aid provider, health care or

public safety worker, assume that the blood and other body fluids from all patients are potentially infectious.



Certain specific factors may mean a percutaneous injury carries a higher risk, for example: ◦  A deep injury ◦  Late-stage HIV disease in the source patient ◦  Visible blood on the device that caused the injury ◦  Injury with a needle that had been placed in a source

patient's artery or vein


Percutaneous injury (cont.): ◦  If percutaneous exposure occurs then the site of

exposure should be washed liberally with soap and water but without scrubbing.

◦  Bleeding should be encouraged by pressing gently around the site of the injury (but taking care not to press immediately on the injury site).

◦  It is best to do this under a running water tap.


Post-expose Prophylaxis (PEP): ◦  The risk of infection with HIV can be reduced by 80% if

prophylactic treatment is taken within 24 hours of an exposure.

◦  Treatment should ideally be started within one hour of an exposure. The recommended treatment is a 28 day course of three anti-viral drugs used in the treatment of established HIV disease.


Post-expose Prophylaxis (PEP): ◦  Sufficient epidemiological data is available to

demonstrate that treatment with one of the drugs, Zidovudine (AZT), can reduce the risk of transmission by 80%. Use of a combination of drugs is likely to further reduce transmission rates.

◦  The long term effects of use of the drugs for prevention of infection has not been fully evaluated, and they have not been licensed for this, although their use is recommended by most authorities and almost all HIV specialist.


Post-expose Prophylaxis (PEP): ◦  The decision on whether to use PEP after an accident is a

personal one. There’s no ‘right’ answer. Infection after an inoculation injury is relatively uncommon. The drugs commonly cause the person taking them to feel unwell and, rarely, have been associated with serious side effects. The prescribing doctor can help calculate the probability of infection occurring, discuss the pros and cons of taking PEP with you and usually recommend whether or not to take treatment but, in the end, you will need to decide.


Statistics: ◦  Up until December 2006, health care workers in the US

reported 57 occupational HIV infections. ◦  Of these, 48 had percutaneous exposure; 5, mucocutaneous

exposure; 2, both percutaneous and mucocutaneous exposure; and 2, an unknown route of exposure.

◦  In addition, 140 possible occupational transmissions have occurred among healthcare personnel. These are cases in which a worker is infected with HIV and has a history of occupational exposure, but did not have a test immediately before and after the possible exposure. As no other risk factors are reported, it is most likely that the infection has occurred as a result of that occupational exposure.



}  Section 1: Introduction }  Section 2: Bloodborne Pathogens and OPIM

}  Section 3: Safety and Prevention in the Workplace }  Section 4: Exposure Incidents and Follow Up


} Reason for Learning ◦  Prevention of occupational exposure to bloodborne

pathogens and OPIM requires a broad approach including risk assessment exposure control planning, engineering, work practice controls and proper use of personal protective equipment. ◦  This section provides an overview of these critical

elements of safety and prevention in the workplace, as it involves you and those you care for


} Contamination: ◦  The presence of microorganisms on an item or surface.

} Cleaning: ◦  The process of removing all foreign material (i.e., dirt,

body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object

} Critical device: ◦  An item that enters sterile tissue or the vascular system.

These must be sterile prior to contact with tissue.


} Decontamination: ◦  The use of physical or chemical means to remove,

inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles.

} Disinfection: ◦  The use of a chemical procedure that eliminates virtually

all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects.


} High level disinfection: ◦  Disinfection that kills all organisms, except high levels of

bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by the U.S. Food and Drug Administration (FDA).

} Intermediate level disinfection: ◦  Disinfection that kills mycobacteria, most viruses, and

bacteria with a chemical germicide registered as a "tuberculocide" by the U.S. Environmental Protection Agency (EPA).


} Low level disinfection: ◦  Disinfection that kills some viruses and bacteria with a

chemical germicide registered as a hospital disinfectant by the EPA.

} Non critical device: ◦  An item that contacts intact skin but not mucous

membranes. It requires low level disinfection. } Semi critical device: ◦  An item that comes in contact with mucous membranes or

non intact skin and minimally requires high level disinfection.


} Sterilization: ◦  The use of a physical or chemical procedure to destroy

all microbial life, including highly resistant bacterial endospores.


