Exposure Control Plan - Blood and Bloodborne Pathogens Guidelines

Hill Country Memorial Health System

Fredericksburg, Texas

Originating Department: Surveillance, Prevention, and Control of Infection

 

TITLE:     EXPOSURE CONTROL PLAN  - BLOOD AND BLOODBORNE PATHOGEN GUIDELINES

POLICY #:

AFFECTED DEPARTMENTS:  ALL

APPROVED:

EFFECTIVE DATE: JAN. 1, 1998

REVISED DATE: January 15, 2002

 

 

View or Print the Hepatitis B Vaccination Consent Form

View or Print the HIV/AIDS and Hepatitis B Training Record Form

 

PURPOSE:  

 

To ensure compliance with the Occupational Health and Safety Administration                                                                     (OSHA) standard 1910.1030 for all employees who have occupational exposure to blood or other potentially infectious materials.

 

DEFINITIONS:

 

Blood:  Human blood, human blood components and products from human blood.

 

Bloodborne Pathogens: Pathogenic microorganisms that are present in human blood and can cause disease in humans.  These pathogens include, but are not limited to, Hepatitis B virus (HBV), and Human Immunodeficiency Virus ( HIV ) and Hepatitis C virus (HCV).

 

Clinical Laboratory:  A workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

 

Contaminated:  The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

 

Contaminated Laundry.  Laundry which has been soiled with blood or other potentially infectious material or may contain sharps.

 

Contaminated Sharps: Any contaminated object that can penetrate the skin including but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of wires such as dental wires, and orthopedic wires.

 

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 and the surface oritem is rendered safe for handling, use or disposal.

 

Engineering Controls:  Control (e.g. sharps disposal container, needleless system, needle recappers ) that isolate or remove the bloodborne pathogen hazard from the workplace.

 

Exposure Incident:  A specific eye, mouth, or other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious material that results from the performance of an employee's duties.

 

Handwashing Facilities:  A facility providing an adequate supply of running, potable water, soap and single use towels or hot air drying machines.

 

Licensed Healthcare Professional:  A person whose legally permitted scope of practice allows him/her to independently perform Hepatitis B vaccination and post-exposure follow-up and evaluation.

 

Occupational Exposure:  Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material that results from the performance of an employee's duties.

 

Other Potentially Infectious Materials:  The following human body fluids:

  1. semen

  2. vaginal secretions

  3. cerebrospinal fluid

  4. synovial fluid

  5. pleural fluid

  6. pericardial fluid

  7. peritoneal fluid

  8. amniotic fluid

  9. saliva in dental procedure

  10. any body fluid that contains visible blood

  11. Any unfixed tissue or organ ( other than intact skin) from a human (living or dead).

  12. HIV containing cell or tissue cultures, organ  cultures, and HIV or HBV containing culture medium or other solutions

  13. Blood, organs or other tissues from experimental animals infected with HIV, HBV, or HCV.

 

Parenteral:  Piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.

 

Personal Protective Equipment (PPE):  Specialized clothing or equipment worn by an employee for protection against a hazard.  General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

 

Regulated Waste:  Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items which are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during  handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

 

Source Individual:  Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to a healthcare worker.

 

Sterilize:  The use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.  

 

Standard Precautions:  An approach to infection control.  According to the concept of standard precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, HCV, and other pathogens.

 

Work Practice Controls:  Controls that reduce the likelihood of exposure by altering the manner in which a task is performed ( e.g. prohibiting recapping of used needles).

 

EXPOSURE CONTROL PLAN

 

The Exposure Control Plan consists of the following elements:

 

Availability of Guidelines to Employees

 

The Exposure Control Plan is placed in the Provision of Patient Services Manual.  Seven of these manuals are located strategically around the organization, with easy access assured for all patient care areas.  Employees are oriented to the placement of these manuals in New Employee General Orientation and again on a yearly basis with Annual Safety Training.  Department may choose to place a copy of the Plan in Department Specific manuals if they desire.   Employees are welcomed to copy the plan for their own use at any time.  The Infection Control Practitioner retains the original copy of the Exposure Control Plan on computer and hard copy in the Quality Management Department.

