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Safety and Health Controls
In order to comply with the safety standards and thereby
protect the health and safety of healthcare providers and
patients, a hierarchy of controls is utilized. The hierarchy
of safety and health controls include (CDC, 2004a):
- Legal and regulatory controls.
- Administrative and Training controls.
- Engineering controls.
- Work practice controls.
- Personal protective equipment (this will be covered in
Element IV of this training).
Legal and Regulatory Controls
The Occupational Safety and Health Administration (OSHA)
Occupational Safety and Health Act of 1970, General Duty
Clause requires that each employer:
- Furnish to each employee employment and a place of employment
which are free from recognized hazards that are causing
or are likely to cause death or serious physical harm to
employees;
- Complies occupational safety and health standards promulgated
under this Act.
And each employee must comply with occupational safety and
health standards and all rules, regulations, and orders issued
pursuant to this Act.
In 1991 OSHA promulgated the Occupational Exposure to
Bloodborne Pathogens Standard. This standard was designed
to protect millions of healthcare workers and related occupations
from the risk of exposure to blood or other potentially infectious
materials. It has multiple components including the use of
standard precautions (explained below in the work practice
control section) and expanded transmission-based precautions,
exposure determination (employers must identify all job classifications,
as well as all tasks and procedures where exposure to bloodborne
pathogens is possible as part of routine work).
A clear example of a legal control is the 2008 law that included
physicians, physician assistants and specialist assistants
as professionals who are legally required to adhere to scientifically
accepted principles and practices of infection control. The
previously mentioned incident of unsafe injection practices
at a pain clinic on Long Island facilitated the creation of
this law. Reportedly, the physician at this clinic had been
under surveillance for years regarding his infection control
practices and many of the 10,500 patients that were notified
of possible exposure to bloodborne pathogens contracted HCV
and HBV (USA Today, 2008). Unfortunately physicians were not
previously included in the legal requirement to utilize proper
infection control; the 2008 law is a legal control that was
enacted, at least in part, in response to this particular
situation.
Administrative and Training Controls
Administrative and training controls include all of
the policies and procedures related to infection control that
each healthcare facility must provide to employees of that
facility. These policies and procedures relate to any issue
in the healthcare setting in which an employee would have
to utilize proper infection controls practices. The training
of employees regarding infection control issues are also a
component of administrative controls, as each facility determines
the need for training.
It is important to remember that some training controls are
also a legal control, for example this course is a legislated
requirement for licensed healthcare providers in New York
State.
Engineering Controls
Engineering controls eliminate or reduce exposure
to a threat such as a pathogen or physical hazard through
the use or substitution of engineered machinery or equipment.
Examples include needleless syringes, sharps disposal containers,
self-sheathing needles, safer medical devices such as sharps
with engineered injury protections and needleless systems,
specialized requirements for heating, cooling and ventilation
in areas that house infectious diseases (operating rooms,
intensive care units) (CDC, 2003a), high-efficiency particulate
air (HEPA) filtration, ultraviolet lights, safety interlocks,
and splatter shields on medical equipment associated with
risk prone procedures (e.g., locking centrifuge lids). Well-designed
engineering controls eliminate human error thus giving the
healthcare worker greater protection from the hazard.
Whenever possible, safer devices must be utilized in order
to prevent sharps injuries. This includes the need to evaluate
and select safer devices. Those healthcare providers who will
be utilizing the safer device need to be involved in the process
of decision making. It is preferable to utilize devices wherein
the safety feature is integrated into the device, rather than
one in which the safety equipment is an accessory device or
one in which the healthcare provider must change practice
habits (passive vs. active safety features). Safer devices
that are specific to a particular clinical area or setting
are ideal; devices that provide immediate and continuous protection
are preferable. All staff who may utilize the new equipment
or device must be educated as to the proper use of the device.
Whenever possible, eliminate the traditional, or non-safety,
alternative, so that staff must utilize the safer device.
Another example of an engineering control is the puncture-resistant
containers for the disposal and transport of needles and
other sharp objects.
Immediately or as soon as possible after use, contaminated
reusable sharps must be placed in appropriate containers
until properly reprocessed. These containers must be:
- Puncture resistant;
- Labeled or color-coded;
- Leakproof on the sides and bottom.
Single-use contaminated sharps must be discarded immediately
or as soon as feasible in containers that are:
- Closable;
- Puncture resistant;
- Leakproof on sides and bottom; and
- Labeled or color-coded.
During use, containers for contaminated sharps must be:
- Easily accessible to personnel and located as close as
is feasible to the immediate area where sharps are used
or can be reasonably anticipated to be found (e.g., laundries);
- Maintained upright throughout use; and
- Replaced routinely and not be allowed to overfill.
