Control of Infections Related to Bloodborne Pathogens

June 1, 2000

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

For a complete list of references click here