 

Exposure Determination  

 

All employees whose duties include routine or occasional tasks or procedures where there is a potential for exposure to blood and/or other potentially infectious materials are included in the plan.  These duties include but are not limited to:

 

Job Classifications with Occupational Exposure included but are not limited to:

 

 

METHODS OF COMPLIANCE

 

STANDARD PRECAUTIONS

 

Since medical history and examination cannot reliably identify all patients infected with HIV or other bloodborne pathogens, blood and body-fluid precautions should be consistently used for ALL patients.  This approach recommended by CDC is referred to as "universal blood and body-fluid precautions" or "Standard Precautions", should be used in the care of all patients.   This is especially important for those in emergency care setting in which the risk of blood exposure is increased and the infectious status of patients is usually unknown.

 

Guidelines for using "Standard Precautions"

 

1. All Healthcare workers should routinely use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with blood or other body fluids of any patient is anticipated.  Appropriate barrier precautions include the use of Personal Protective Equipment:

 

A. Gloves

Non-sterile, powder-free latex gloves are provided by HCMH in all areas where patient care occurs.  For those individuals allergic to latex, vinyl gloves are provided for individual employees as they require them.  Gloves should be worn when the employee has a potential for direct skin contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin.  Gloves should also be worn when handling items or touching surfaces contaminated or potentially contaminated with blood or body fluids.  Sterile gloves should be used for procedures involving contact with sterile body cavities.  In certain situations where delicate or intricate procedures are being performed, gloves that fit well are necessary to reduce the risk of injury.  In such instances, sterile gloves may be the only option as non-sterile gloves come in only limited sizes.  

 

Gloves should be changed between patients, and when they become grossly contaminated or non-intact.  Surgical or examination gloves should not be washed for multiple use, rather discarded after one use.  

 

Utility gloves should be worn by housekeeping, sterile processing and dietary employees in situations when there is a potential for contact with blood and/or body fluids.  Utility gloves may be disinfected and reused but must be discarded when they become torn, punctured, cracked or otherwise non-intact.  

 

In certain instances where large volumes of blood and /or  body fluid are present, such as in surgery, deliveries and trauma, it is pertinent to wear 2 pair of gloves.

 

The use of gloves does not preclude adequate handwashing.  Handwashing must be accomplished before and after the donning of gloves, regardless of the amount of contamination occurring or being anticipated.

 

B. Gowns

Appropriate protective clothing shall be worn when the employee has the potential for exposure to blood and/or body fluids due to splashing.  Fluid resistant gowns are available in all patient care areas and are to be worn when there is reasonable anticipation that blood and/or body fluid with splash.  The Clinical Laboratory supplies their staff with fluid resistant lab coats that are laundered by the hospital laundry.  All other patient care areas provide disposable fluid resistant gowns for the staff.    Fluid resistant gowns are designed to protect work clothes, street clothes,  undergarments,  and skin from blood and / or body fluids.  When large quantities of blood / body fluids are present, the HCW may choose to use a fluid proof gown, especially when there is anticipation of pressure being applied to the fluid which may cause it to soak through the gown.  Fluid proof gowns are package separately and are located in those areas where they will most often be needed - Emergency Department, Surgery Department and

 

Labor and Delivery.  

Disposable caps or hoods, and shoe covers will be worn if there is a potential for hair and shoes to become contaminated with blood and/or body fluids.

 

Gowns, caps or hoods, and shoe covers are to be disposed of when leaving the patient room.  Supplies of gowns, shoe covers, and caps are kept in all patient care areas.

 

C. Masks and Eye Protection

 

Masks with eye shields or chin length shields are worn whenever splashes, sprays, spatters, droplets or aerosols of blood or other potentially infectious materials may be generated and there is a potential for eye, nose and mouth contamination.  Masks with attached eye shields are located in all patient care areas and are designed to be used as a unit - not separated.  Chin length eye shields are located in the operating room.

 

Masks with eye shields are disposable and are discarded after each patient use.

 

Chin length eye shields are non-disposable and are cleaned with disinfectant after each use.

 

2. Care of personal protective equipment

 

A. All personal protective equipment should be removed immediately upon leaving the patient room or area, and placed in an appropriate designated area or container for disposal or cleaning.