} Exposure Control Plan ◦  Every employer that has employee(s) with a risk of

occupational exposure to blood or OPIM must perform an assessment of this risk and develop a written plan to eliminate or minimize it. ◦  The plan must be accessible whenever an employee or

his or her designated representative requests it.


} Exposure Control Plan ◦  The plan must contain: �  Exposure determination.

�  A list of all job classifications, tasks and procedures with a risk of occupational exposure to blood or OPIM.

�  Schedule and method of implementation. �  A written description of how employers put bloodborne pathogen

compliance into practice.


} Exposure Control Plan ◦  The plan must contain (continued): �  Documentation that engineering controls (such as

needleless systems) have been considered and where possible, implemented.

�  Procedures for evaluating the circumstances surrounding an exposure incident.


}  Exposure Control Plan ◦  Must be reviewed and updated at least

annually. ◦  Must document that the employer has

requested input in the identification, evaluation, and selection of effective engineering and work practice controls from employees. �  Particularly from front line healthcare

workers who are responsible for providing patient care.


}  Engineering Controls ◦  Equipment or devices that help reduce exposure to

potential hazards either by isolating the hazard or by removing it from the work environment (i.e., sharps container).

◦  Engineering controls must be examined and maintained or replaced on a regular schedule.


}  Engineering Controls ◦  Signs and warning labels are a type of engineering control. ◦  Must be attached to all containers that are used to store,

transport or ship blood or OPIM. ◦  Containers must be marked with either a biohazard symbol or

placed in a colored-coded container such as a red bag.


}  Work Practice Controls ◦  Procedures that reduce the likelihood of exposure by

altering the manner in which a task is performed (for example, not bending or recapping contaminated needles).


} High risk practices and procedures: ◦  A. Percutaneous exposures �  1. Exposures occurring through handling/disassembly/

disposal/reprocessing of contaminated needles and other sharp objects: �  a. Manipulating contaminated needles and other sharp objects

by hand (e.g., removing scalpel blades from holders, removing needles from syringes),

�  b. Delaying or improperly disposing (e.g., leaving contaminated needles or sharp objects on counters/workspaces or disposing in non-puncture-resistant receptacles),

�  c. Recapping contaminated needles and other sharp objects using a two-handed technique.


} High risk practices and procedures: �  2. Performing procedures where there is poor visualization,

such as: �  a. Blind suturing, �  b. Non-dominant hand opposing or next to a sharp, �  c. Performing procedures where bone spicules or metal

fragments are produced. ◦  B. Mucous membrane/non-intact skin exposures �  1. Direct blood or body fluids contact with the eyes, nose,

mouth, or other mucous membranes via: �  a. Contact with contaminated hands, �  b. Contact with open skin lesions/dermatitis, �  c. Splashes or sprays of blood or body fluids (e.g., during

irrigation or suctioning).


} High risk practices and procedures: ◦  C. Parenteral exposures �  1. Injection with infectious material may occur during:

�  a. Administration of parenteral medication, �  b. Sharing of blood monitoring devices (e.g., glucometers,

hemoglobinometers, lancets, lancet platforms/pens), �  c. Infusion of contaminated blood products or fluids.


} Safe injection practices and procedures designed to prevent disease transmission from patient to patient and healthcare worker to patient. ◦  A. Unsafe injection practices have resulted in one or

more of the following: �  Transmission of bloodborne viruses, including hepatitis B

and C viruses to patients; �  Notification of thousands of patients of possible exposure to

bloodborne pathogens and recommendation that they be tested for hepatitis C virus, hepatitis B virus, and human immunodeficiency virus (HIV);


} Safe injection practices (cont) �  Referral of providers to licensing boards for disciplinary action; and �  Malpractice suits filed by patients. ◦  B. Pathogens including HCV, HBV, and human

immunodeficiency virus (HIV) can be present in sufficient quantities to produce infection in the absence of visible blood. �  Bacteria and other microbes can be present without clouding or

other visible evidence of contamination. �  The absence of visible blood or signs of contamination in a used

syringe, IV tubing, multi- or single-dose medication vial, or blood glucose monitoring device does NOT mean the item is free from potentially infectious agents.


