Occupational Health and Ebola

Ebola virus disease presents a unique occupational health challenge to healthcare institutions, and Ebola readiness and response can drain al-ready-scarce infection prevention resources. This is reflected in a recent survey of infection preventionists at U.S. hospitals conducted by the Association for Professionals in Infection Control and Epidemiology (APIC) in which only 6 percent of healthcare institutions are well-prepared to receive a patient with the Ebola virus. Infection preventionists everywhere are hoping that the Ebola crisis can shed new light on the importance of a properly funded and resourced department.

By Kelly M. Pyrek

Ebola virus disease presents a unique occupational health challenge to healthcare institutions, and Ebola readiness and response can drain al-ready-scarce infection prevention resources. This is reflected in a recent survey of infection preventionists at U.S. hospitals conducted by the Association for Professionals in Infection Control and Epidemiology (APIC) in which only 6 percent of healthcare institutions are well-prepared to receive a patient with the Ebola virus. Infection preventionists everywhere are hoping that the Ebola crisis can shed new light on the importance of a properly funded and resourced department.

The survey asked APIC’s infection preventionist members, “How prepared is your facility to receive a patient with the Ebola virus?” Of the 1,039 U.S.-based respondents working in acute-care hospitals, about 6 percent reported their facility was well-prepared, while about 5 percent said it was not prepared. The remaining responses reported various levels of preparedness in between the two extremes, with the majority (40 percent) indicating they were somewhat prepared. Survey responses were received from hospitals that ranged in size from less than 100 to more than 400 beds.

According to the survey, 1 in 2 hospitals (51 percent) had only one or less than one full-time equivalent infection preventionist on staff. Among hospitals with 0 to 1 infection preventionists on staff, 4 percent felt well-prepared to receive a patient with the Ebola virus, compared to 31 percent of survey respondents with 11 or more infection preventionists on staff.

“We know that many hospitals do not have enough staff dedicated to infection prevention and control,” says Jennie Mayfield, BSN, MPH, CIC, president of APIC. “Facilities that are inadequately staffed to begin with are stretched beyond capacity at a time like this. The current crisis demonstrates our lack of surge capacity and should concern everyone. Because our infection preventionist members are having to focus so much attention on Ebola, they are very worried about what other infectious diseases we might be missing. The infection preventionist’s skills have never been in more demand.”

“The survey highlights the short shrift given to infection prevention at many U.S. hospitals,” says APIC's CEO Katrina Crist, MBA. “The Ebola outbreak illustrates why facility-wide infection prevention programs are critical and require adequately trained, staffed, and resourced infection control departments. The unique skill set of the infection preventionist is needed to get out in front of this outbreak and prevent the next public health issue from escalating to a crisis.” In a press conference held in late October, Crist added, "APIC is concerned that infection prevention and control efforts are not being supported at the level they need to be to protect patients and healthcare workers."
As Mayfield emphasizes, "This survey confirms our belief that many hospitals do not have enough staff dedicated to infection prevention and control. And this is particularly apparent at smaller facilities. In many cases, infection preventionists are wearing multiple hats -- they are often responsible for occupational and employee health, quality improvement, risk management and other duties. What's clear is facilities that are inadequately staffed to begin with, are now being stretched beyond capacity. The current Ebola crisis demonstrates our lack of surge capacity and this should concern everyone. Because IPS are focusing so much attention on Ebola, they are worried about what other processes or infec-tious diseases in their hospitals that they might be missing."

APIC is calling on healthcare facilities to assess their infection prevention programs by looking at all the care and services provided by the in-stitution and determining the appropriate level of personnel and resources necessary to meet the increased need. APIC is urging facilities to focus on three aspects of infection prevention in order to effectively protect healthcare workers, patients, and the public.
• Personnel: Because Ebola readiness demands intense, in-person training and drilling led by infection prevention experts, adequate infection prevention staffing is critical.
• Training: To ensure that guidelines are followed precisely 100 percent of the time, healthcare workers must be trained and drilled on safe-ty protocols so that they can demonstrate proficiency in essential infection control practices.
• Technology and equipment: To maximize efficiencies and provide real-time data to help infection preventionists detect and control infec-tious diseases, healthcare facilities must invest in infection tracking and monitoring technology.