 

B. Person protective equipment is supplied by the hospital at no expense to the employee.  PPE is repaired, replaced, clean or laundered by the hospital at no cost to the employee.

 

3. Other Considerations:

 

A.  Eating, drinking, smoking, applying cosmetic or lip balm, and handling contact lenses is prohibited in areas where patient care occurs and where contact with blood and/or body fluids is a potential.

 

B.  Food and drink are not stored in refrigerators, freezers or cabinets where blood or other potentially infectious material is stored, or on counter tops where food or drink may come in contact with or be contaminated by blood and/or body fluids.

 

C. All procedures involving blood or other potentially infectious material shall be

performed in such a manner as to minimize splashing, spraying or aerosolization of these substances.

 

D. Mouth pipetting or mouth suctioning is prohibited.

 

E. Disposable ambu bags are located at the head of all patient beds and in all other areas where patient care is delivered.  Mouth - to - mouth resuscitation is prohibited within the confines of the hospital, and employees are instructed during regular CPR classes on the use of these ambu bags.

 

F. All clinical specimens must be placed in a leakproof container which is not contaminated on the outside.  Plastic zip-lock bags marked with the biohazard sign are available in all areas where specimens are collected.  Specimen collection containers should be placed in these bags for transport to the laboratory.

 

G. Any piece of equipment that must be sent to biomedical maintenance or to sterile processing for cleaning must be marked with the biohazard sign if there is a possibility that is may be contaminated with blood and/or body fluids.

 

4.  Care after exposure to blood and/or body fluids:

 

A. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids.  Hands should be washed immediately after gloves are removed.

 

B. All healthcare workers should take precautions to prevent injuries caused by needles, scalpels and other sharp instruments or devices during procedures and when cleaning used instruments after procedures.  To prevent needlestick injuries, needle should not be recapped, purposely bent, clipped or broken by hand, removed from disposable syringes or otherwise manipulated by hand.  Clean needles may be recapped,  dirty/ used needles are not recapped unless a needle recapping device or the one handed method is used.  All employees are instructed on the one-handed recapping method at the time of initial orientation.

 

All dirty / used sharps should be placed in puncture resistant containers.  RED, rigid sided containers with lids that are closeable and tamper resistant with the biohazard sign displayed are located in all patient care areas including patient rooms, special procedure rooms, soiled utility rooms, on medication carts, in radiology procedure rooms, in the laboratory and on phlebotomy trays.  

 

Reusable sharps are placed in rigid containers with sides and lids for transport to sterile processing for cleaning and resterilization.

 

C. Healthcare workers who have exudative lesion or weeping dermatitis should refrainfrom all direct patient care and from handling patient care equipment until the condition resolves.  These employees should be evaluated by the Employee Health Nurse and must refrain from all direct patient care and from handling patient-care equipment until such evaluation has occurred.

 

D. Pregnant Healthcare Workers are not known to be at greater risk for contracting HIV, HBV, HCV or any other bloodborne illness; however, if the pregnant healthcare worker develops an illness during pregnancy, the fetus is at risk for infection.  Because of this risk, pregnant healthcare workers, although not banned from usual activities in the course of performing their duties, should be especially familiar with and strictly adherent to precautions to minimize the risk of transmission of illness to the fetus.

 

E. Disposable items contaminated with blood and/or body fluids should be bagged in red bags at the site of generation, then placed in the soiled utility area where the environmental services department will collect and remove them for transfer to the incinerator.  Red bagged trash is placed in solid sided carts with wheels and transported to the incinerator several times a day as needed.

 

F. Reusable items contaminated with blood and/or body fluids should be bagged in clear bags, a biohazard sticker (found in all soiled utility rooms ) placed on the bag, and transported to sterile processing for cleaning or cleaning and sterilization. If the possibility of puncture of the bag is present, a second bag also marked with a biohazard label should be placed over the first bag.