} Safe injection practices (cont) �  All used injection supplies and materials are potentially

contaminated and should be discarded. ◦  C. Providers should: �  1. Maintain aseptic technique throughout all aspects of

injection preparation and administration: �  a. Medications should be drawn up in a designated "clean"

medication area that is not adjacent to areas where potentially contaminated items are placed.

�  b. Use a new sterile syringe and needle to draw up medications while preventing contact between the injection materials and the non-sterile environment.

�  c. Ensure proper hand hygiene before handling medications.


} Safe injection practices (cont) �  d. If a medication vial has already been opened, the rubber

septum should be disinfected with alcohol prior to piercing it. �  e. Never leave a needle or other device (e.g. “spikes”) inserted

into a medication vial septum or IV bag/bottle for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid.

�  f. Medication vials should be discarded upon expiration or any time there are concerns regarding the sterility of the medication.

�  2. Never administer medications from the same syringe to more than one patient, even if the needle is changed.


} Safe injection practices (cont) �  3. Never use the same syringe or needle to administer IV

medications to more than one patient, even if the medication is administered into the IV tubing, regardless of the distance from the IV insertion site. �  a. All of the infusion components from the infusate to the

patient's catheter are a single interconnected unit. �  b. All of the components are directly or indirectly exposed to the

patient's blood and cannot be used for another patient. �  c. Syringes and needles that intersect through any port in the IV

system also become contaminated and cannot be used for another patient or used to re-enter a non-patient specific multi-dose medication vial.


} Safe injection practices (cont) �  d. Separation from the patient's IV by distance, gravity and/or

positive infusion pressure does not ensure that small amounts of blood are not present in these items.

�  4. Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient.

�  5. Dedicate vials of medication to a single patient, whenever possible. �  a. Medications packaged as single-use must never be used for

more than one patient: �  1) Never combine leftover contents for later use;


} Safe injection practices (cont) �  b. Medications packaged as multi-use should be assigned to a

single patient whenever possible; �  1) Never use bags or bottles of intravenous solution as a common

source of supply for more than one patient. �  6. Never use peripheral capillary blood monitoring devices

packaged as single-patient use on more than one patient: �  a. Restrict use of peripheral capillary blood sampling devices to

individual patients. �  b. Never reuse lancets. Consider selecting single-use lancets

that permanently retract upon puncture.


} Safe injection practices and procedures designed to prevent disease transmission from patient to healthcare worker. ◦  A. Refer to OSHA guidelines, available at: http://www.osha.gov/pls/oshaweb


}  Universal Precautions ◦  An approach to infection control. ◦  To “observe universal precautions” means that whether

or not you think the victim’s blood or body fluid is infected, you act as if it is.

◦  Always place a barrier between you and a person’s blood or body fluid.


}  PPE ◦  Employers must provide at appropriate PPE such as,

disposable gloves, gowns, laboratory coats, face shields, eye protection, pocket masks, or bag-mask devices (used for resuscitation) at no cost to the employee.

◦  Employers must make certain that employees use PPE.


}  Selecting PPE: ◦  All PPE clothing and equipment should be of safe

design and construction, and should be maintained in a clean and reliable fashion.

◦  Select PPE that fits well and is comfortable to wear. ◦  Most PPE are available in multiple sizes.


}  Selecting PPE (continued): ◦  Care should be taken to select the proper size. ◦  If your PPE does not fit properly, it can make the

difference between being safely protected or dangerously exposed.


}  PPE Training: ◦  Employers are required to train each employee who must use

PPE before they are allowed to perform any work requiring its use.

◦  You must know: �  When PPE is necessary. �  What PPE is necessary. �  How to put on, take off, adjust, and wear PPE. �  Limitations of the PPE. �  Proper care, maintenance, useful life, and disposal of PPE.


}  Disposable Gloves: ◦  Use disposable, single-use gloves to protect your

hands. ◦  All cuts or sores on your hands should be covered with

a bandage as additional protection before applying gloves.

◦  Inspect gloves before putting them on. If a glove is damaged, don’t use it!

◦  Wearing two pairs of gloves can provide an additional barrier and further reduce risk.


