Control of Infections Related to Bloodborne Pathogens

Control of Infections Related to Bloodborne Pathogens

By Terri Goodman, RN, MA, PhD

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This article:
  • Lists the three interrelated elements that must be present for infection to occur.
  • Defines the major components of OSHA's Bloodborne Pathogens Standard.
  • Reviews the guidelines in the CDC's Standard Precautions published in 1998.

Prior to the early 1980s and the introduction of AIDS into society, infection control practices were designed almost exclusively to protect the patient from developing a nosocomial infection--an infection acquired after admission to the hospital. Protocols were focused on protecting the patient with little or no emphasis on the healthcare worker's potential to become infected. Hepatitis B has been a significant occupational hazard for healthcare workers for decades and is 100 times more infectious than the AIDS virus, but it was the AIDS epidemic in the early '80s that brought an awareness of exposure vulnerability to bloodborne pathogens. This awareness led to the development of the first protocols designed to protect healthcare workers, the Guideline for Infection Control in Hospital Personnel published by the Centers for Disease Control (CDC) in 1983.1

Chain of Infection

To understand the importance preventive measures in cross-contamination, it helps to understand the chain of infection--the three interrelated elements that must be present for an infection to occur. There must first be an infectious agent present--in this case, a bloodborne pathogen. There must be a means of transmission. In the healthcare setting, many aspects of patient care involve potential contact with a patient's blood or body fluids (BBF). Last, there must be a susceptible host. In the case of bloodborne pathogens, even caregivers who are in generally good health are susceptible.

Controlling infection involves breaking the chain. Caregivers' hands play an important role in transmitting microorganisms. Many of the microbial inhabitants on the hands are capable of colonizing and infecting wounds, cuts, and other susceptible sites. The single most effective means of preventing the transmission of infection is through conscientious handwashing.

History

In 1987, the CDC developed a system of infection control guidelines commonly referred to as universal blood and body fluid precautions.2 Universal Precautions refers to a system of infection control practices that encourages caregivers to presume that all patients are potentially infected with HIV, HBV, or other bloodborne pathogens. Specific infection control precautions are used with all patients to minimize the risk of exposure to blood or body fluids.

As a supplement to universal precautions, the CDC permits healthcare facilities to design their own systems of isolation. For instance, body substance isolation focuses on the separation of the hands of the caregiver from all body substances of all patients by using appropriate shielding techniques, particularly gloves, to reduce contact transmission.

OSHA's Final Rule

The CDC guidelines did not carry the force of the law, but in 1991, the Occupational Safety and Health Administration (OSHA), using its authority under the Occupational Safety and Health Act, issued enforcement instructions for a bloodborne pathogen standard regarding occupational exposure to HBV and HIV, the Final Rule on Occupational Exposure to Bloodborne Pathogens,3 based on the concept of universal precautions to prevent occupational exposure to bloodborne pathogens.

The Final Rule defines occupational exposure as any "reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material(s) that may result from the performance of an employee's duties." According to OSHA, infectious materials include semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. Infectious materials also include unfixed tissue or organ other than intact skin from a human (living or dead), HIV-containing cell or tissue cultures, and HIV or Hepatitis B-containing culture media or other solutions as well as blood, organs, or other tissues from experimental animals infected with HIV or HBV.

OSHA's "final rule" made it mandatory that healthcare facilities assumed responsibility for protecting their employees from exposure to bloodborne pathogens. The law had eight primary components:

  • Exposure control plan
  • Universal precautions
  • Engineering controls
  • Work practice controls
  • Personal protective equipment
  • Hepatitis B prophylaxis
  • Training and education
  • Recordkeeping

The Exposure Control Plan required a facility to develop a written document detailing specific needs, including exposure determination, a schedule and method of implementation for compliance, and procedures for the evaluation of exposure incidents. The plan must be accessible to all employees and must be reviewed and updated annually.

Universal precautions is an infection control system that assumes that every direct contact with blood and body fluids is potentially infectious. The system is based on the premise that not all patients with bloodborne infections have been diagnosed, and therefore, precautions must be applied universally.

Engineering controls address devices that are used to isolate or remove the bloodborne pathogen hazards from the workplace. These controls include (among other things), sharps disposal containers, needle resheathing devices, needleless vascular access systems, and biohazardous waste containers.

Work practice controls provide procedures and practices to describe methods of performing a task in a way that is designed to reduce the likelihood of exposure. Replacing the practice of recapping needles with two hands with a one-handed technique that is much safer is an example of a work practice control.

Personal protective equipment (PPE) refers to barrier equipment designed to shield the employee from blood and body fluid contamination. This equipment, that includes gloves, fluid-resistant masks and gowns, splash shields and eye protection, is used whenever there is a risk of exposure to blood or other potentially infectious material. The supply and repair of PPE is the responsibility of the employer. Non-employee healthcare professionals such as physicians and contractors must comply with the facility's Exposure Control Plan and use of PPE. This compliance is to ensure their own safety as well as the safety of the facility's employees and patients.

The type and characteristics of the equipment must be appropriate for the task being performed and the degree of exposure anticipated. In exposure-prone procedures, employees may require more extensive barrier protection. For instance, a helmet system may be used in surgical procedures where aerosolized blood particle inhalation during irrigation is possible.