When moving containers of contaminated sharps from the area
of use, the containers shall be:
- Closed immediately prior to removal or replacement to
prevent spillage or protrusion of contents during handling,
storage, transport, or shipping;
- Placed in a secondary container if leakage is possible.
The second container shall be:
- Closable;
- Constructed to contain all contents and prevent leakage
during handling, storage, transport, or shipping; and o
Labeled or color-coded.
- Reusable containers shall not be opened, emptied, or cleaned
manually or in any other manner which would expose employees
to the risk of percutaneous injury.
The New York State Department of Health (2007) addressed
the used needles, syringes, and lancets used by millions of
people at home during their routine health care. This public
service pamphlet can be obtained from http://www.health.state.ny.us/publications/0909.pdf.
It is aimed at preventing sharps injuries to family members
and pets, preventing the sharps from being re-used or shared,
and protecting the environment.
Sharps containers for the home can be bought at local drugstores,
or alternatively a puncture-resistant bottle, such as a laundry
bottle can be used. Instruct patients to screw the cap on
tightly, apply tape over the cap and write "Contains Sharps"
on the bottle. Instruct patients to put sharps into the container
immediately after use and keep the container closed and away
from children and pets and those who may be interested in
re-using needles /syringes (NYSDOH, 2007). Instruct patients
to (NYSDOH, 2007):
- Never put the used sharps container in the trash.
- Never flush used sharps down the toilet or drop them into
a sewer drain.
- Never clip, bend, or put the cap back on used sharps.
- Never put loose used sharps or your used sharps container
in with the recyclables.
- Never use soda cans, milk cartons, glass bottles or containers
that can be broken or punctured.
- Avoid coffee cans because the plastic lid easily comes
off and may leak. When the used sharps container is almost
full, instruct patients to bring it to a safe disposal site:
- Some drugstores, health clinics, and community service
agencies have large metal boxes (called kiosks) for sharps
disposal. Call 1-800-541-2437 to find a kiosk near you.
- Used sharps can be brought to any hospital or nursing
home in New York State. It is important to contact the facility
to determine hours, days and location where used sharps
can be brought. Call the New York State Department of Health
at 1-800-522-5006 (Growing Up Healthy hotline) to find sharps
disposal sites in your area. TTY: 1-800-655-1789. To find
places with sharps disposal kiosks, call 1-800-541-2437.
For a list of disposal sites and kiosks by county, visit
http://www.nyhealth.gov/diseases/aids/?harm_reduction/needles_syringes/sharps/directory_?sharpscollection.htm.
Another example of both an engineering control and a legal
control, is the New York State law in 2000 that prohibited
the use of sharps that do not incorporate engineered sharps
injury protections with certain allowable exceptions when
(NIOSH, 2002):
- appropriate engineered sharps are not available in the
market;
- the use of sharps without engineered sharps injury protections
is essential to the performance of a specific medical procedure;
or
- based on objective product evaluation, sharps with engineered
injury protections are not more effective in preventing
exposure incidents than sharps without engineered injury
protections.
This New York State law was in response to OSHA's revision
of the Bloodborne Pathogen Standard (a federal law).
Work Practice Controls
Work practice controls relate to how work is done.
They consist of multiple interventions which, when utilized
properly, insure worker safety when engineering controls are
not possible or available. Work practice controls alter the
manner in which a task is performed, thereby reducing exposure
to bloodborne pathogens (e.g., prohibiting recapping of needles
by a two-handed technique).
Precautions are a set of infection control practices
that healthcare personnel use to reduce transmission of microorganisms
in healthcare settings. A very common work practice control
is the use Standard Precautions.
- Standard precautions combine the major features
of Universal Precautions (UP) and Body Substance Isolation
(BSI) and are based on the principle that all blood, body
fluids, secretions, excretions except sweat, nonintact skin,
and mucous membranes may contain transmissible infectious
agents. Standard Precautions include a group of infection
prevention practices that apply to all patients, regardless
of suspected or confirmed infection status, in any setting
in which healthcare is delivered (CDC, 2007).
These include: hand hygiene; use of gloves, gown, mask,
eye protection, or face shield, depending on the anticipated
exposure; and safe injection practices. Also, equipment
or items in the patient environment likely to have been
contaminated with infectious body fluids must be handled
in a manner to prevent transmission of infectious agents
(e.g., wear gloves for direct contact, contain heavily
soiled equipment, properly clean and disinfect or sterilize
reusable equipment before use on another patient). The
application of Standard Precautions during patient care
is determined by the nature of the healthcare worker-patient
interaction and the extent of anticipated blood, body
fluid, or pathogen exposure (CDC, 2007). Standard Precautions
are also intended to protect patients by ensuring that
healthcare personnel do not carry infectious agents to
patients on their hands or via equipment used during patient
care (CDC, 2007).
