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Fluid management and disposal in the operating room (OR) can get messy especially during orthopedic and neurological surgery but fortunately, a myriad of options exists for getting rid of fluid efficiently and thereby reducing exposure to infection.
The topic could scarcely be more important, according to the Association of Occupational Health Professionals in Healthcare (AOHP). The group surveyed members about what the most important public policy issues are for their 2007- 09 agenda and consequently rated exposure to bloodborne pathogens in the top three. AOHP will be addressing this issue in a partnership with the Occupational Safety & Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH).Â²Â
Members of AOHP advocate that a healthcare worker (HCW) who has been exposed to an infectious bodily fluid should receive an HIV test as quickly as possible, in order to shorten the time that HIV anti-viral prophylaxis is needed, and to reduce anxiety levels of the HCW.Â² Fortunately, if the right precautions are taken, these tests are not necessary.
The term bloodborne pathogens refers to potentially infectious pathogenic microorganisms that are in blood or other bodily fluids. In the OR, any and all fluid that comes into bodily contact is considered by OSHA to be a potential bloodborne pathogen.Â¹ According to OSHAs bloodborne pathogens standard, possibly infectious materials include all body fluids in situations where it is difficult or impossible to differentiate between body fluids, as well as:
The document also states that eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure, to the aforementioned fluids.Â¹ Due to splashes and other hazards, HCWs are at risk of exposure to blood and body fluids (BBF), and therefore to human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV), according to research from the Duke Health and Safety Surveillance System.
The Duke research team monitored 24,425 HCWs who had the possibility of coming into contact with BBF between 1998-2002. During that time span, the study population reported 2,730 BBF exposures.7
Much higher rates were observed for house staff, nurse anesthetists, inpatient nurses, phlebotomists, and surgical/operating room technicians, according to the study. While continued training efforts need to be directed toward new HCWs, our data also suggest that employees who have been in their job one to four years continue to be at higher risk of BBF exposures.
One integral way to reduce staff exposure to infectious fluids is to maintain well-stocked spill kits, and to put them in as many places as possible, says Theresa Farley, RN, director of the North Tower OR at William Beaumont Hospital in Michigan. The kits are very important, Farley says. There are very easy steps to follow, and everyone must be trained.
Properly educating employees can require persistence.
Culture change takes time, Farley claims. Wearing eye protection was a fight with some people and I could never understand why anyone would want to expose themselves like that people get used to doing things a certain way. You have to change that and you have to be vigilant about making rounds and doing quality assurance audits.
Everyone has to be trained, but the level of training should depend on what exposure the HCW is likely to have to infectious fluids, Farley adds. Her facility checks up on staff often and consistently to make certain that members know how to use spill kits properly.
Dozens, if not hundreds, of spill kits are on the market. In general, bodily fluid spill kits that meet federal OSHA recommendations include items such as fluid solidifier, disposable gloves, gowns and other items of personal protective equipment (PPE), disposable towels, germicidal wipes, biohazard bags, and a guide to cleaning bodily fluid spills.
General OSHA education guidelines state that training sessions should be during the employees work shift, take place at least once per year, cover the modes of bloodborne pathogen transmission and include information about the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.
Employees should also be aware of what protocol they should follow in the case of exposure (who to contact, what to do), and should receive a follow up evaluation after any potentially dangerous exposure.
Since technology generally improves over time, OSHAs revised exposure control plan states that, Employers must implement the safer medical devices that are appropriate, commercially available, and effective and document consideration and implementation of safer medical devices annually.
The plan adds that employers should solicit product and systems input from HCWs who are directly responsible for patient care, and that the input should be documented.4
Personal Protective Equipment
Personal protective equipment, of course, is the most important precaution a HCW can take against exposure to bloodborne pathogens. According to OSHAs bloodborne pathogens standard, staff should don disposable gloves, gowns, aprons and a choice of eyewear (with solid side shields) or chin-length face mask any time that splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.
The type and characteristics (of PPE) will depend upon the task and degree of exposure anticipated, the document continues. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated.Â¹
To Solidify or Not to Solidify?
Some experts believe that solidifying fluids reduces HCWs exposure to bloodborne pathogens, and makes the materials easier to transport. Solidifiers work in different ways, and have varying results, says Kathy Feuerman, general manager of Colby Manufacturing. Colbys products contain and control fluid in the OR. One product is a solidifier called Virasorb and is extremely helpful, Feuerman says.
The likelihood that your canister is going to fall and break is not so much, but if it does, what are you going to do about that fluid? Feuerman asks. According to her, infectious fluid that is contained in a solid state is easier to handle than when it is in liquid form.
