Using Technology to Streamline Infection Control Training Efforts
By Mary Brachman, RN, MS, CIC
The increasing number of new and incurable diseases is altering the way healthcare facilities address infection control. There's the assumption that everyone, from those who provide direct patient care to those who support patient care activities, are potentially at risk of an occupationally acquired infection, such as hepatitis or HIV. While each healthcare worker (HCW) is responsible for remaining sensitive to the risk of occupational exposure and adhering to prevention measures, on-the-job training programs are critical to ensuring workers have the knowledge and skills to protect themselves and others from infection. Now, a new, technology-driven training method can help to ensure workers' competence and meet the training standards set forth by the Occupational Safety and Health Administration (OSHA) and other organizations.
One area of particular importance is preventing transmission of bloodborne pathogens to HCWs.
The Changing Face of Occupational Risks
In terms of occupational exposure, the 1970s and early 1980s saw a large number of hepatitis B cases. This serious risk of infection confronted HCWs well into the 1980s, when a vaccine was developed, and is still a threat today for those who are not vaccinated. Toward the end of the 1980s and into the early 1990s, however, it was clear that another virus, HIV, would capture the medical community's--and the world's--attention.
The inherent risk to HCWs is continually evolving, as evidenced by the discovery of the hepatitis C virus (HCV), which is found in the blood of persons who have this disease. HCV was discovered in 1988, but it wasn't new. It was previously known as non-A non-B hepatitis, which today causes 20% to 40% of all cases of acute hepatitis in the US.1
HCV is the most common bloodborne infection to create unrecoverable ailments in the US, making it a worthwhile case study in bloodborne pathogen control efforts. Approximately 4 million Americans, or 2% of the population, are infected with HCV. Another 35,000 Americans contract hepatitis C each year.2
Consequences of infection can include:
- Chronic infection
- Cirrhosis of the liver
- Liver cancer
- Unknowingly infecting others
The Centers for Disease Control and Prevention (CDC) has acknowledged the risk posed by the spread of HCV, which occurs through exposure to an infected person's blood, and may take 20 to 30 years to show clinical signs of infection in an individual.3
In addition to intravenous drug users, hemodialysis patients and transfusion recipients, HCWs who have job duties with potential exposure to blood are at an increased risk of acquiring hepatitis C. HCV has been spread from infected patients to HCWs from needlesticks and cuts from a sharp instrument. The risk of acquiring HCV from a needlestick is approximately 2%, or 1 in 50 HCV positive exposures, but in some studies has been reported as high as 7%.4-6 Transmission of HCV from a blood splash to the eyes has also been described.7 Persons who have had other types of hepatitis are not immune, either; they can still acquire HCV.
There is nothing simple about HCV. What may be a serious threat for some individuals is not serious for others. Often, persons with acute HCV have no symptoms at the time of initial infection. Still, symptoms may appear months or years later when chronic HCV develops. It's estimated that 75% to 85% of those who get HCV will become chronically infected, meaning they can carry the virus in their blood for the rest of their lives, and can spread the virus to others.1,3 It is believed that 10% to 20% of people with chronic HCV will eventually develop cirrhosis (scarring of the liver due to death of liver cells).3 Persons with chronic HCV also have an increased risk of liver cancer.1,3
Unfortunately, there is no vaccine for HCV, and the vaccines for hepatitis B and hepatitis A do not provide immunity against hepatitis C. There are no effective immunoglobulin preparations (e.g., immune serum globulin) to give after an occupational exposure to prevent HCV infection. Therefore, the best protection is to prevent exposure to blood.
How this and other safety precautions are communicated to workers is up to each healthcare facility. OSHA states, "The content of a company's training program and the methods of presentation should reflect the needs and characteristics of the particular workforce."8 Clearly, however, there are training programs that are much more effective than others.
Regulations and Accreditation Standards Aim to Improve Worker Training
OSHA, in response to occupational transmission of HIV to HCWs in the early 1990s, created the Bloodborne Pathogen Standard. In it, OSHA cites specific requirements of employee training, including what topics the training must include, the frequency of training, who must be trained and the documentation requirements.9 The standard, however, does not dictate the methods to accomplish the training requirements.