 

G. Soiled linen is placed in yellow bags at the point of generation.  No sorting, rinsing, or other processing is done by the HCMH staff.  The clear bags are closed at the site or generation, taken to the soiled utility area, and placed in linen hampers.  These linen hampers are then transferred to closed carts and picked up by the laundry service contracted by HCMH.  The laundry service practices "Standard Precautions" (see exhibit D), therefore, special markings on the clear linen bags are not necessary.  Linen bags that are torn or punctured are placed in a second bag to prevent leakage of any blood and/or body fluid that is present.

 

5  Isolation

 

A. Although we adhere to "Standard Precautions" we also add another level of protection for the HCW and the patients in the form of Transmission Based Isolation.  (See Isolation policy).  In certain instances, standard PPE is replaced by more appropriate forms of protection as stated in the Isolation Policy.

 

6.  Engineering and Work Practice Controls

 

A. Work practices are evaluated continuously to identify areas for improvement. Equipment and plant design are also evaluated on a continuous basis.  Some engineering and work practice controls in place that assist in preventing exposure to blood and/or body fluids are:

  1. Sharps containers

  2. Isolyzer for congealing and disinfecting blood / body fluid spills.

  3. Disposable suction canisters

  4. Needle free items for administration of IV medications

  5. Spill kits

  6. Personal Protective Equipment

  7. Needle recappers

  8. Red bagging of contaminated trash

  9. Use of automated instrument washer

  10. Use of automated endoscope washer

  11. Safety needles

 

The above list is an example of engineering and work practice controls and is not intended to be all inclusive.  New products and procedure are added and developed continuously.

 

7.  Use of Personal Protective Equipment and Work Practice Controls

 

A. The use of Personal Protective Equipment and Work Practice Controls is not optional at HCMH.  Employees are expected to use appropriate equipment and practice appropriate work controls.  Failure to utilize proper procedures and available equipment will result in disciplinary action.

 

B. If an employee temporarily and briefly declines to use personal protective equipment under rare extraordinary circumstances, it must be the employee's professional judgement that in this specific instance its use would have prevented the delivery of health care or public safety services or would have increased the hazard to the worker or a coworker.  When this is done, the circumstances will be investigated and documented to determine whether changes must be instituted to prevent such occurrences in the future.

 

C. If any garment is penetrated by blood or other potentially infectious material, the garment should be removed immediately an clean, unsoiled garment put on in its place.   Personal clothing soiled with blood / body fluid can be laundered at HCMH  using regular laundry detergent with the addition of bleach ( if appropriate for the material ).  Laundering of personal clothing is limited to those rare occasions when unavoidable soiling with blood and/or body fluid occurs in the line of duty.

 

D. Sharps safety:  Prevention of percutaneous injuries is accomplished by the use of a Needle free system for IV access, and additional items to prevent injury.  All stylets from IV catheters will be placed in Sims-Portex needle holders ( 1 needle per holder ) immediately after removal from the IV catheter.  These needle holders are made available in bulk at all patient care areas for the HCW to have ready access.  Also, needles use for parenteral injections or specimen collection will be equipped with orange plastic covers.  Immediately after giving injection or obtaining specimen, the cover is placed over the needle using one hand to apply a small amount of pressure on the side of the cover and needle to snap the cover into place.  ( The needle cover is attached to be base of the needle and covers the needle from the side when closed. ).  Regardless of how the needle is protected, it will be disposed of in a sharps container with the protection intact.

 

8. Housekeeping / Environmental Services

 

A. All worksites will be maintained in a clean and sanitary condition.  Cleaning is done on a schedule which is documented in the Environmental Services Department.  Extent, type of chemical used, and frequency of cleaning is determined for each area individually and based on location, type of services provided in the area, type of surfaces in the area, type of soil present and type of tasks being performed in the area.  Specific schedules and instructions for cleaning are maintained in the Environmental Services Department Manual.

 

Equipment

All equipment and environmental and working surfaces shall be properly cleaned and disinfected after contact with blood or other potentially infectious materials.  Instruments that enter sterile cavities or tissues are sterilized in the autoclave or Steris.  Instruments that come in contact with intact mucus membranes are high level disinfected using a 20 minute Gluteraldehyde soak after thorough removal of organic material.  Some semi-critical items are sterilized using the Steris.