"APIC is sounding the alarm," Mayfield says. "We can't protect patients and healthcare personnel from threats like Ebola and HAIs without adequate numbers of properly trained professionals. We're concerned that because our infection preventionists are devoting so much time to Ebola they are not able to conduct their surveillance work to detect, track and manage multiple-resistant organisms like MRSA, C. difficile and CRE. With limited human and technological resources, our members are unable to provide the type of education and observation of frontline teams, oversight on environmental cleaning, and the kind of rounding we desperately need right now to educate healthcare workers on how to prevent infections." 

Linda Greene, RN, MPS, CIC, manager of infection prevention at Highland Hospital and who serves on APIC's regulatory review panel, notes, "We do know many of the nation's infection prevention programs are under-resourced -- this means that in some hospitals, some IPs are unable to do those things they really need to do, such as conducting rounds, teaching, and observing on the units to make sure policies and procedures are followed, because good infection prevention starts at the bedside. We believe this is a vital part of their roles and it is an essential part of patient safety. The current crisis sheds light on how critically important properly resourced IP programs are. The Ebola crisis reinforces how im-portant it is that all healthcare workers understand basic practices -- we can use this as a wake-up call to strengthen those practices. It also highlights how essential it is to conduct training, to do drills, have demonstrations and make sure healthcare personnel do those return demon-strations. This way, IPs know care teams on the front line know how to put on and remove protective gear, how to identify, isolate and com-municate an Ebola patient. One of the things the CDC recommends is the buddy system where you are observing another healthcare worker donning and doffing their PPE. But if we take the larger picture in terms of patient safety, we can apply this to our everyday work, reminding others and looking out for other healthcare workers. APIC thinks the role of the IP is a coach and mentor, never more important, but if you don't have the resources to be out there and work with frontline teams, to be coaching and watching people -- you don't know where the gaps are. We need to be mindful of not taking our eyes off the ball, ensuring prompt recognition and communication of other diseases. We have flu, enterovirus and C. difificile, but because of Ebola, IPs have had to put these things on the back burner. APIC is urging facilities to focus on personnel, training, technology and equipment to support these vital infection prevention programs. The safety of our patients, our healthcare workers, and our nation depends on this."

Updated CDC Guidance
In an Oct. 20, 2014 press conference, CDC director Tom Frieden, MD, MPH, introduced new guidance on personal protective equipment (PPE) that he described as providing "an increased margin of safety." Frieden also said this updated guidance of recommendations issued on Aug. 1, 2014  "provide a consensus on better protecting healthcare workers because even a single healthcare worker infection is unacceptable. One of the many challenges dealing with Ebola is that there's never been a case in this country until less than a month ago. It is truly unprece-dented here."

The current guidelines for Ebola and other hemorrhagic fevers which were issued in 2008 and updated in August 2014 were developed by experts at CDC with consultation and approval from infectious disease control experts around the U.S. and are consistent with World Health Organization (WHO) guidelines and have been used successfully before, Frieden noted, adding, "The hospital caring for the first patient, Mr. Duncan, relied on these guidelines. Two healthcare workers became infected. This is unacceptable. Even a single healthcare worker infection is one too many. We may never know exactly how that happened, but the bottom line is that the guidelines didn't work for that hospital. Dallas showed that taking care of Ebola is hard.  The way care is given in this country is riskier than in Africa. There is more hands-on nursing care and there are more high-risk procedures such as intubation." Frieden emphasized that the latest guidance has been reviewed by experts in institu-tions with significant experience treating Ebola in the U.S., such as Doctors Without Borders, Emory University, the University of Nebraska, and the National Institutes of Health (NIH) Clinical Center. 

