Contain and Confine: Keeping Staff Safe From Infectious Spills
By Kelly M. Pyrek
Of the many hazards healthcare workers (HCWs) face daily, exposure to bloodborne pathogens and infectious bodily substances in the operating room (OR) has some of the most serious consequences. While exposure to disease is a fact of life for HCWs, following proper protocol, donning personal protective equipment (PPE) and using the right equipment can help personnel contend with the cleanup of spills.
Having well-stocked spill kits located throughout the OR and the rest of the healthcare facility is essential to infectious fluid management and chemical spill cleanup. Equipment must include, at the minimum, the following items:
- PPE, including disposable gloves, protective eyewear, disposable face masks, disposable gowns or aprons and antiseptic towelettes
- Spill cleanup equipment including disposable absorbent material such as pads, pillows and cloths, red medical-waste or biohazard bags for disposal, an appropriate germicidal solution, and forceps or other mechanical means to pick up sharps and other hazardous material
Spill kits can be assembled according to the healthcare facility's specific needs or pre-assembled commercial kits can be purchased from a number of vendors in the marketplace. Regardless of the type of spill kit used, the following steps should be taken when cleaning and decontaminating spills of blood or other potentially infectious and hazardous materials:
1. Don appropriate PPE.
2. Control access to the area of the spill and prevent other personnel from walking through the affected area and thereby tracking infectious fluids and substances to other clinical areas.
3. Contain the spill by using absorbent materials found in the spill kit.
4. Use forceps, a plastic scoop or other mechanical means to remove any sharps from the spill area, taking care not to create aerosols. Place the hazardous materials in a thick-walled plastic bag, plastic-lined cardboard box or other solid container that will prevent the sharps from puncturing the surface and creating an opportunity for leakage. Place this container or bag into the red biohazard bag for proper disposal.
5. Apply the appropriate disinfectant or germicidal solution. To avoid creating aerosols, never spray a disinfectant directly onto the spilled fluids. Instead, gently pour or spray the disinfectant on the spill kit's absorbent materials or cleaning cloths, or gently flood the affected area first around the perimeter of the spill, then work the disinfectant slowly into the spilled material.
6. Allow several minutes of contact time with the disinfectant.
7. Pick up all absorbent materials and place carefully in red bags for proper disposal. Do not seal the bags.
8. Clean the affected area again with disinfectant and new cleaning cloths. Place these used cloths in the red bags for disposal. Do not seal the bags.
9. Let the affected area dry.
10. Many commercial spill kits are equipped with a powder substance that solidifies a spill and includes a plastic scoop used to pick up the solidified material. If using such a kit, HCWs should follow the instructions provided by the manufacturer.
11. Once the spill is completely cleaned, place all used spill-control equipment in red bags for disposal. Do not seal the bags.
12. Remove the articles of PPE and place in the red bags for disposal. The items should be removed in the following order: remove the soiled gown or apron, remove the outer pair of disposable gloves and remove the face mask and protective eyewear. Do not remove PPE from the face with soiled gloves. Remove the soiled outer gloves first and place them in a red bag for disposal. Use the clean inner glove to remove PPE from the face. This help prevents the transfer of blood or other potentially infectious fluid to the mucous membranes of the face via a contaminated glove. Take care not to aerosolize the infectious fluids while removing PPE.
13. Once all used PPE, spill-control equipment and other potentially contaminated items are in the red bags, seal them securely and place them in a proper biohazard waste receptacle.
14. Wash hands thoroughly with soap and water, using friction for at least 30 seconds.
Environmental spill specialists Cairn Technology of Britain recently conducted a survey on spill response in local hospitals. The company discovered that:
- The contents of spill kits varied from paper towels, sand and sawdust to more comprehensive facility-prepared kits or commercially available kits.
- Protective clothing was sometimes included but often in a separate area.
- Spill equipment was often kept in cabinets or on shelves, in a supervisor's office or in a corridor behind other objects and even sometimes in the room where the hazardous material was being used.
- Workers were unsure about spill procedures with a vague idea about kits since they had "never had a spill and were never likely to."