 

Environmental services, although rarely associated with the transmission of disease, are cleaned on a daily basis using "Omega", EPA, FDA, approved germicide solution.

 

Equipment is decontaminated after each use.  In the event equipment cannot be completely decontaminated, a biohazard label is placed on the equipment to alert all employees until such time as the equipment can be thoroughly cleaned and decontaminated ( possibly by biomedical services ).  The biohazard labels are located in the soiled utility rooms on each patient care area.  In the event that equipment must be disassembled for decontamination, the equipment is labeled, taken out of service and stored in the soiled utility room until biomedical services can service it.

 

Equipment is decontaminated on a regularly scheduled basis to assure periodic inspection and cleaning.

 

Work Surfaces

Work surfaces are decontaminated with Omega after completion of each procedure or daily ( which ever is more frequent ).  Floors and furniture in patient care areas, diagnostic departments such as Imaging, Clinical Laboratory and the Dietary department are cleaned daily.  

 

Blood Spills

Blood spills should be cleaned up in a timely manner but first sprinkling the spill with Isolyzer powder and allowing the powder to crystallize ( gel ) the spill.  When the spill has gelled, the housekeeping department dons gloves and removes the gel from the floor ( or other spill area ) using a small scoop and places it in a red bag.  The area of the spill is then cleaned, using Omega and routine cleaning protocol.

 

Sharps / Broken Glass

Broken glass which may be contaminated with blood or other potentially hazardous fluids is fluids is treated like all other sharps.  It should be mechanically picked up (with the help of a dustpan and brush) and disposed of in appropriately color coded and marked sharps containers.  All sharps (objects capable of inflicting puncture wounds, lacerations, or other parenteral injury) will be disposed of in sharps containers. These containers are color coded red, marked with the biohazard sign, have hard  plastic sides, top and bottom, and are mounted in all patient care areas.  These containers are leakproof and disposable.  Containers are disposed of when ½ to 2/3 full and replaced with a new container.  Once lids are closed, they are not able to be reopened.  Closed sharps containers are incinerated as soon as possible after closure and collection by the housekeeping department.  Depending on the amount of material generated by a specific location, sharps containers are issued in small or large sizes.  See Exhibit C for types of medical waste.

 

Specimens

Specimens of bodily fluids ( including but not limited to blood ) are placed in closeable leakproof bags have the biohazard label embossed on the outside of the bag.  The bag should be closed, and transported to the appropriate receiving department.

 

Linen

Linen is placed in yellow bags at the site of generation.  No rinsing, sorting or other manipulation of linen should occur.  The bags are closed and transported to the soiled utility room and placed in the linen hamper.  Linen is processed off site,  The off site laundry practices Universal Precautions, therefore, special labeling of linen bags is not required (See Exhibit D).

 

Regulated Waste

 

The method of disposal of infective waste is determined by the relative risk of disease transmission and application of local regulations.   In all cases, federal, state and local regulations are adhered to.  Please refer to Hill country Memorial Hospital's "Disposal of Waste" procedure for specific recommendations.  All regulated waste will be placed in red bags and will be incinerated on site. If outside contamination of waste containers occurs ( or is likely to occur ) the container must be placed in a second red bag.  Individual red bags will be placed in all rooms where patient care or treatment occurs.  Large receptacles for the collection of individual red bags will be stored in the soiled utility rooms ( consist of a stand on which a  large red bag is placed.)  

 

Warning Labels

 

Warning labels shall be affixed to containers of infectious waste, refrigerators and  freezers containing blood or other potentially infectious materials or other containers used to store or transport blood or other potentially infectious materials.

 

Biohazard labels are fluorescent orange with black writing.  The label is either an integral part of the container or is closely attached to the container.  When specific color coding is designated in this plan, the color coding precludes the use of biohazard labels.

 

MEDICAL SURVEILLANCE

 

The Medical Director of the Infection Control Department is a licensed physician and supervises the medical evaluation program, procedures, vaccinations, vaccination series and post-exposure evaluation and follow-up, including prophylaxis.  All of these services are provided at no cost to the employee, and within a designated time period from the injury and/or exposure.  Current recommendations from CDC are followed as directed by the Infection Control Committee and the Quality Council of Hill Country Memorial Hospital.