The updated recommendations, Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Pa-tients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing), provides detailed guid-ance on the types of PPE to be used and on the processes for donning and doffing PPE for all healthcare workers entering the room of a pa-tient hospitalized with Ebola virus disease. The guidance also emphasizes the importance of training, practice, competence and observation of healthcare workers in correct donning and doffing of PPE selected by the facility.

This guidance contains the following key principles:
1. Prior to working with Ebola patients, all healthcare workers involved in the care of Ebola patients must have received repeated training and have demonstrated competency in performing all Ebola-related infection control practices and procedures, and specifically in don-ning/doffing proper PPE.
2. While working in PPE, healthcare workers caring for Ebola patients should have no skin exposed.
3. The overall safe care of Ebola patients in a facility must be overseen by an onsite manager at all times, and each step of every PPE don-ning/doffing procedure must be supervised by a trained observer to ensure proper completion of established PPE protocols.

In healthcare settings, Ebola is spread through direct contact (e.g., through broken skin or through mucous membranes of the eyes, nose, or mouth) with blood or body fluids of a person who is sick with Ebola or with objects (e.g., needles, syringes) that have been contaminated with the virus. For all healthcare workers caring for Ebola patients, PPE with full body coverage is recommended to further reduce the risk of self-contamination.

To protect healthcare workers during care of an Ebola patient, healthcare facilities must provide onsite management and oversight on the safe use of PPE and implement administrative and environmental controls with continuous safety checks through direct observation of healthcare workers during the PPE donning and doffing processes.

Recommended Administrative and Environmental Controls for Healthcare Facilities
Protecting healthcare workers and preventing spread of Ebola requires that proper administrative procedures and safe work practices be carried out in appropriate physical settings. These controls include the following:
• At an administrative level, the facility’s infection prevention management system, in collaboration with the facility’s occupational health de-partment, should: 
Establish and implement triage protocols to effectively identify patients who may have Ebola and institute the precautions detailed in this document.
Designate individuals as site managers responsible for overseeing the implementation of precautions for healthcare workers and patient safety. A site manager’s sole responsibility is to ensure the safe and effective delivery of Ebola treatment. These individuals are responsible for all aspects of Ebola infection control including supply monitoring and evaluation with direct observation of care before, during, and after staff en-ter an isolation and treatment area. At least one site manager should be on-site at all times in the location where the Ebola patient is being cared for.
Identify critical patient care functions and essential healthcare workers for care of Ebola patients, for collection of laboratory specimens, and for management of the environment and waste ahead of time.
Ensure healthcare workers have been trained in all recommended protocols for safe care of Ebola patients before they enter the patient care area.
Train healthcare workers on all PPE recommended in the facility’s protocols. Healthcare workers should practice donning and doffing pro-cedures and must demonstrate during the training process competency through testing and assessment before caring for Ebola patients. Use trained observers to monitor for correct PPE use and adherence to protocols for donning and doffing PPE, and guide healthcare workers at each point of use using a checklist for every donning and doffing procedure.
Document training of observers and healthcare workers for proficiency and competency in donning and doffing PPE, and in performing all necessary care-related duties while wearing PPE.
Designate spaces so that PPE can be donned and doffed in separate areas.
Key safe work practices include the following:
Identify and isolate the Ebola patient in a single patient room with a closed door and a private bathroom as soon as possible.
Limit the number of healthcare workers who come into contact with the Ebola patient (e.g., avoid short shifts), and restrict non-essential personnel and visitors from the patient care area.
Monitor the patient care area at all times, and log at a minimum entry and exit of all healthcare workers who enter the room of an Ebola patient.
Ensure that a trained observer watches closely each donning and each doffing procedure, and provides supervisory assurance that donning and doffing protocols are followed.
Ensure that healthcare workers have sufficient time to don and doff PPE correctly without disturbances.
Ensure that practical precautions are taken during patient care, such as keeping hands away from the face, limiting touch of surfaces and body fluids, preventing needlestick and sharps injuries, and performing frequent disinfection of gloved hands using an alcohol-based handrub (ABHR), particularly after handling body fluids.
Disinfect immediately any visibly contaminated PPE surfaces, equipment, or patient-care area surfaces using an EPA-registered disinfectant wipe.
Perform regular cleaning and disinfection of patient-care area surfaces, even absent visible contamination. This should be performed only by nurses or physicians as part of patient care activities in order to limit the number of additional healthcare workers who enter the room.
Implement observation of healthcare workers in the patient room, if possible (e.g., glass-walled intensive care unit room).
Establish a facility exposure management plan that addresses decontamination and follow-up of an affected healthcare worker in case of any unprotected exposure. Training on this plan and follow-up should be part of the healthcare worker training.