Specifically, the Bloodborne Pathogen Standard states that the training program must contain minimum elements, such as "an explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment (PPE)," and "an explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials." Training programs also must include the epidemiology, symptoms, and transmission of bloodborne pathogens. The methods to prevent exposure include safe work practices, engineering controls, and PPE. There must be an explanation of the facility's signs, labels and/or color-coding used to alert HCWs to a potentially hazardous risk of exposure. Training must also include what to do if an exposure occurs, the processes for medical evaluation, testing and treatment if appropriate, and an explanation of the facility's exposure control plan, including how the HCW can access a written copy of the plan.
Recently the Bloodborne Pathogen Standard became more stringent following approval of the Needlestick Safety and Prevention Act. This new law directed OSHA to revise the Bloodborne Pathogen Standard to include additional rules regarding the evaluation and use of needles and other sharps. The new provisions are designed to reduce the number of needlestick and sharps related injuries and went into effect in April 2001.10 It also serves as a reminder about the importance of training healthcare workers to reduce injuries.
Training Through Technology
The medical industry has been at the forefront of technology for the purposes of patient care. Now, technology is able to assist the industry in efforts to effectively and efficiently train its workers.
Well-designed training programs will meet the recommendations on bloodborne pathogens set forth by OSHA and other organizations, such as the CDC, which recommends "education of healthcare personnel about the risk for and prevention of bloodborne infections...with information routinely updated to ensure accuracy."11
The CDC guidelines also state to "Provide educational information appropriate, in content and vocabulary, to the educational level, literacy, and language of the employee."
Regulatory agencies and accreditation standards look for training programs that are appropriate to the individual and the setting, provided on a timely basis, and updated when there are changes in practice or problems identified. And, they are looking for evidence that HCWs have demonstrated competency in infection control practices, including bloodborne pathogen precautions.
Interactive technology-delivered learning (TDL) is an emerging tool to help managers implement more effective training programs. Its advantages are numerous, especially in the area of measuring workers' knowledge and documenting results.
Technology-delivered learning, that is, job training that is taught through a computer with on-screen words or phrases used in conjunction with audio and graphics to explain and demonstrate concepts, has the ability to increase workers' job knowledge by offering familiar links between the content and how to use it on the job.
There are various forms of TDL with a wide range of capabilities that make them useful in most training circumstances. Of particular importance is the ability to measure workers' understanding of important infection control concepts, at the completion of training and over time. Probes throughout the training and reinforcement scenarios help the learner master the content. Post tests also reinforce learning and provide a tool for the trainer to know in what areas, if any, further training is indicated. Some TDL systems are designed so that the trainer can sort the posttest results by topic, department and even job title, giving the trainer valuable information for assessing immediate and future learning needs.
Customizable TDL programs allow for variations in practices between and within facilities. For example, the specific control measures for antibiotic resistant organisms and how to implement contact precautions in the ICU may be different than in the outpatient clinic. Therefore, the ability to customize the content to the area and the worker's responsibility is critical to ensure that healthcare workers receive information applicable to their work.
Other benefits of some TDL programs, such as those listed below, can be realized:
- Workers learn at their own pace; they can go forward or back to review materials as often as needed.
- Employees can assess their own understanding of the content with spot checks and post tests. The training is interactive, which helps facilitate learning.
- The training is often in small units that relate to job tasks. Trainers can combine the units or train on only selected topics depending on the worker's job responsibilities.
- It can generate reports of participation, assist the trainer in evaluating their employees'-competence, and maintains records of training.
Methods for training HCWs are continually evolving. In going beyond previous training programs, TDL offers healthcare workers an interactive, at-your-own-pace, measurable way of learning information critical to a safe working environment.
Mary Brachman, RN, MS, CIC is an IC consultant and certified infection control specialist with 18 years of experience.