By Mary Brachman, RN, MS, CIC
Theincreasing number of new and incurable diseases is altering the way healthcarefacilities address infection control. There's the assumption that everyone, fromthose who provide direct patient care to those who support patient careactivities, are potentially at risk of an occupationally acquired infection,such as hepatitis or HIV. While each healthcare worker (HCW) is responsible forremaining sensitive to the risk of occupational exposure and adhering toprevention measures, on-the-job training programs are critical to ensuringworkers have the knowledge and skills to protect themselves and others frominfection. Now, a new, technology-driven training method can help to ensureworkers' competence and meet the training standards set forth by theOccupational Safety and Health Administration (OSHA) and other organizations.
One area of particular importance is preventing transmission of bloodbornepathogens to HCWs.
The Changing Face of Occupational Risks
In terms of occupational exposure, the 1970s and early 1980s saw a largenumber of hepatitis B cases. This serious risk of infection confronted HCWs wellinto the 1980s, when a vaccine was developed, and is still a threat today forthose who are not vaccinated. Toward the end of the 1980s and into the early1990s, however, it was clear that another virus, HIV, would capture the medicalcommunity's--and the world's--attention.
The inherent risk to HCWs is continually evolving, as evidenced by thediscovery of the hepatitis C virus (HCV), which is found in the blood of personswho have this disease. HCV was discovered in 1988, but it wasn't new. It waspreviously known as non-A non-B hepatitis, which today causes 20% to 40% of allcases of acute hepatitis in the US.1
HCV is the most common bloodborne infection to create unrecoverable ailmentsin the US, making it a worthwhile case study in bloodborne pathogen controlefforts. Approximately 4 million Americans, or 2% of the population, areinfected with HCV. Another 35,000 Americans contract hepatitis C each year.2
Consequences of infection can include:
The Centers for Disease Control and Prevention (CDC) has acknowledged therisk posed by the spread of HCV, which occurs through exposure to an infectedperson's blood, and may take 20 to 30 years to show clinical signs of infectionin an individual.3
In addition to intravenous drug users, hemodialysis patients and transfusionrecipients, HCWs who have job duties with potential exposure to blood are at anincreased risk of acquiring hepatitis C. HCV has been spread from infectedpatients to HCWs from needlesticks and cuts from a sharp instrument. The risk ofacquiring HCV from a needlestick is approximately 2%, or 1 in 50 HCV positiveexposures, but in some studies has been reported as high as 7%.4-6Transmission of HCV from a blood splash to the eyes has also been described.7Persons who have had other types of hepatitis are not immune, either; they canstill acquire HCV.
There is nothing simple about HCV. What may be a serious threat for someindividuals is not serious for others. Often, persons with acute HCV have nosymptoms at the time of initial infection. Still, symptoms may appear months oryears later when chronic HCV develops. It's estimated that 75% to 85% of thosewho get HCV will become chronically infected, meaning they can carry the virusin their blood for the rest of their lives, and can spread the virus to others.1,3It is believed that 10% to 20% of people with chronic HCV will eventuallydevelop cirrhosis (scarring of the liver due to death of liver cells).3Persons with chronic HCV also have an increased risk of liver cancer.1,3
Unfortunately, there is no vaccine for HCV, and the vaccines for hepatitis Band hepatitis A do not provide immunity against hepatitis C. There are noeffective immunoglobulin preparations (e.g., immune serum globulin) togive after an occupational exposure to prevent HCV infection. Therefore, thebest protection is to prevent exposure to blood.
How this and other safety precautions are communicated to workers is up toeach healthcare facility. OSHA states, "The content of a company's trainingprogram and the methods of presentation should reflect the needs andcharacteristics of the particular workforce."8 Clearly, however,there are training programs that are much more effective than others.
Regulations and Accreditation Standards Aim to Improve Worker Training
OSHA, in response to occupational transmission of HIV to HCWs in the early1990s, created the Bloodborne Pathogen Standard. In it, OSHA cites specificrequirements of employee training, including what topics the training mustinclude, the frequency of training, who must be trained and the documentationrequirements.9 The standard, however, does not dictate the methods toaccomplish the training requirements.
