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The following standards are mandated by the Occupational
Safety and Health Administration (OSHA) While HBV and HIV
are specifically identified in the standard, "Bloodborne Pathogens"
include any pathogen present in human blood or other potentially
infectious materials (OPIM) that can infect and cause disease
in people exposed to the pathogen. Bloodborne pathogens may
also include HCV, Hepatitis D, malaria, syphilis, babesiosis,
brucellosis, leptospirosis, arboviral infections, relapsing
fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma
(caused by HTLV-I), HTLV-I associated myelopathy, diseases
associated with HTLV-II, and viral hemorrhagic fever.
According to the CDC, Hepatitis C infection (HCV) is the
most common chronic bloodborne infection in the United States.
HCV is a viral infection of the liver transmitted primarily
by exposure to blood.
Exposure Control Plan
Each employer must develop an Exposure Control Plan (ECP).
The plan requires the employer to identify those tasks and
procedures in which occupational exposure may occur. It also
requires the employer to identify the individuals who will
receive the training, protective equipment, vaccination, and
other benefits of the standard.
This ECP shall contain at least the following elements:
- A written exposure determination that includes
those job classifications and positions in which employees
have the potential for occupational exposures. The exposure
determination shall have been made without taking into consideration
the use of personal protective clothing or equipment. It
is important to include those employees who are required
or expected to administer first aid.
- The procedure for evaluating the circumstances surrounding
exposure incidents, including maintenance of a "Sharps Injury
Log".
- The infection control system used in that workplace.
- Documentation of consideration and implementation of
appropriate, commercially available safer medical devices
designed to eliminate or minimize occupational exposure.
- The ECP must be updated on at least an annual basis and
whenever changes occur that effect occupational exposure.
Universal Precautions/Standard Precautions
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Case Study
#7
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The HIV coordinator was used to having staff and patients
walk into her office with questions. However, the day
Julie showed up crying at her door she was slightly
surprised. She did not know Julie well, but did not
expect that she would be the type to cry unless something
was very wrong. She escorted her into the office, closed
the door, and asked what had happened. Julie explained
that she delivers supplies to different locations within
the hospital including the autopsy room. She always
wears protective foot gear, gloves, and eye glasses.
The day after she restocked supplies in the autopsy
suite, someone told her that the procedure that day
was on a patient with HIV. She became very upset, and
demanded to know why she wasn't warned before entering
the room. She was afraid that she may have contracted
HIV from the air or from walking in any blood or tissue
left on the floor (although she did not remember anything
visible to her at the time). Her worst worry was taking
something home to infect her husband and children. By
the time the whole story unfolded she was sobbing.
The coordinator explained the routes of HIV infection,
and the probability of infection even with a needle
stick. She reassured her that HIV could not be spread
by aerosolized particles or from stepping on blood or
tissue when wearing shoes. She discussed the limited
viability of HIV outside the body. She complimented
her on using universal precautions while she worked,
and assured her than doing so would provide adequate
protection. Julie felt much more reassured about her
own health when she left, and confident that she had
not exposed her family to the virus.
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Universal precautions, as defined by CDC, are designed
to prevent transmission of bloodborne pathogens in healthcare
and other settings. Under universal precautions, blood/OPIM
of all patients should always be considered
potentially infectious for HIV and other pathogens.
Standard Precautions is a newer definition that hospitals
and other healthcare settings are moving toward. Standard
Precautions include all recommendations made for Universal
Precautions plus body substance isolation (BSI) when
OPIM is present.
Bodily fluids that have been recognized as OPIM and
linked to the transmission of HIV, HBV and HCV, and to which
Standard Precautions and Universal Precautions apply are:
blood, semen, blood products, vaginal secretions, cerebrospinal
fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial
fluid, amniotic fluid, and specimens with concentrated HIV,
HBV and HCV viruses.
Although the terms are not interchangeable, most people are
more familiar with the term Universal Precautions.
For this course, the term Standard Precautions will be used,
although there may be some settings (like daycare) where body
substance isolation may not be needed.
Personal Protective Equipment
Universal and Standard Precautions involve the use of protective
barriers to reduce the risk of exposure of the employee's
skin or mucous membranes to blood and OPIM. It is also recommended
that all healthcare workers take precautions to prevent injuries
caused by needles, scalpels, and other sharp instruments or
devices. Both Universal and Standard Precautions apply to
blood and OPIM listed above.
Gloves, masks, protective eyewear and chin-length plastic
face shields are examples of personal protective equipment
(PPE). PPE shall be provided and worn by employees in
all instances where they will or may come into contact with
blood or OPIM. This includes, but is not limited to dentistry,
phlebotomy or processing of any bodily fluid specimen, and
postmortem (after death) procedures.
Traditionally, latex gloves have been used when dealing with
blood or OPIM. However, there have been documented cases of
people with allergies to latex. In most circumstances, nitrile
and vinyl gloves meet the definition of "appropriate" gloves
and may be used in place of latex gloves. Employers
are required to provide non-latex alternatives to employees
with latex and other sensitivities.
Reusable PPE must be cleaned and decontaminated, or laundered
by the employer. Lab coats and scrubs are general considered
to be worn as uniforms or personal clothing. When contamination
is reasonably likely, protective gowns must be worn. If lab
coats or scrubs are worn as PPE, they must be removed as soon
as practical and laundered by the employer.
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, 2007),
high-efficiency particulate air (HEPA) filtration, ultraviolet
lights, scavenging devices, sound-dampening materials to reduce
noise levels, safety interlocks, splatter shields on medical
equipment associated with risk prone procedures (e.g., locking
centrifuge lids), and radiation shielding. 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 automatically engaged and 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.
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).
Continue on to: Management
of HIV in the Healthcare Workplace, Con't.
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