 

The initial evaluation occurs at the time of hire and is done by an Emergency Department Physician.  The evaluation includes occupational /medical history, including any medical problem which could interfere with an employee's ability to use protective clothing and equipment or receive vaccination and the status of the HBV vaccination.  The physical examination is limited to those systems and areas which will be relative to their job performance as determined by the Emergency Department Physician.  The employees will receive training and be offered the HBV vaccine within ten days of initial assignment.  The offering of HBV vaccine is based on each specific employees potential for exposure to blood and/or body fluids while performing their job duties.   The employee may decline the HBV series, but is asked to sign a declination form ( Exhibit E ) .  If, at a later date, the employee decides to have the HBV series, or transfers to a job where exposure is a potential, they may elect to have the series at that time.  There is no cost to the employee for the HBV vaccine series.

 

HBV antibody testing shall be made available to an employee who desires such testing, and who has a reasonable indication that immunity might exist, prior to deciding whether or not to receive HBV vaccine.  If the employee is found to be immune to HBV but virtue of adequate antibody titer, the vaccine will no be offered to that employee.   Antibody testing after initial vaccination is not required or recommended, however, the employee may request such antibody testing if they desire that have it done.

 

An employee covered by this document who has a parenteral or mucous membrane exposure to blood or other body fluids or who has a cutaneous exposure involving large amount of blood or prolonged contact with blood, especially when the exposed skin is chapped, abraded, or afflicted with dermatitis will have a confidential medical evaluation and follow-up provided.

 

As part of the confidential medical record, the circumstances of exposure will be recorded.  Relevant information includes route of exposure, the activity in which the worker was engaged at the time of exposure, the extent to which the appropriate work practices and protective equipment were used and a description of the source of exposure will be recorded.  All reporting responsibilities under federal and state laws will be performed.

 

Once an exposure has occurred, a blood sample will be obtained from the source individual, unless identification is not possible.  The lab will check the medical record of the source individual to determine if HIV testing consent has been obtained.  If consent has not been obtained, testing will be done in accordance with the Texas Communicable Disease Prevention and Control Act.  

 

The source patient will be tested for HB Surface Antigen, Hepatitis B core antibody, HCV and HIV antibodies.  Pre and Post test counseling as well a referrals to appropriate facilities and /or treatment will be made by the source patients physician.  Results of the source individual's test results will be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

 

An exposed employee's blood is collected as soon as possible after the event and tested after consent is obtained.  If baseline blood is drawn, but the employee does not consent to HIV serological testing, the sample shall be preserved for at least 90 days.  If within 90 days of the exposure incident, the employee elects to have the sample tested, such testing will be done at that time.

 

See attached algorithms for exact procedure for the treatment of exposures to Hepatitis B and HIV.( Exhibits F and G respectively )

 

The exposed employee is given a written opinion by a qualified healthcare professional within fifteen days after the exposure.  The written opinion will be limited to:

  1. Statement that the employee has been informed of the results of the evaluation

  2. Statement that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

 

A written opinion is given to employee and a copy stored in the infection control office in a locked file.  All identifying information is removed from the test results.  The report of injury forms that describe the exposure incident are kept in the employees confidential health file in the Human Resources Department.  The Human Resources Department is responsible for keeping the OSHA 200 Log.

 

Healthcare Workers with impaired immune systems resulting from HIV infection or other causes are at increased risk of acquiring or experiencing serious complication of infectious diseases.  Of particular concern is the risk of severe infection following exposure to patient with infectious diseases that are easily transmitted if appropriate precautions are not taken.  An worker know to have an impaired immune system is counseled about the potential risk associated with taking care of patients with any transmissible infection and is encouraged to follow recommendations for infection control to minimize exposure to infectious agents.

 

Healthcare workers infected with HIV, or HBV, especially those who perform invasive procedures, are reviewed on an individual basis regarding their ability to adequately and safely perform patient care duties and when and if their assignments should be changed to accommodate their individual situations.  This review would take place by an Expert Review Committee as designated by the Administration of Hill Country Memorial Hospital.