The use of standard precautions assumes that the blood
or body fluids of any person could be infectious, therefore
personal protective equipment (PPE) may be needed as a
barrier to transmission of infectious agents. Decisions
about the use of PPE are determined by the type of interaction
the healthcare worker has with the patient (CDC, 2004a).
PPE for standard precautions include (CDC, 2002; CDC,
2004a; CDC, 2007):
- Gloves when touching blood, body fluids, secretions,
excretions, mucous membranes, non-intact skin, or contaminated
surfaces and objects.
- Gowns during procedures and patient care activities
likely to generate splashes or sprays of blood/body
fluids, secretions, or excretions; be careful to secure
the gown fully and to remove it immediately after the
procedure/care.
- Mask during procedures that are likely to
generate splashes or sprays of blood, bodily fluids,
secretions, and excretions.
- Eye protection during procedures and activities
likely to generate splashes, sprays of blood, body fluids.
- Face shield during patient care activities
likely to generate splashes or sprays of blood, body
fluids, secretions or excretions.
According to the CDC's Guidelines for Isolation Precautions:
Preventing Transmission of Infectious Agents- 2007,
there are 3 additional components of Standard Precautions:
Respiratory Hygiene/Cough Etiquette, safe injection practices,
and use of masks for insertion of catheters or injection
of material into spinal or epidural spaces via lumbar
puncture procedures (e.g., myelogram, spinal or epidural
anesthesia). While most elements of Standard Precautions
evolved from Universal Precautions that were developed
for protection of healthcare personnel, these new elements
of Standard Precautions focus on protection of patients.
Safe injection practices have been addressed previously
in this course.
Respiratory Hygiene/Cough Etiquette grew out of
the 2003 SARS outbreaks. The elements of Respiratory Hygiene/Cough
Etiquette include 1) education of healthcare facility
staff, patients, and visitors; 2) posted signs, in language(s)
appropriate to the population served, with instructions
to patients and accompanying family members or friends;
3) source control measures (e.g., covering the mouth/nose
with a tissue when coughing and prompt disposal of used
tissues, using surgical masks on the coughing person when
tolerated and appropriate); 4) hand hygiene after contact
with respiratory secretions; and 5) spatial separation,
ideally >3 feet, of persons with respiratory infections
in common waiting areas when possible. Covering sneezes
and coughs and placing masks on coughing patients are
proven means of source containment that prevent infected
persons from dispersing respiratory secretions into the
air. Masking may be difficult in some settings. These
measures should be effective in decreasing the risk of
transmission of pathogens contained in large respiratory
droplets (CDC, 2007).
- Expanded Precautions include the following:
- Contact Precautions
- Droplet Precautions
- Airborne Infection Isolation Room (AIIR) Precautions
PPE for contact precautions include: gowns and gloves
for contact with patient or environment of care (e.g.
medical equipment, environmental surfaces). In some instances
gowns are required when entering a patient's environment.
PPE for droplet precautions: surgical masks within three
to ten feet of patient (CDC, 2003; CDC, 2007).
PPE for airborne precautions: particulate respirator.
In addition negative pressure isolation room is also needed.
Cleaning of Blood and Body Fluid
Spills
Promptly clean and decontaminate spills of blood or other
potentially infectious materials. Initial removal of bulk
material is followed by disinfection with an appropriate disinfectant
- Follow proper procedures for site decontamination of
spills of blood or blood-containing body fluids:
- Use protective gloves and other PPE appropriate for
this task;
- If the spill contains large amounts of blood or body
fluids, clean the visible matter with disposable absorbent
material, and discard the used cleaning materials in
appropriate, labeled containers.
- Swab the area with a cloth or paper towels moderately
wetted with disinfectant, and allow the surface to dry.
- Use germicides registered by the Environmental Protection
Agency (EPA) for use as hospital disinfectants and labeled
tuberculocidal or registered germicides on the EPA Lists
D and E (i.e., products with specific label claims for HIV
or HBV) in accordance with label instructions to decontaminate
spills of blood and other body fluids.
- An EPA-registered sodium hypochlorite product is preferred,
but if such products are not available, generic sodium hypochlorite
solutions (e.g., household chlorine bleach) may be used:
- Use a 1:100 dilution (500--615 ppm available chlorine)
to decontaminate nonporous surfaces after cleaning a
spill of either blood or body fluids in patient-care
settings;
- If a spill involves large amounts of blood or body
fluids, or if a blood or culture spill occurs in the
laboratory, use a 1:10 dilution (5,000--6,150 ppm available
chlorine) for the first application of germicide before
cleaning.
Element V of this course will further address the proper
handling/disposal of blood and body fluids, decontamination
of patient care items and work surfaces.
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