}  Disposable Gloves (continued): ◦  Never wash or reuse disposable gloves. ◦  If you find yourself in a first aid situation and you don’t have

any gloves - improvise. Use a towel, plastic bag, or some other barrier to help avoid direct contact.

◦  Make sure there is always a fresh supply of gloves in your first aid kit.

◦  When taking contaminated gloves off, do it carefully. Don’t snap them, this may cause blood to splatter.


}  Recommended Technique ◦  Proper Removal of Contaminated Gloves


}  Eye Protection: ◦  Bloodborne viruses can be transmitted through the

mucous membranes of the eyes from blood splashes or from touching the eyes with contaminated fingers or other objects.

◦  Eye protection provides a barrier to this transmission.


}  Eye Protection ◦  Goggles or glasses with solid side shields, or chin-length face

shields, must be worn whenever splashes, spray, spatter, or droplets of blood or OPIM may be produced or reasonably anticipated.

◦  Appropriately fitted, indirectly-vented goggles with a manufacturer’s anti-fog coating provide the most reliable practical eye protection from blood splashes and sprays.


}  Protection during Resuscitation: ◦  Resuscitation devices must be made readily available to

employees who are designated or can reasonably be expected to perform resuscitation procedures (CPR).

◦  These employees must be properly trained in the various types, use and location of these devices according to the manufacturer's instructions and/or accepted medical practice.


}  Although mouth-to-mouth breathing is a quick and effective method to provide oxygen to a person who is not breathing, unprotected mouth-to-mouth resuscitation should not be used by any emergency response personnel. Bag-Mask Device

Pocket Mask


}  Protective Body Clothing: ◦  Protective body clothing such as gowns, aprons,

laboratory coats, clinic jackets, surgical caps, or shoe covers must be provided at no cost to the employee.


}  Contaminated PPE: ◦  Any PPE that become soiled with infectious material must be

removed as soon as possible. ◦  Handle with caution. ◦  PPE that is dripping with blood or body fluids (grossly

contaminated) should be placed into a container that is marked with a biohazard symbol or placed in a red bag.

◦  PPE lightly soiled with spots of blood or OPIM can be discarded in the regular trash.


}  Always place contaminated sharps in a closable, appropriately labeled or color coded, puncture-resistant, and leak-proof container immediately or as soon as possible after use.


}  Hand Hygiene: ◦  Handwashing is one of the most important and easy

work practices used to prevent transmission of bloodborne pathogens.

◦  Hands or other exposed skin should be thoroughly washed as soon as possible following an exposure incident and after removal of gloves or other personal protective equipment.


}  Hand Hygiene (continued): ◦  Employers must provide handwashing facilities that

are readily accessible to employees. ◦  When this is not possible, employers must provide

either an appropriate antiseptic hand-cleanser or antiseptic towelettes.

◦  The Centers for Disease Control and Prevention recommends routinely decontaminating hands with an alcohol-based hand rub.


}  Hand Hygiene (continued): ◦  Compared with soap and water, alcohol-based hand

rubs are more effective in reducing bacteria on hands and cause less skin irritation.

◦  If an alcohol-based hand rub is not available, or your hands are visibly soiled with blood or OPIM, wash with either a non-antimicrobial soap and water or an antimicrobial soap and water.


}  Hand Hygiene: ◦  Recommended Technique

�  Alcohol-Based Hand Rub �  Apply product to palm of one hand. �  Rub hands together, covering all surfaces of hands and

fingers, until hands are dry.


}  Hand Hygiene: ◦  Recommended Technique

�  Soap and Water �  Wet hands first with warm water. �  Apply soap to hands. Rub hands and fingers together

vigorously for at least 15 seconds. �  Rinse hands with water and dry thoroughly with a disposable

towel. �  Use towel to turn off the faucet


}  Decontamination: ◦  A work practice control using physical or chemical

means to remove, inactivate, or destroy bloodborne pathogens on a surface.

◦  All spills of blood or OPIM must be immediately contained and cleaned up by professionals or properly trained staff.

◦  Gross contamination should be cleaned up first with a soap and water solution.