 

RECORD KEEPING

 

An accurate record for each employee subject to medical surveillance under this document will be maintained and will include:

  1. The name and social security number of the individual employee

  2. A copy of his/her Hepatitis B vaccination status including the dates of all Hepatitis B vaccinations and any medical records relative to the employee's ability to receive the vaccine.

  3. A history of the employees ability to wear protective clothing and equipment and receive vaccination.

  4. A history of the circumstance of an occupational exposure incident.

  5. A copy of all results of physical examination, medical testing, and follow-up procedure as they relate to the employee's ability to wear protective clothing and equipment and receive vaccination or post-exposure evaluation following an occupational exposure incident.

  6. A copy of the physician's or healthcare professional's written opinion

  7. A copy of information provided to the healthcare professional as required by this document.

 

The employees medical record will be kept confidential and will not be disclosed or reported without the employee's expressed written consent to any person within or outside the workplace except as required or permitted by law.

 

These records will be maintained for at least the duration of employment, plus 30 years.

Training records will include the dates of the training sessions, the contents or a summary of the training sessions, the names and qualifications of persons conducting the training and the names and job tittles of all persons attending the training sessions.  These records shall be maintained for 3 years.

 

Required records will be made available upon request to those persons permitted by law to have access.  These records are also made available to the employee upon request by the employee or to another person having written consent of the stated employee.

 

Records will be transferred as required by federal law 29 CFR 1910.20.  Any state or federal laws governing transfer of these records will be followed in accordance with these directives.

 

TRAINING

 

All employees of Hill Country Memorial Hospital shall participate in a training program at the time of their initial employment and annually thereafter at no cost to them and during working hours.  The initial training will be part of their new employee orientation.  Material appropriate in content and vocabulary to the educational level, literacy, and language background of the employees shall be used.  These levels are determined to the best of the knowledge of the hospital based on personal interviews and completing of appropriate paperwork at the time of hire.  

 

The training program will include discussion on the location of the OSHA Standard on Occupational Exposure to Bloodborne Pathogens (29 CFR part 1910.1030) and an explanation of the content of the standards.  An explanation of:

  1. epidemiology and symptoms of bloodborne disease

  2. Modes of transmission

  3. The written exposure control plan

  4. How an employee can obtain a copy of the exposure control plan

  5. Appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials

  6. Use and limitation of equipment

  7. Practices that will prevent and reduce exposure

  8. Appropriate engineering control and work practice

  9. Personal protective equipment and its specific use.

  1. Types

  2. Proper use

  3. Location

  4. Removal

  5. Handling

  6. Decontamination and/or disposal

  7. Basis for selection

  1. Appropriate actions to take and person to contact in an emergency

  2. Explanation of procedure to follow when an occupation exposure occurs, including the method of reporting , the medical follow-up, and counseling available.

  3. Signs and labels as well as color coding for this environment

  4. Hepatitis B vaccine and its availability at no cost to the employee  The employee will have a opportunity to ask questions and discuss the information that has been presented.

 

SPECIAL TRAINING CONSIDERATIONS

 

The following policy attempts to reduce the risk of transmission of HIV during CPR training.

 

The following recommendations will be adhered to in applicable situations:

 

1. The manufacturer's recommendation and provisions for sanitary practice for the training mannequins will be followed as appropriate.

 

2. Students and instructors with dermatologic lesions on hands or I oral or circumoral areas, known active Hepatitis B, Upper respiratory infections, AIDS, or other infectious processes will not be permitted to participate in CPR training until such lesions or diseases are controlled.

 

3. Students should be told in advance if the training sessions will involve close personal contact with another individual.

 

4. Students should have contact with only one mannequin of each size during a class

 

5. Appropriate Infection Control practices should be employed, ( handwashing,  no eating or drinking during class, proper mannequin cleaning procedures before, between and after student contact with mannequins, and proper maintenance of mannequins and accessories.

 

6. Equipment is inspected at the beginning and the end of each class for signs of deterioration.  Equipment in poor condition is taken out of service.

 

7. Students in the Hospital Environment are training to ventilate the mannequins with an Ambu Bag, just as they would ventilate a real person.  Students are given the principles of mouth - to - mouth resuscitation but are instructed not to use this principle inside the hospital.  Students are also encourage to obtain masks with one-way valves for their own personal use when not in the hospital.