(Virasorb creates a substance) thats more like Jell-O which is wobbly and gelatinous as opposed to (other) solidifiers that solidify more like snow cones, like little encapsulated beads, Feuerman contends. They sort of scatter all over the floor and are slippery. Virasorb, though wobbly and a little oozy, at least stays in one place Solidified products stick to the inside of the canister when the canister is turned upside down and if by chance the product is disgorged from the canister it will hold together in big clumps.
Another manufacturer, Multisorb Technologies, produces the SaniSorb medical liquid solidifier which is used on suction canister waste. The product is a pre-measured pouch (of varying sizes) that is put into containers and bursts upon contact with fluids. The fluid congeals into a gelatinous state, and, according to manufacturers, becomes nearly or completely odorless.
Multisorb representatives state that SaniSorb greatly reduces the amount of common bacterial and infectious diseases in the matter. Sanisorb is both simple and high tech at the same time, says Russell DAnna, who helped develop the pouch. He serves as business development leader for MultiSorb.
One version of Sanisorb includes polymer while the other includes polymer and a disinfectant.
The Japanese developed a water soluble paper in WWII and we actually use a very similar paper thats coated on one side with an adhesive, DAnna says. We create a pouch and fill it with this super absorbent polymer powder. You seal it up and you have a pouch, and when it comes in contact in fluid, the fluid will penetrate the pores the little tiny openings in the paper and it gets to the polymer and causes it to swell up and makes the paper rupture, and then the paper dissolves. The product has been available since the mid nineties. Its pretty easy just to add the pouch in at the end of the procedure, DAnna says. Its very convenient.
Metrex offers solidification products and a closed delivery system which eliminates potentially hazardous cross contamination, safely and simply, according to product manufacturers. The (PremiCideÂ®) PremiGuard Cap is a patented product that solidifies and sanitizes in one process (and) the closed delivery system prevents potential splashing, spilling and aerosolization of infectious liquid medical waste.6
Lots of fluid management products are available, and healthcare facilities in general are open to the changes, says Jack McGurk, MPA, president of healthcare consulting firm Systems Improvement Initiators, Inc. (SI3) and past president of the California Environmental Health Association. Hospitals are constantly looking at new products, McGurk says. Theyre evaluating and theyve got to have a material safety data sheet for every product, so I think theres a lot of diligence that takes place in hospitals from the way fluid is handled all the way to how the floors are cleaned.
Speaking of floors, fluid should never be allowed to pool there for more than a few seconds, according to Feuerman.
You treat all this contaminated fluid as if it contained the most dangerous of all potentially infectious agents, so you dont want anyone coming into contact with it anywhere, Feuerman says. The likelihood of fluid on the floor actually coming into contact with some other patient is slim to less, but nonetheless, its for the protection not only of the patient and the HCW, but also of cleaning staff.
The body leaks around the instrumentation and its not always clear where the fluids are going to go, she adds. These are very wet procedures and in some way or another fluids are going to get on the floor.
Products that address this problem include absorbent floor pads that are rolled up, thrown away, and incinerated after use. They can be squishy under foot but are certainly preferable to linen, which some facilities still use, Feuerman says.
The problem with linen is the associated handling costs, she shares. People think, Well, well just throw down a sheet or a towel and that doesnt cost us anything, but there is a cost associated with handling contaminated laundry and then theres the yuck factor because that sheet could end up on someones bed the next day (after being washed).Â
Other products include discs such as Colbys 9-inch diameter WaterBug, which glides over the floor, suctions fluid directly and disposes of it through an attached tube. Similar stationary products also aim to keep OR rooms dry and safe. Colbys WaterBoom is a 32-inch strip that holds 12 feet of flexible suction tubing. The WaterBoom can be stepped on rolled over and will still suction effectively, according to Feuerman.
In many parts of the world HCWs still dont accept that OR rooms should not allow fluids to pool, but in the U.S. there has been a steady welcoming of fluid containment practices over the years, according to Feuerman. Facilities are absolutely getting better, she says. Domestically, its rare anymore that we come across anyone who hasnt bought in to the concept.
Feuerman claims that her companys products and some others are very simple, but very effective.
There are so many areas of healthcare that have increased in costs and new, better technology is constantly evolving, but sometimes its these tried and true things, these low-tech things, that meet the need in the most cost effective manner, she says.
According to DAnna, the most competitive products right now are wall units. You hook it up to the electrical lines inside the OR unit and it treats the waste and puts it down the drain, he says. The downside? They can cost around $30,000, according to DAnna. If its a high volume type of hospital where a lot of surgical procedures are preformed, then it may be an option, he adds.
Such products have been a staple for Dornoch Medical Systems. Dornochs fluid collection and disposal products were developed by inventor and 20-year OR veteran, Jim Dunn, RN. They include the high fluid cart and the safety station, which together form Dornochs suction canister waste management Transposal System.