}  Disinfectants: ◦  Dilute 1/4 cup household bleach (5.25% sodium

hypochlorite) in 1 gallon of cool water. ◦  Bleach and water loses its strength and is weakened

by heat and sunlight. ◦  Mix a fresh bleach solution every day for maximum

effectiveness. ◦  Contact time for bleach is generally considered to be

the time it takes the product to air dry.


}  Disinfectants (continued): ◦  Other disinfectants include EPA registered antimicrobial

products and “hospital grade” disinfectants cleared by the FDA.

◦  Effectiveness of a disinfectant is governed by strict adherence to the instructions on the label.

◦  Employees must be trained in their proper use.


}  Equipment and Surfaces: ◦  All equipment and working surfaces must be cleaned

and decontaminated after contact with blood or OPIM.


}  Recommended Technique ◦  Clean Up and Disinfection of Blood or OPIM Spills

1.  Locate and open spill clean-up kit 2.  Put on appropriate protective clothing, including disposable aprons, caps and eye

protection. 3.  Wear double gloves. 4.  Pour an adsorbent material over the spill 5.  Use a scoop to pickup material. Wipe up any remaining blood or OPIM with an

absorbent towel. 6.  Apply a disinfectant to the area. 7.  Place all cleanup supplies, including protective body clothing in a red bag for proper

disposal. 8.  Thoroughly wash your hands.


}  Reusable Containers: ◦  Bins, pails, cans, or similar containers that are reused

and may be contaminated with blood or OPIM must be inspected regularly and decontaminated immediately or as soon as possible if they are visibly contaminated.


}  Broken Glass: ◦  Do not pick up broken glassware directly with your

hands; use mechanical means, such as use a brush and dustpan, tongs, or forceps.

◦  Place the glassware into an appropriate sharps container.


}  Laundry: ◦  Handle contaminated laundry as little as possible. ◦  Place wet contaminated laundry in leak-proof and

color-coded or labeled containers, at the location where it was used.

◦  Normal laundry cycles should be used following the washer and detergent manufacturer's recommendations.


} Universal principles ◦  A. Instruments, medical devices and equipment should be

managed and reprocessed according to recommended/appropriate methods regardless of a patient’s diagnosis except for cases of suspected prion disease. �  Special procedures are required for handling brain, spinal, or nerve

tissue from patients with known or suspected prion disease (e.g., Creutzfeldt-Jakob disease [CJD]). Consultation with infection control experts prior to performing procedures on such patients is warranted.


} Universal principles ◦  B. Industry guidelines as well as equipment and chemical

manufacturer recommendations should be used to develop and update reprocessing policies and procedures. ◦  C. Written instructions should be available for each

instrument, medical device, and equipment reprocessed.


} Potential for contamination is dependent upon ◦  A. Type of instrument, medical device, equipment, or

environmental surface �  Potential for external contamination (e.g., presence of hinges,

crevices). �  Potential for internal contamination (e.g., presence of lumens). �  Physical composition, design, or configuration of the instrument,

medical device, equipment, or environmental surface. ◦  B. Frequency of hand contact with instrument medical device,

equipment, or environmental surface.


} Potential for contamination is dependent upon ◦  C. Potential for contamination with body substances or

environmental sources of microorganisms. ◦  D. Level of contamination. �  Types of microorganisms �  Number of microorganisms �  Potential for cross-contamination


} Steps of Reprocessing ◦  A. Pre-cleaning �  Removes soil, debris, lubricants from internal and external surfaces �  To be done as soon as possible after use ◦  B. Cleaning ◦  Manual (e.g., scrubbing with brushes) ◦  Mechanical (e.g., automated washers) ◦  Appropriate use and reprocessing of cleaning equipment (e. g.,

do not reuse disposable cleaning equipment) ◦  Frequency of solution changes


} Steps of Reprocessing ◦  C. Disinfection- requires sufficient contact time with

chemical solution ◦  D. Sterilization- requires sufficient exposure time to heat,

chemicals, or gases


} Choice/Level of reprocessing sequence ◦  A. Based on intended use: �  Critical instruments and medical devices require sterilization. ◦  Semi critical instruments and medical devices minimally require

high level disinfection. ◦  Noncritical instruments and medical devices minimally require

cleaning and low level disinfection.


