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By Terri Goodman, RN, MA, PhD
Prior to the early 1980s and the introduction of AIDS into society, infection controlpractices were designed almost exclusively to protect the patient from developing anosocomial infection--an infection acquired after admission to the hospital.Protocols were focused on protecting the patient with little or no emphasis on thehealthcare worker's potential to become infected. Hepatitis B has been a significantoccupational hazard for healthcare workers for decades and is 100 times more infectiousthan the AIDS virus, but it was the AIDS epidemic in the early '80s that brought anawareness of exposure vulnerability to bloodborne pathogens. This awareness led to thedevelopment of the first protocols designed to protect healthcare workers, the Guidelinefor Infection Control in Hospital Personnel published by the Centers for DiseaseControl (CDC) in 1983.1
To understand the importance preventive measures in cross-contamination, it helps tounderstand the chain of infection--the three interrelated elements that must be presentfor 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 bodyfluids (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 importantrole in transmitting microorganisms. Many of the microbial inhabitants on the hands arecapable of colonizing and infecting wounds, cuts, and other susceptible sites. The singlemost effective means of preventing the transmission of infection is through conscientioushandwashing.
In 1987, the CDC developed a system of infection control guidelines commonly referredto as universal blood and body fluid precautions.2 Universal Precautions refersto a system of infection control practices that encourages caregivers to presume that allpatients are potentially infected with HIV, HBV, or other bloodborne pathogens. Specificinfection control precautions are used with all patients to minimize the risk of exposureto blood or body fluids.
As a supplement to universal precautions, the CDC permits healthcare facilities todesign their own systems of isolation. For instance, body substance isolation focuses onthe separation of the hands of the caregiver from all body substances of all patients byusing appropriate shielding techniques, particularly gloves, to reduce contacttransmission.
The CDC guidelines did not carry the force of the law, but in 1991, the OccupationalSafety and Health Administration (OSHA), using its authority under the Occupational Safetyand Health Act, issued enforcement instructions for a bloodborne pathogen standardregarding occupational exposure to HBV and HIV, the Final Rule on Occupational Exposure toBloodborne Pathogens,3 based on the concept of universal precautions to preventoccupational 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 infectiousmaterial(s) that may result from the performance of an employee's duties." Accordingto OSHA, infectious materials include semen, vaginal secretions, cerebrospinal fluid,synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, salivain dental procedures, any body fluid visibly contaminated with blood, and all body fluidsin 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 ahuman (living or dead), HIV-containing cell or tissue cultures, and HIV or HepatitisB-containing culture media or other solutions as well as blood, organs, or other tissuesfrom experimental animals infected with HIV or HBV.
OSHA's "final rule" made it mandatory that healthcare facilities assumedresponsibility for protecting their employees from exposure to bloodborne pathogens. Thelaw had eight primary components:
The Exposure Control Plan required a facility to develop a written document detailingspecific needs, including exposure determination, a schedule and method of implementationfor compliance, and procedures for the evaluation of exposure incidents. The plan must beaccessible to all employees and must be reviewed and updated annually.
Universal precautions is an infection control system that assumes that every directcontact with blood and body fluids is potentially infectious. The system is based on thepremise that not all patients with bloodborne infections have been diagnosed, andtherefore, precautions must be applied universally.
Engineering controls address devices that are used to isolate or remove the bloodbornepathogen hazards from the workplace. These controls include (among other things), sharpsdisposal containers, needle resheathing devices, needleless vascular access systems, andbiohazardous waste containers.
Work practice controls provide procedures and practices to describe methods ofperforming 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 techniquethat is much safer is an example of a work practice control.
Personal protective equipment (PPE) refers to barrier equipment designed to shield theemployee from blood and body fluid contamination. This equipment, that includes gloves,fluid-resistant masks and gowns, splash shields and eye protection, is used whenever thereis a risk of exposure to blood or other potentially infectious material. The supply andrepair of PPE is the responsibility of the employer. Non-employee healthcare professionalssuch as physicians and contractors must comply with the facility's Exposure Control Planand use of PPE. This compliance is to ensure their own safety as well as the safety of thefacility's employees and patients.