The high-fluid cart which works by itself, or with the safety system uses wall suction to collect 48 liters of surgical fluid in one or two reservoirs. The cart is hooked to a vacuum source and can connect with up to four different targets, each of which can be adjusted for high or low suction.5
After surgery, a HCW wheels the high-fluid cart to Dornochs evac unit which empties, cleans and disinfects the cart with the help of plugs, sensor lines, hot water, and bleach. The cleansing process takes about three-and-a-half minutes. For smaller spaces, a 24-liter reservoir cart is available.5
As for the safety station, it should be set up as close to the OR or decontamination room as possible. It works as follows: a HCW brings filled canisters to the decontamination room, places one or two sealed canisters in the safety station, closes the safety station lid and presses start.
The machine removes the canister lids, empties the containers, cleans and disinfects them via spray heads, hot water and an enzyme solution, and later disinfects with a solution of cold water and household bleach. Then canisters are rinsed again in cold water.
The safety station can use 1800cc disposable canisters, or 2800cc reusable canisters. Lids for each are disposable.5 Reusing fluid collectors can cut down on OR infectious waste by up to 70 percent, Donoch representatives say.
Equipment of this nature is initially expensive but since the canisters are reusable, there can be cost savings over time, according to McGurk.
More Than One Right Way
Overall, hospitals and other healthcare facilities are getting increasingly vigilant when it comes to fluid containment, and protecting HCWs, McGurk says, and ultimately, there are many good ways to make this happen. In his opinion, a tip for facilities that pour bodily fluids down the drain is to outfit the sinks with splashguards to protect HCWs.
Farleys staff members have given a lot of thought to the issue of proper fluid management, and have settled on a system that at least for the time being seems to be their best option. We do not use solidifiers, Farley reports. Ive talked to a couple places some were happy and some werent so Beaumont has never tried a solidifier here. The facilitys team chose a suction canister system instead.
At Beaumont, HCWs used to dump (the fluids) down the hopper, Farley says, but now their protocol is to the remove the (suction) canister, obviously with gloves and eye protection on at the end of the case, take the canister out, put it on the case cart, take it around to soiled utility and it does go into our biohazard bin full that way. We do not dump it out, she says.
The main reason for this system is to reduce exposure to the fluids, particularly in the form of splashes that can occur when liquid is poured. Farley and her team have tried some free fluid management product samples and are not against the idea of experimenting more with solidifiers or other products.
If we thought there was something out there that would be an improvement, of course we would try it, but Im not aware of any, Farley says. Her staff is trained on how to properly close the tops of canisters. Shes never seen one break or leak.
Theyre very sturdy, she says.
Years back, Beaumont experimented with a wall unit that had a wand attached. It drained fluid into a big container Farley says, but when the machine occasionally went on the fritz, it required staff members to determine contingency plans on the fly. Farley is confident, however, that the technology must be better now.
Fluid is usually not a big problem for Farley and her colleagues, but when liquid does make it past the suction canister and onto the floor, the Beaumont staff members use a simple solution.
During the case theyll place a towel on it so that people dont slip on it, Farley says. The towel goes into a soiled linen hamper, down the linen shoot, and all that is treated as contaminated. We do every single case like its an infected case, and every room gets cleaned that way Every single linen is washed the same way, it doesnt matter where its been.
If the prepping fluid contains a lot of blood, the staff puts down a bleach solution during the surgery. The process usually goes smoothly but can be a little chaotic every once in a while, according to Farley.
Cleaning and Disposal
According to OSHAs bloodborne pathogens standard, Employers shall ensure that the worksite is maintained in a clean and sanitary condition. The employer shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area. All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials shall be inspected and decontaminated on a regularly-scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination, the document continues.
Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the workshift if they may have become contaminated during the shift, the document continues. Broken glassware which may be contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps.Â¹Â
Fluids should be treated with utmost caution, but that doesnt mean that staff should throw anything and everything thats damp or wet into red bags, according to Hospitals for a Healthy Environment (H2E). H2E representatives claim that waste which is soaked in urine, feces or vomit should be considered clear bag waste, as should blood tainted waste (for example, gauze that has a bit of blood on it).
The following should always be considered red bag waste:
1. OSHAs bloodborne pathogen standard: www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051Â Â
2. Association of Occupational Health Professionals in Healthcare, www.aohp.orgÂ
3. Health Care Without Harm, hospital red bag waste reduction initiative. www.h2e-online.orgÂ
4. OSHAs technical background and summary of bloodborne pathogen standard: www.osha.gov/needlesticks/needlefact.htmlÂ
5. Dornoch Medical Systems website, www.dornoch.com/product.htmlÂ
6. Metrex website: www.metrex.com/index/metrexÂ
7. Dement JM. Blood and body fluid exposure risks among health care workers: results from the Duke Health and Safety Surveillance System. American Journal of Industrial Medicine. December 2004.