} Choice/Level of reprocessing sequence ◦  B. Based on manufacturer's recommendations �  Compatibility among equipment components, materials, and

chemicals used �  Equipment heat and pressure tolerance �  Time and temperature requirements for reprocessing


} Effectiveness of reprocessing instruments, medical devices and equipment ◦  A. Cleaning prior to disinfection ◦  B. Disinfection �  1. Selection and use of disinfectants

�  a. Surface products �  b. Immersion products

�  2. Presence of organic matter �  3. Presence of biofilms


} Effectiveness of reprocessing instruments, medical devices and equipment

�  4. Monitoring �  a. Activity and stability of disinfectant �  b. Contact time with internal and external components �  c. Record keeping/tracking of instrument usage and reprocessing

�  5. Post-disinfection handling and storage ◦  C. Sterilization �  1. Selection and use of methods


} Effectiveness of reprocessing instruments, medical devices and equipment

�  2. Monitoring �  a. Biologic monitors �  b. Process monitors (tape, indicator strips, etc.) �  c. Physical monitors (pressure, temperature gauges) �  d. Record keeping and recall/ tracking system for each sterilization

processing batch/item �  3. Post-sterilization handling, packaging and storage (event-related

criteria)


} Recognizing potential sources of cross-contamination in the healthcare environment ◦  A. Surfaces or equipment which require cleaning between

patient procedures/treatments ◦  B. Practices that contribute to hand contamination and the

potential for cross-contamination ◦  C. Consequences of reuse of single-use/disposable

instruments, medical devices or equipment


}  Factors that have contributed to contamination in reported cases of disease transmission ◦  A. At any point in reprocessing or handling, breaks in infection control

practices can compromise the integrity of instruments, medical devices or equipment. ◦  B. Specific factors

�  Failure to reprocess or dispose of items between patients �  Inadequate cleaning, disinfection, or sterilization �  Contamination of disinfectant or rinse solutions �  Improper packaging, storage and handling �  Inadequate/inaccurate record keeping of reprocessing requirements


} Expectations of health professionals with respect to differing levels of disinfection and sterilization methods and agents based on the area of professional practice setting and scope of responsibilities ◦  A. Professionals who practice in settings where handling,

cleaning, and reprocessing equipment, instruments or medical devices is performed elsewhere (e.g., in a dedicated Sterile Processing Department):


�  1. Understand core concepts and principles �  a. Standard and Universal Precautions (e.g., wearing of personal

protective equipment) �  b. Cleaning, disinfection, and sterilization described in Sections III

and IV above �  c. Appropriate application of safe practices for handling instruments,

medical devices and equipment in the area of professional practice. �  d. Designation and physical separation of patient care areas from

cleaning and reprocessing areas is strongly recommended by NYSDOH

�  2. Verify with those responsible for reprocessing what steps are necessary prior to submission �  a. Pre-cleaning �  b. Soaking


◦  B. Professionals who have primary or supervisory responsibilities for equipment , instruments or medical device reprocessing (e.g., Sterile Processing Department staff or clinics and physician practices where medical equipment is reprocessed on-site): �  1. Understand core concepts and principles

�  a. Standard and Universal Precautions �  b. Cleaning, disinfection, and sterilization described in Sections III and IV

above �  c. Appropriate application of safe practices for handling instruments, medical

devices, and equipment in the area of professional practice �  d. Designation and physical separation of patient care areas from cleaning

and reprocessing areas is strongly recommended by NYSDOH


◦  2. Determine appropriate reprocessing practices taking into consideration: �  a. Selection of appropriate methods

�  i. Antimicrobial efficacy �  ii. Time constraints and requirements for various methods �  iii. Compatibility among equipment/materials

�  Corrosiveness �  Penetrability �  Leaching �  Disintegration �  Heat tolerance �  Moisture sensitivity


�  iv. Toxicity �  Occupational health risks �  Environmental hazards �  Abatement methods �  Monitoring exposures �  Potential for patient toxicity/allergy

�  v. Residual effect �  Antibacterial residual �  Patient toxicity/allergy.