- Staff were often not confident about using spill equipment -- absorbents or other kit items -- and unclear as to whether the kit was suitable for the liquid being tackled.
- Some departments or hospitals were extremely well prepared to manage spills.
- Spill procedures were accessible and clear, with staff having a full understanding. Spill stations were appropriate and well equipped, with staff trained in using them. All these well-prepared units had at some time experienced a major spillage incident resulting in either staff or patient exposure, a unit closing temporarily or scrutiny from public health authorities.
This British study underscores the need for constant education about exposure to infectious bodily fluids and bloodborne pathogens and the need for compliance with the Bloodborne Pathogens Standard (BPS) issued by the Occupational Safety and Health Administration (OSHA). This rule mandates policies and procedures aimed at reducing the risk of contracting the hepatitis B virus (HBV) and human immunodeficiency virus (HIV) via spills, needlesticks and other natural and mechanical means.
While HBV and HIV are specifically identified in the standard, the term "bloodborne pathogen" includes any pathogenic microorganism that is present in human blood or other potentially infectious material (OPIM) and can infect and cause disease in persons who are exposed to blood containing the pathogen. Pathogenic microorganisms can also cause diseases such as hepatitis C, 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.
Provision 29 CFR 1910.1030(d), in the section "Methods of Compliance," establishes the method by which employers must protect their employees from the hazards of bloodborne pathogens and comply with this standard through the use of universal precautions, engineering controls, work practice controls, personal protective equipment, proper housekeeping and handling of regulated waste. Standard precautions are OSHA's required methods of control to protect employees from exposure to all human blood and OPIM. The term refers to a concept of bloodborne disease control which requires that all human blood and OPIM be treated as if known to be infectious for HIV, HBV, HCV or other bloodborne pathogens, regardless of the perceived "low risk" status of a patient or patient population. Alternative concepts in infection control are called Body Substance Isolation (BSI). These methods define all body fluids and substances as infectious. These methods incorporate not only the fluids and materials covered by this standard but expand coverage to include all body fluids and substances. These concepts are acceptable alternatives to universal precautions, provided that facilities utilizing them adhere to all other provisions of this standard.
The BPS also addresses cleaning of the healthcare environment and takes into account the location within the facility (e.g., OR vs. patient room), type of surface to be cleaned (e.g., hard-surfaced flooring versus carpeting), type of soil present (e.g., gross contamination vS. minor splattering), and tasks and procedures being performed (e.g., laboratory analyses vs. routine patient care). The particular disinfectant used, as well as the frequency with which it is used, will depend upon the circumstances in which the cleaning and decontamination task occurs.
Since environmental contamination is an effective method of disease transmission for HBV (the CDC states that HBV can survive for at least one week in dried blood on environmental surfaces or contaminated needles and instruments), the BPS provides the minimum requirements for the cleaning and decontamination of environmental and working surfaces that come into contact with blood or OPIM, whether it is during routine care or during surgery. OSHA requires that work surfaces are to be cleaned with an "appropriate disinfectant" which includes a diluted bleach solution and EPA-registered tuberculocides, sterilants registered by the Environmental Protection Agency (EPA), products registered against HIV/HBV or sterilants/high-level disinfectants cleared by the Food and Drug Administration (FDA). Fresh solutions of diluted household bleach made up daily (every 24 hours) are also considered appropriate for disinfection of environmental surfaces and for decontamination of sites following initial cleanup of spills of blood or other potentially infectious materials. While OSHA mandates the appropriate times for interval, terminal and emergency-spill cleaning, the BPS acknowledges, "There may be some instances in which immediate decontamination of overt contamination and spills may not be practical as in, for example, an operating table during surgery."
Additionally, the BPS addresses the handling of sharps that may have been involved in a spill cleanup, since contaminated broken glass is capable of inflicting percutaneous injury and direct inoculation of bloodborne pathogens into the bloodstream. It stipulates, "Broken glassware which may be contaminated must not be picked up directly with the hands. The tools which are used in cleanup (e.g., forceps) must be properly decontaminated or discarded after use and the broken glass placed in a sharps container, and employees must be given specific information and training with respect to this task."