Principles of PPE
Healthcare workers must understand the following basic principles to ensure safe and effective PPE use, which include that no skin may be exposed while working in PPE:
• Donning
PPE must be donned correctly in proper order before entry into the patient care area and not be later modified while in the patient-care area. The donning activities must be directly observed by a trained observer.
• During Patient Care
PPE must remain in place and be worn correctly for the duration of exposure to potentially contaminated areas. PPE should not be adjust-ed during patient care.
Healthcare workers should perform frequent disinfection of gloved hands using an ABHR, particularly after handling body fluids.
If during patient care a partial or total breach in PPE (e.g., gloves separate from sleeves leaving exposed skin, a tear develops in an outer glove, a needlestick) occurs, the healthcare worker must move immediately to the doffing area to assess the exposure. Implement the facility exposure plan, if indicated by assessment.
• Doffing
The removal of used PPE is a high-risk process that requires a structured procedure, a trained observer, and a designated area for removal to ensure protection
PPE must be removed slowly and deliberately in the correct sequence to reduce the possibility of self-contamination or other exposure to Ebola virus
A stepwise process should be developed and used during training and daily practice
Double gloving provides an extra layer of safety during direct patient care and during the PPE removal process. Beyond this, more layers of PPE may make it more difficult to perform patient care duties and put healthcare workers at greater risk for percutaneous injury (e.g., needle-sticks), self-contamination during care or doffing, or other exposures to Ebola. If healthcare facilities decide to add additional PPE or modify this PPE guidance, the CDC says they must consider the risk/benefit of any modification, and train healthcare workers on correct donning and doff-ing in the modified procedures.

Training on Correct Use of PPE
Training ensures that healthcare workers are knowledgeable and proficient in the donning and doffing of PPE prior to engaging in man-agement of an Ebola patient. Comfort and proficiency when donning and doffing are only achieved through repeated practice on the correct use of PPE. Healthcare workers should be required to demonstrate competency in the use of PPE, including donning and doffing while being observed by a trained observer, before working with Ebola patients. In addition, during practice, healthcare workers and their trainers should assess their proficiency and comfort with performing required duties while wearing PPE. Training should be available in formats accessible to individuals with disabilities or limited English proficiency. Target training to the educational level of the intended audience.

Use of a Trained Observer
Because the sequence and actions involved in each donning and doffing step are critical to avoiding exposure, a trained observer will read aloud to the healthcare worker each step in the procedure checklist and visually confirm and document that the step has been completed cor-rectly. The trained observer is a dedicated individual with the sole responsibility of ensuring adherence to the entire donning and doffing process. The trained observer will be knowledgeable about all PPE recommended in the facility’s protocol and the correct donning and doffing proce-dures, including disposal of used PPE, and will be qualified to provide guidance and technique recommendations to the healthcare worker. The trained observer will monitor and document successful donning and doffing procedures, providing immediate corrective instruction if the healthcare worker is not following the recommended steps. The trained observer should know the exposure management plan in the event of an unintentional break in procedure.