The type and characteristics of the equipment must be appropriate for the task beingperformed and the degree of exposure anticipated. In exposure-prone procedures, employeesmay require more extensive barrier protection. For instance, a helmet system may be usedin surgical procedures where aerosolized blood particle inhalation during irrigation ispossible.
In a medical emergency, PPE may be temporarily abandoned in the interest oflife-threatening patient care requirements. However, as soon as the urgency has beenaddressed, full compliance with the use of barrier protection should be initiated. It isthe employer's responsibility to evaluate any situation in which PPE was abandoned toassure 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 healthcarefacility. OSHA does not permit contaminated clothing to be laundered at home due to thehighly resistant nature of the Hepatitis B virus.3
Overcompliance in the use of PPE is not beneficial, necessary, or cost effective. AllPPE must be removed and disposed of properly before leaving the immediate work area toprevent transmission of contaminants and possible cross-infection.
Employers must provide Hepatitis B vaccine at no cost to any of their employees who arelikely to be exposed to bloodborne pathogens. Policies and procedures detailing requiredpostexposure follow-up practices include medical evaluation, laboratory testing, andprovisions for confidentiality. The employee is responsible for reporting any exposureincident immediately to his or her supervisor.
Training and education are hallmarks of any program whose success requires individualparticipation. Healthcare workers must recognize that cooperation and compliance with thecomponents of the Final Rule are essential. Compliance with OSHA's rules and regulationsis a matter of control: infection control through control of the environment and controlof behavior.
Employers are required to provide a training program at no cost and during workinghours for all employees with potential for occupational exposure to blood and body fluidexposure upon initial assignment and at least annually thereafter. Employers must maintainmedical and training records for each employee with actual or potential occupationalexposure 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 beenexpanded beyond bloodborne pathogen transmission. This expansion includes the use ofprotective barriers when having contact with urine and saliva to prevent transmission ofother infections, such as herpes, cytomegalovirus, etc.
In 1998, CDC published, Guideline for infection control in health care personnel,a revision of their 1983 guidelines.5 The revised guidelines were designed toprovide methods for reducing the transmission of infections from patient to healthcarepersonnel and from personnel to patients. Prevention strategies in the revised documentinclude immunizations for vaccine-preventable diseases, isolation precautions, managementof personnel exposure to infectious persons (including postexposure prophylaxis), and workrestrictions for exposed or infected healthcare personnel. This document also addressesissues related to latex hypersensitivity.
The revised guidelines contain two tiers of precautions. The first and most importantare the Standard Precautions designed for the care of all patients in hospitals regardlessof their diagnosis or presumed infection status. Implementation of these standardprecautions is the primary strategy for successful nosocomial infection control. Standardprecautions synthesize the major features of Universal Precautions (Blood and Body Fluid)and Body Substance Isolation (designed to reduce the risk of transmission of pathogensfrom moist body substances).
Even with detailed guidelines, controls, and quality educational programs in place,managing cross-contamination and preventing infection in patients and healthcare workersdepends the employee's compliance with prevention practices. Healthcare workers mustunderstand the goals of infection control, the mechanisms of cross-contamination, andprevention protocols, but most important, employees must commit themselves to infectioncontrol practices. At the group level, active involvement and encouragement from key staffmembers may help to promote and sustain positive behavior.5 Coaching employeesdemonstrates respect for individuality and for the employee's desire to be supportive andis much more effective than using manipulative methods to promote compliance.6
When compliance is difficult or time-consuming, implementation is heavily influenced bythe healthcare worker's commitment to excellence. For example, the need for meticuloushandwashing occurs frequently in a normal workday and competes for time that healthcareworkers would prefer to devote to patient care. It is the integrity of the employee thatmotivates an individual to do what should be done instead of what's easiest todo--integrity and commitment promote the success of an infection control program.
For references, access the ICT Web site.
OSHA Definition: controls that reduce the likelihood of exposure by altering the manner in which a task is performed.
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:
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