 

8. Sweeping the mouth during "Obstructed Airway" training is simulated to prevent exposure and body fluids that might have collected in the mouth of the mannequin.

 

9. Instructors who are responsible for disassembly and contamination of the mannequins will wear appropriate personal protective equipment - gloves, gown, mask and eye protection if splashing is anticipated.  Cleaning procedures will occur as follows:

  1. Disassemble the mannequin as directed

  2. Thoroughly wash all external surfaces with warm soapy water to remove organic debris.

  3. Rinse all surfaces with fresh water

  4. Wet all surfaces with a sodium hypochlorite solution having at least 500 ppm of free available chlorine (1/4 cup house-hold bleach to one gallon of water ) for 10 minutes.  The solution must be mixed fresh at the beginning of each class session and discarded when finished.

  5. Rinse with fresh water and immediately dry all external and internal surfaces. Rinsing with alcohol will aid in drying of internal surfaces.

 

10. Mannequins with removable faces, or disposable lungs/face shields, will have these changed between each student.

 

11. Persons responsible for use and maintenance of CPR mannequins should not rely totally on the presence of a disinfectant to protect them and their students from cross contamination.  Thorough physical cleaning, as well as application of disinfectant should take place after each use of the mannequins.

 

MINIMIZING RISK OF TRANSMISSION OF HIV AND HBV DURING ACTUAL CPR

 

No transmission of Hepatitis B virus infection during mouth-to-mouth resuscitation has been documented.  However, because of the theoretical risk of salivary transmission of HIV during mouth-to-mouth resuscitation, special attention should be given to the use of disposable airway equipment or resuscitation bags and the wearing of gloves when in contact with blood or other body fluids.  Resuscitation equipment and devices known or suspected to be contaminated with blood or other body fluids should be used one, and disposed of or thoroughly cleaned and disinfected after each use.

 

Disposable Ambu bags are available for use during resuscitation efforts in all patient care areas.  Patient care staff are training in the use of the Ambu bag, especially with respect to making an adequate seal on the face and maintaining a patent airway.  Such a device requires two hands to secure a proper face seal and to maintain an open airway.  As an additional precaution, the rescuer must wear latex gloves because saliva or blood on the victim's mouth or face may be transferred to the rescuer's hands.

 

APPENDIX

 EXHIBIT I

Subject:  Recapping of Needles

 

Policy :

Hospital policy prevents the recapping of contaminated needles without the use of a needle recapping device or the employment of the one-handed scoop method of recapping.   Recapping of clean needles is discourage as well.

 

Procedure:

 

  1. Needles may be recapped in one of the following methods:

  1. Using a recapping device

  2. Using the one handed scoop method

  1. The cap from the needle is placed on a flat surface with the open end facing the practitioner.

  2. Using a scooping motion, the needle is slipped into the cap using only the hand holding the needle.  The free hand must be kept away from the cap until the needle is safely sheathed.

  3. The needle is considered safely sheathed when ½ or more of the needle is contained within the cap.

 

  1. Needles used for specialty procedures ( collection of Arterial Blood Gases ) are Recapped or plugged using a specially designed recapping/plugging device.  This procedure is carried out only by specially trained employees in the Cardiopulmonary department and Clinical Laboratory.

 

EXHIBIT H

Subject:  Transportation of sharps to appropriate containers

 

Procedure:

 

1. Sharps containers are located all patient care areas.

 

2. Sharps are disposed of as soon as they have been used in the nearest sharps Container.

 

3. Special care should be taken when transporting the sharp from the bedside to the sharps container.  The transporter should be keenly aware of other person's positions and movement within the room.

 

4. Sharps shall be held with the sharp area away from the body of the person carrying the item.  If another person is in the immediate area and there is a  potential that he/she will be injured by or exposed to the contaminated sharp, the person carrying the sharp object will verbally announce that he/she is in possession of a sharp by stating clearly "Sharp".

 

5. Other HCW's in the area will respond by moving aside or otherwise displacing themselves from the area where exposure is likely to occur until the person holding the sharp has left the area.