Designating Areas for PPE Donning and Doffing
Facilities should ensure that space and layout allow for clear separation between clean and potentially contaminated areas. It is critical that physical barriers (e.g., plastic enclosures) be used where necessary, along with visible signage, to separate distinct areas and ensure a one-way flow of care moving from clean areas (e.g., area where PPE is donned and unused equipment is stored) to the patient room and to the PPE removal area (area where PPE is removed and discarded).
Post signage to highlight key aspects of PPE donning and doffing, including
• Designating clean areas vs. potentially contaminated areas
• Reminding healthcare workers to wait for a trained observer before removing PPE
• Reinforcing need for slow and deliberate removal of PPE to prevent self-contamination
• Reminding healthcare workers to perform disinfection of gloved hands in between steps of the doffing procedure, as indicated below.

Designate the following areas with appropriate signage:
1. PPE Storage and Donning Area
This is an area outside the Ebola patient room (e.g., a nearby vacant patient room, a marked area in the hallway outside the patient room) where clean PPE is stored and where healthcare workers can don PPE before entering the patient’s room. Do not store potentially contaminat-ed equipment, used PPE, or waste removed from the patient’s room in this area. If waste must pass through this area, it must be properly con-tained.
2. Patient Room
This is a single-patient room. The door is kept closed. Any item or healthcare worker exiting this room should be considered potentially con-taminated.
3. PPE Removal Area
This is an area in proximity to the patient’s room (e.g., anteroom or adjacent vacant patient room that is separate from the clean area) where healthcare workers leaving the patient’s room can doff and discard their PPE. Alternatively, some steps of the PPE removal process may be performed in a clearly designated area of the patient’s room near the door, provided these steps can be seen and supervised by a trained observer (e.g., through a window such that the healthcare worker doffing PPE can still hear the instructions of the trained observer). Do not use this clearly designated area within the patient room for any other purpose. Stock gloves in a clean section of the PPE removal area accessi-ble to the healthcare worker while doffing.

In the PPE removal area, provide supplies for disinfection of PPE and for performing hand hygiene and space to remove PPE, including a place for sitting that can be easily cleaned and disinfected, where the healthcare workers can remove boot covers. Provide leak-proof infec-tious waste containers for discarding used PPE. Perform frequent environmental cleaning and disinfection of the PPE removal area, including upon completion of doffing procedure by healthcare workers. If a facility must use the hallway outside the patient room as the PPE removal area, construct physical barriers to close the hallway to through traffic and thereby create an anteroom. In so doing, the facility should make sure that this hallway space complies with fire-codes. Restrict access to this hallway to essential personnel who are properly trained on recom-mended infection prevention practices for the care of Ebola patients. Facilities should consider making showers available for use by healthcare workers after doffing of PPE.

Selection of PPE for Healthcare Workers During Management of Ebola Patients
The key to all PPE is consistent implementation through repeated training and practice. A facility should select and standardize the PPE to be used by all essential healthcare workers directly interacting with Ebola patients and provide a written protocol outlining procedures for donning and doffing of this PPE, which will be reviewed and monitored by the trained observer.
The CDC recommends facilities use a powered air-purifying respirator (PAPR) or an N95 or higher respirator in the event of an unexpected aerosol-generating procedure.
For healthcare workers who may spend extended periods of time in PPE while caring for Ebola patients, safety and comfort are critical. Standardizing attire under PPE (e.g., surgical scrubs or disposable garments and dedicated washable footwear) facilitates the donning and doff-ing process and eliminates concerns of contamination of personal clothing.
If facilities elect to use different PPE from what is outlined below (e.g., coveralls with either an integrated hood or a surgical hood with inte-grated full face shield), they must train healthcare workers in this use and ensure that donning and doffing procedures are adjusted and prac-ticed accordingly.

