By Kelly M. Pyrek
Of the many hazards healthcare workers (HCWs) face daily, exposure tobloodborne pathogens and infectious bodily substances in the operating room (OR)has some of the most serious consequences. While exposure to disease is a factof life for HCWs, following proper protocol, donning personal protectiveequipment (PPE) and using the right equipment can help personnel contend withthe cleanup of spills.
Having well-stocked spill kits located throughout the OR and the rest of thehealthcare facility is essential to infectious fluid management and chemicalspill cleanup. Equipment must include, at the minimum, the following items:
Spill kits can be assembled according to the healthcare facility's specificneeds or pre-assembled commercial kits can be purchased from a number of vendorsin the marketplace. Regardless of the type of spill kit used, the followingsteps should be taken when cleaning and decontaminating spills of blood or otherpotentially infectious and hazardous materials:
1. Don appropriate PPE.
2. Control access to the area of the spill and prevent other personnel fromwalking through the affected area and thereby tracking infectious fluids andsubstances 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 anysharps from the spill area, taking care not to create aerosols. Place thehazardous materials in a thick-walled plastic bag, plastic-lined cardboard boxor other solid container that will prevent the sharps from puncturing thesurface and creating an opportunity for leakage. Place this container or baginto the red biohazard bag for proper disposal.
5. Apply the appropriate disinfectant or germicidal solution. To avoidcreating aerosols, never spray a disinfectant directly onto the spilled fluids.Instead, gently pour or spray the disinfectant on the spill kit's absorbentmaterials or cleaning cloths, or gently flood the affected area first around theperimeter of the spill, then work the disinfectant slowly into the spilledmaterial.
6. Allow several minutes of contact time with the disinfectant.
7. Pick up all absorbent materials and place carefully in red bags for properdisposal. 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 thatsolidifies a spill and includes a plastic scoop used to pick up the solidifiedmaterial. If using such a kit, HCWs should follow the instructions provided bythe manufacturer.
11. Once the spill is completely cleaned, place all used spill-controlequipment in red bags for disposal. Do not seal the bags.
12. Remove the articles of PPE and place in the red bags for disposal. Theitems 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 andprotective eyewear. Do not remove PPE from the face with soiled gloves. Removethe soiled outer gloves first and place them in a red bag for disposal. Use theclean inner glove to remove PPE from the face. This help prevents the transferof blood or other potentially infectious fluid to the mucous membranes of theface via a contaminated glove. Take care not to aerosolize the infectious fluidswhile removing PPE.
13. Once all used PPE, spill-control equipment and other potentiallycontaminated items are in the red bags, seal them securely and place them in aproper biohazard waste receptacle.
14. Wash hands thoroughly with soap and water, using friction for at least 30seconds.
Environmental spill specialists Cairn Technology of Britain recentlyconducted a survey on spill response in local hospitals. The company discoveredthat:
This British study underscores the need for constant education about exposureto infectious bodily fluids and bloodborne pathogens and the need for compliancewith the Bloodborne Pathogens Standard (BPS) issued by the Occupational Safetyand Health Administration (OSHA). This rule mandates policies and proceduresaimed at reducing the risk of contracting the hepatitis B virus (HBV) and humanimmunodeficiency virus (HIV) via spills, needlesticks and other natural andmechanical means.
While HBV and HIV are specifically identified in the standard, the term"bloodborne pathogen" includes any pathogenic microorganism that ispresent in human blood or other potentially infectious material (OPIM) and caninfect and cause disease in persons who are exposed to blood containing thepathogen. 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-IIand viral hemorrhagic fever.
Provision 29 CFR 1910.1030(d), in the section "Methods ofCompliance," establishes the method by which employers must protect theiremployees from the hazards of bloodborne pathogens and comply with this standardthrough the use of universal precautions, engineering controls, work practicecontrols, personal protective equipment, proper housekeeping and handling ofregulated waste. Standard precautions are OSHA's required methods of control toprotect employees from exposure to all human blood and OPIM. The term refers toa concept of bloodborne disease control which requires that all human blood andOPIM be treated as if known to be infectious for HIV, HBV, HCV or otherbloodborne pathogens, regardless of the perceived "low risk" status ofa patient or patient population. Alternative concepts in infection control arecalled Body Substance Isolation (BSI). These methods define all body fluids andsubstances as infectious. These methods incorporate not only the fluids andmaterials covered by this standard but expand coverage to include all bodyfluids and substances. These concepts are acceptable alternatives to universalprecautions, provided that facilities utilizing them adhere to all otherprovisions of this standard.
The BPS also addresses cleaning of the healthcare environment and takes intoaccount the location within the facility (e.g., OR vs. patient room), type ofsurface to be cleaned (e.g., hard-surfaced flooring versus carpeting), type ofsoil present (e.g., gross contamination vS. minor splattering), and tasks andprocedures being performed (e.g., laboratory analyses vs. routine patient care).The particular disinfectant used, as well as the frequency with which it isused, will depend upon the circumstances in which the cleaning anddecontamination task occurs.
Since environmental contamination is an effective method of diseasetransmission for HBV (the CDC states that HBV can survive for at least one weekin dried blood on environmental surfaces or contaminated needles andinstruments), the BPS provides the minimum requirements for the cleaning anddecontamination of environmental and working surfaces that come into contactwith blood or OPIM, whether it is during routine care or during surgery. OSHArequires that work surfaces are to be cleaned with an "appropriatedisinfectant" which includes a diluted bleach solution and EPA-registeredtuberculocides, sterilants registered by the Environmental Protection Agency(EPA), products registered against HIV/HBV or sterilants/high-leveldisinfectants cleared by the Food and Drug Administration (FDA). Fresh solutionsof diluted household bleach made up daily (every 24 hours) are also consideredappropriate for disinfection of environmental surfaces and for decontaminationof sites following initial cleanup of spills of blood or other potentiallyinfectious materials. While OSHA mandates the appropriate times for interval,terminal and emergency-spill cleaning, the BPS acknowledges, "There may besome instances in which immediate decontamination of overt contamination andspills may not be practical as in, for example, an operating table duringsurgery."
Additionally, the BPS addresses the handling of sharps that may have beeninvolved in a spill cleanup, since contaminated broken glass is capable ofinflicting percutaneous injury and direct inoculation of bloodborne pathogensinto the bloodstream. It stipulates, "Broken glassware which may becontaminated must not be picked up directly with the hands. The tools which areused in cleanup (e.g., forceps) must be properly decontaminated or discardedafter use and the broken glass placed in a sharps container, and employees mustbe given specific information and training with respect to this task."