�  vi. Ease of use �  Need for specialized equipment �  Special training requirements


�  vii. Stability �  Concentration �  Potency �  Efficacy of use �  Effect of organic material

�  viii. Odor �  ix. Cost �  x. Monitoring �  Frequency �  FDA regulations for reprocessing single use devices (refer to the

FDA web site at: �  http://www.fda.gov/cdrh/reprocessing/


}  Section 1: Introduction }  Section 2: Bloodborne Pathogens and OPIM

}  Section 3: Safety and Prevention in the Workplace }  Section 4: Exposure Incidents and Follow Up


} Reason for Learning ◦  If the required controls are in place and the bloodborne

pathogens standard is correctly implemented, exposure incidents should be uncommon events. ◦  However, after an exposure incident has occurred,

immediate first aid, confidential medical evaluation and follow-up are critical components to assure your health and well-being.



} Post-exposure Evaluation and Follow-up. ◦  Following a report of an exposure incident (and after

initial first aid), the employer must make a confidential medical evaluation and follow-up immediately available.


} The evaluation and follow up must include: ◦  The routes of exposure and how the exposure occurred. ◦  Identification and documentation of the source individual ,

unless identification is impossible or prohibited by law. ◦  Arrangements to have the source individual tested in

order to determine if they are infected with HBV or HIV.


} Evaluation and follow up (cont): ◦  The source individual's test results with information about

laws protecting confidentiality. ◦  Testing the employee's blood (after obtaining consent) as

soon as possible after exposure incident. ◦  Results of the testing must be made available to the

exposed employee, and the employee must be informed of all applicable laws and regulations concerning disclosure of the identity and infectious status of the individual.


} Post-exposure evaluation and management ◦  A. Bloodborne pathogens �  1. Prompt evaluation by licensed medical professional �  2. Risk assessment in occupational exposures �  3. Recommendations for approaching source patient and

healthcare worker evaluations �  4. Recommendations for post-exposure prophylaxis

emphasizing the most current NYSDOH and CDC guidelines


} Post-exposure evaluation and management �  5. Post-exposure management of patients or other healthcare

workers when exposure source is a healthcare worker �  a. Professional obligation to inform patients exposed to a healthcare

worker’s blood or other potentially infectious material ◦  B. Airborne or droplet pathogen �  1. Tuberculosis

�  a. Recommendations for post-exposure prophylaxis emphasizing the most current New York State guidelines for post-exposure prophylaxis

�  2. Varicella, Measles, Mumps, Rubella, Pertussis �  a. Consult the most current Federal, State, or local requirements for

post-exposure evaluation and management


} Post-exposure evaluation and management ◦  C. Notification of healthcare workers/public


} Post-exposure vaccination for HBV or the use of antiretroviral drugs to treat HIV infection should be administered as soon as possible, preferably within hours. ◦  All medical records generated by an exposure incident

must be kept confidential and may not be disclosed or reported without the employee's express written consent to any person within or outside the workplace.


} Employers must make certain that a responsible person reviews the circumstances of all exposure incidents. ◦  The following factors must be documented: �  Engineering controls in use at the time of the incident. �  Work practices followed. �  A description of the device being used (syringe, broken

glass, etc.). �  PPE or clothing in use at the time of the incident


} The following factors must be documented (continued): ◦  Location of the incident. ◦  Procedure being performed at the time of the incident. ◦  Employee's training. ◦  All injuries from contaminated sharps must be recorded

in a Sharps Injury Log.


} Evaluation of healthcare workers infected with HIV, HBV and/or HCV or other bloodborne pathogens ◦  A. Review New York State Department of Health Policy on HIV

testing of healthcare workers ◦  B. Criteria for evaluating infected health care worker’s for risk

of transmission �  1. Nature and scope of professional practice �  2. Techniques used in performance of procedures that may pose a

transmission risk to patients �  3. Assessed compliance with infection control standards �  4. Presence of weeping dermatitis, draining or open skin wounds


} Evaluation of healthcare workers infected with HIV, HBV and/or HCV or other bloodborne pathogens �  5. Overall health

�  a. Physical health �  B. Cognitive status

◦  C. Expert panels for evaluation of healthcare workers infected with bloodborne pathogens


}  New York State – Department of Health ◦  NYS Infection Control Syllabus Elements (2010)

}  American Safety & Health Institute ◦  Bloodborne Pathogens Course (2005)


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Training...

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nys2011 Infection control