Specifically, the Bloodborne Pathogen Standard states that the trainingprogram must contain minimum elements, such as "an explanation of the useand limitations of methods that will prevent or reduce exposure includingappropriate engineering controls, work practices, and personal protectiveequipment (PPE)," and "an explanation of the appropriate methods forrecognizing tasks and other activities that may involve exposure to blood andother potentially infectious materials." Training programs also mustinclude the epidemiology, symptoms, and transmission of bloodborne pathogens.The methods to prevent exposure include safe work practices, engineeringcontrols, and PPE. There must be an explanation of the facility's signs, labelsand/or color-coding used to alert HCWs to a potentially hazardous risk ofexposure. Training must also include what to do if an exposure occurs, theprocesses for medical evaluation, testing and treatment if appropriate, and anexplanation of the facility's exposure control plan, including how the HCW canaccess a written copy of the plan.
Recently the Bloodborne Pathogen Standard became more stringent followingapproval of the Needlestick Safety and Prevention Act. This new law directedOSHA to revise the Bloodborne Pathogen Standard to include additional rulesregarding the evaluation and use of needles and other sharps. The new provisionsare designed to reduce the number of needlestick and sharps related injuries andwent into effect in April 2001.10 It also serves as a reminder aboutthe importance of training healthcare workers to reduce injuries.
Training Through Technology
The medical industry has been at the forefront of technology for the purposesof patient care. Now, technology is able to assist the industry in efforts toeffectively and efficiently train its workers.
Well-designed training programs will meet the recommendations on bloodbornepathogens set forth by OSHA and other organizations, such as the CDC, whichrecommends "education of healthcare personnel about the risk for andprevention of bloodborne infections...with information routinely updated toensure accuracy."11
The CDC guidelines also state to "Provide educational informationappropriate, in content and vocabulary, to the educational level, literacy, andlanguage of the employee."
Regulatory agencies and accreditation standards look for training programsthat are appropriate to the individual and the setting, provided on a timelybasis, and updated when there are changes in practice or problems identified.And, they are looking for evidence that HCWs have demonstrated competency ininfection control practices, including bloodborne pathogen precautions.
Interactive technology-delivered learning (TDL) is an emerging tool to helpmanagers implement more effective training programs. Its advantages arenumerous, especially in the area of measuring workers' knowledge and documentingresults.
Technology-delivered learning, that is, job training that is taught through acomputer with on-screen words or phrases used in conjunction with audio andgraphics to explain and demonstrate concepts, has the ability to increaseworkers' job knowledge by offering familiar links between the content and how touse it on the job.
There are various forms of TDL with a wide range of capabilities that makethem useful in most training circumstances. Of particular importance is theability to measure workers' understanding of important infection controlconcepts, at the completion of training and over time. Probes throughout thetraining and reinforcement scenarios help the learner master the content. Posttests also reinforce learning and provide a tool for the trainer to know in whatareas, if any, further training is indicated. Some TDL systems are designed sothat the trainer can sort the posttest results by topic, department and even jobtitle, giving the trainer valuable information for assessing immediate andfuture learning needs.
Customizable TDL programs allow for variations in practices between andwithin facilities. For example, the specific control measures for antibioticresistant organisms and how to implement contact precautions in the ICU may bedifferent than in the outpatient clinic. Therefore, the ability to customize thecontent to the area and the worker's responsibility is critical to ensure thathealthcare workers receive information applicable to their work.
Other benefits of some TDL programs, such as those listed below, can berealized:
Methods for training HCWs are continually evolving. In going beyond previoustraining programs, TDL offers healthcare workers an interactive,at-your-own-pace, measurable way of learning information critical to a safeworking environment.
Mary Brachman, RN, MS, CIC is an IC consultant and certified infectioncontrol specialist with 18 years of experience.