Recommended Personal Protective Equipment
• PAPR or N95 Respirator. If a NIOSH-certified PAPR and a NIOSH-certified fit-tested disposable N95 respirator is used in facility protocols, en-sure compliance with all elements of the OSHA Respiratory Protection Standard, 29 CFR 1910.134, including fit testing, medical evaluation, and training of the healthcare worker.
PAPR: A PAPR with a full face shield, helmet, or headpiece. Any reusable helmet or headpiece must be covered with a single-use (disposa-ble) hood that extends to the shoulders and fully covers the neck and is compatible with the selected PAPR. The facility should follow manufac-turer’s instructions for decontamination of all reusable components and, based upon those instructions, develop facility protocols that include the designation of responsible personnel who assure that the equipment is appropriately reprocessed and that batteries are fully charged before reuse. A PAPR with a self-contained filter and blower unit integrated inside the helmet is preferred. A PAPR with external belt-mounted blower unit requires adjustment of the sequence for donning and doffing:
N95 Respirator: Single-use (disposable) N95 respirator in combination with single-use (disposable) surgical hood extending to shoulders and single-use (disposable) full face shield. If N95 respirators are used instead of PAPRs, careful observation is required to ensure healthcare workers are not inadvertently touching their faces under the face shield during patient care.
• Single-use (disposable) fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood. Coveralls with or without integrated socks are acceptable. Consideration should be given to selecting gowns or coveralls with thumb hooks to secure sleeves over inner glove. If gowns or coveralls with thumb hooks are not available, personnel may consider taping the sleeve of the gown or coverall over the inner glove to prevent potential skin exposure from separation between sleeve and inner glove during activity. However, if taping is used, care must be taken to remove tape gently. Experience in some facilities suggests that taping may increase risk by making the doffing process more difficult and cumbersome.
• Single-use (disposable) nitrile examination gloves with extended cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs.
• Single-use (disposable), fluid-resistant or impermeable boot covers that extend to at least mid-calf or single-use (disposable) shoe covers. Boot and shoe covers should allow for ease of movement and not present a slip hazard to the worker.
Single-use (disposable) fluid-resistant or impermeable shoe covers are acceptable only if they will be used in combination with a coverall with integrated socks.
•Single-use (disposable), fluid-resistant or impermeable apron that covers the torso to the level of the mid-calf should be used if Ebola pa-tients have vomiting or diarrhea. An apron provides additional protection against exposure of the front of the body to body fluids or excrement. If a PAPR will be worn, consider selecting an apron that ties behind the neck to facilitate easier removal during the doffing procedure.
Environmental Control
The CDC's Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus recommends that hospitals:
- Be sure environmental services staff wear proper PPE to protect against direct skin and mucous membrane exposure of cleaning chemicals, contamination, and splashes or spatters during environmental cleaning and disinfection activities. If reusable heavy-duty gloves are used for cleaning and disinfecting, they should be disinfected and kept in the room or anteroom. Be sure staff are instructed in the proper use of per-sonal protective equipment including safe removal to prevent contaminating themselves or others in the process, and that contaminated equip-ment is disposed of appropriately.
- Use a U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant with a label claim for a non-enveloped virus (e.g., no-rovirus, rotavirus, adenovirus, poliovirus) to disinfect environmental surfaces in rooms of patients with suspected or confirmed Ebola virus infec-tion. Although there are no products with specific label claims against the Ebola virus, enveloped viruses such as Ebola are susceptible to a broad range of hospital disinfectants used to disinfect hard, non-porous surfaces. In contrast, non-enveloped viruses are more resistant to disinfectants. As a precaution, selection of a disinfectant product with a higher potency than what is normally required for an enveloped virus is being recom-mended at this time. EPA-registered hospital disinfectants with label claims against non-enveloped viruses (e.g., norovirus, rotavirus, adenovirus, poliovirus) are broadly antiviral and capable of inactivating both enveloped and non-enveloped viruses.
- Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic or other cov-ering that fluids cannot get through. Do not place patients with suspected or confirmed Ebola virus infection in carpeted rooms and remove all upholstered furniture and decorative curtains from patient rooms before use.
- To reduce exposure among staff to potentially contaminated textiles (cloth products) while laundering, discard all linens, non-fluid-impermeable pillows or mattresses, and textile privacy curtains into the waste stream and disposed of appropriately.
The Ebola virus is a classified as a Category A infectious substance by and regulated by the U.S. Department of Transportation’s (DOT) Haz-ardous Materials Regulations (HMR, 49 C.F.R., Parts 171-180). Any item transported offsite for disposal that is contaminated or suspected of being contaminated with a Category A infectious substance must be packaged and transported in accordance with the HMR. This includes med-ical equipment, sharps, linens, and used health care products (such as soiled absorbent pads or dressings, kidney-shaped emesis pans, portable toilets, used Personal Protection Equipment (gowns, masks, gloves, goggles, face shields, respirators, booties, etc.) or byproducts of cleaning) contaminated or suspected of being contaminated with a Category A infectious substance.