In a medical emergency, PPE may be temporarily abandoned in the interest of life-threatening patient care requirements. However, as soon as the urgency has been addressed, full compliance with the use of barrier protection should be initiated. It is the employer's responsibility to evaluate any situation in which PPE was abandoned to assure that the urgent nature of patient care truly existed.

In the event that the individual's personal clothing becomes contaminated with blood, the clothing should be removed as soon as possible and laundered by the healthcare facility. OSHA does not permit contaminated clothing to be laundered at home due to the highly resistant nature of the Hepatitis B virus.3

Overcompliance in the use of PPE is not beneficial, necessary, or cost effective. All PPE must be removed and disposed of properly before leaving the immediate work area to prevent transmission of contaminants and possible cross-infection.

Employers must provide Hepatitis B vaccine at no cost to any of their employees who are likely to be exposed to bloodborne pathogens. Policies and procedures detailing required postexposure follow-up practices include medical evaluation, laboratory testing, and provisions for confidentiality. The employee is responsible for reporting any exposure incident immediately to his or her supervisor.

Training and education are hallmarks of any program whose success requires individual participation. Healthcare workers must recognize that cooperation and compliance with the components of the Final Rule are essential. Compliance with OSHA's rules and regulations is a matter of control: infection control through control of the environment and control of behavior.

Employers are required to provide a training program at no cost and during working hours for all employees with potential for occupational exposure to blood and body fluid exposure upon initial assignment and at least annually thereafter. Employers must maintain medical and training records for each employee with actual or potential occupational exposure for a designated period of time.

Universal precautions provide the minimum of behaviors and protocols required by law. In many settings, such as hospitals, the application of universal precautions has been expanded beyond bloodborne pathogen transmission. This expansion includes the use of protective barriers when having contact with urine and saliva to prevent transmission of other infections, such as herpes, cytomegalovirus, etc.

CDC's Standard Precautions

In 1998, CDC published, Guideline for infection control in health care personnel, a revision of their 1983 guidelines.5 The revised guidelines were designed to provide methods for reducing the transmission of infections from patient to healthcare personnel and from personnel to patients. Prevention strategies in the revised document include immunizations for vaccine-preventable diseases, isolation precautions, management of personnel exposure to infectious persons (including postexposure prophylaxis), and work restrictions for exposed or infected healthcare personnel. This document also addresses issues related to latex hypersensitivity.

The revised guidelines contain two tiers of precautions. The first and most important are the Standard Precautions designed for the care of all patients in hospitals regardless of their diagnosis or presumed infection status. Implementation of these standard precautions is the primary strategy for successful nosocomial infection control. Standard precautions synthesize the major features of Universal Precautions (Blood and Body Fluid) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances).

Summary

Even with detailed guidelines, controls, and quality educational programs in place, managing cross-contamination and preventing infection in patients and healthcare workers depends the employee's compliance with prevention practices. Healthcare workers must understand the goals of infection control, the mechanisms of cross-contamination, and prevention protocols, but most important, employees must commit themselves to infection control practices. At the group level, active involvement and encouragement from key staff members may help to promote and sustain positive behavior.5 Coaching employees demonstrates respect for individuality and for the employee's desire to be supportive and is much more effective than using manipulative methods to promote compliance.6

When compliance is difficult or time-consuming, implementation is heavily influenced by the healthcare worker's commitment to excellence. For example, the need for meticulous handwashing occurs frequently in a normal workday and competes for time that healthcare workers would prefer to devote to patient care. It is the integrity of the employee that motivates an individual to do what should be done instead of what's easiest to do--integrity and commitment promote the success of an infection control program.

For references, access the ICT Web site.

Figure 1: Engineering Controls Examples
  • Readily accessible handwashing facilities
  • Antimicrobial handwashes that are both effective and gentle to the skin
  • Conveniently located sharps disposal systems
  • Self-sheathing needles
  • Needless vascular access systems
  • Leakproof, closed-lid containers for transporting contaminated instruments
  • Clearly marked biohazard bags or containers for proper disposal of hazardous waste
Figure 2: Work Practice Controls

OSHA Definition: controls that reduce the likelihood of exposure by altering the manner in which a task is performed.

Examples:

  • Establishing a neutral zone on the sterile field that replace hand-to-hand passage of sharp instruments: the "no touch" technique
  • Using blunt tipped needles wherever appropriate
  • Using an electrosurgical pencil in place of a scalpel where appropriate
  • Wearing appropriate protective equipment (fluid-proof apron, glove, eye protection) when handling contaminated instruments.
  • Decontaminating contaminated surfaces as soon as possible following contamination
  • Wearing gloves when handling sharps. It has been shown that the sheathing action of the glove over the needle during a puncture reduces blood exposure from the surface of the needle.
  • Recognize that wearing gloves does not preclude the need for handwashing
  • Never eating in areas where there is reasonable likelihood of exposure to BBF contamination
  • Separating soiled from clean instruments at the point of use
  • Transporting soiled instruments to the decontamination area in a leakproof container as soon after use as possible
  • Processing contaminated instruments in enzymatic cleaner or prewash prior to physically handling them
Figure 3: Standard Precautions

Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized source of infection in hospitals.

Standard Precautions apply to:

  • Blood
  • All body fluids, secretions, and excretions (except sweat) regardless of whether they contain visible blood
  • Non-intact skin
  • Mucous membranes


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