Ebola-Contaminated Medical Waste
The recent outbreak of Ebola virus disease has raised questions about the correct handling of Ebola contaminated biohazardous medical waste. A joint advisory statement issued by AAMI, AORN, APIC, AST and IAHCSMM is intended to provide guidance to personnel and healthcare organizations for handling biohazardous medical waste, including waste contaminated with the Ebola virus. This statement addresses the use of sterilizers for processing biohazardous waste in the healthcare facility, but it does not address transportation of biohazardous waste, or pro-cessing of contaminated reusable medical devices and textiles.

The statement recognizes that sterilization modalities other than moist heat may be used for processing biohazardous waste, the term “sterilizer” is used rather than “autoclave” as used in other guidelines. The associations issuing this guidance emphasize that this is an evolving issue and healthcare professionals should review current research and incorporate new evidence into practice to mitigate occupational and patient risk associated with handling biohazardous medical waste.

AAMI, AORN, APIC, AST and IAHCSMM recommend that:
1. Healthcare organizations should not circumvent established protocols for handling biohazardous medical waste.
2. Biohazardous medical waste should not be brought into clean areas where processing reusable medical devices is performed.
3. Biohazardous medical waste should not be inactivated in a sterilizer that is used for processing reusable medical devices.
4. Sterilizers used to inactivate biohazardous medical waste should be designed and validated for that particular purpose.
5. Organizations should work with infection preventionists and keep abreast of evolving professional and regulatory guidelines for handling biohazardous medical waste.

Ebola-Contaminated Healthcare Textiles
The Healthcare Laundry Accreditation Council (HLAC) is advising healthcare laundries to follow the current guidelines offered by the Centers for Disease Control and Prevention (CDC) regarding the processing of linens that have been used in the care of suspected or confirmed patients with Ebola. Specifically, HLAC, which inspects and accredits healthcare laundries, is recommending against any subsequent processing of linens used in the care of Ebola patients. HLAC is urging all healthcare laundries - on-premises laundries as well as offsite laundries -- to advise their staff and hospital partners that, in accordance with CDC guidelines, linens, including non-fluid-impermeable pillows or mattresses, and textile privacy curtains that have been exposed to suspected or confirmed Ebola Virus Disease (EVD) patients, are to be placed in a red bio-hazard precaution bag and disposed of according to the healthcare facility's hazardous waste disposal policy and procedure. Bio-hazardous waste should not be transported other than by properly licensed and equipped professional hazardous waste disposal companies.

"Laundries should advise their healthcare customers to remind their staff that red-bagged bio-hazard materials should never be sent to healthcare laundries with soiled linen," says Gregory Gicewicz, president of HLAC. "Also at this time, we're telling our laundries that any Ebola-affected linens received by them should be disposed of in accordance with proper professional bio-hazard disposal processes."

Gicewicz adds that such red-bag linens should not be left on a dock or on the floor area of the laundry but need to be temporarily stored in a locked room and contained in a clearly marked bio-hazard 55-gallon drum that is securely sealed. "In all of this, it's best to err on the side of caution - common sense is the order of the day," Gicewicz says.

Reference:
Centers for Disease Control and Prevention (CDC). Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing).

             

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