Monday, October 28, 2013

Post-Exposure Follow-Up

Post-Exposure Follow-up

Potential Hazard
  • No post-exposure follow-up made available after a needlestick/sharps injury to help document injury or offer medically indicated post-exposure prophylaxis.
Possible Solutions
  • Employer should ensure that a Post-Exposure Evaluation and Follow-up is in place to handle needlestick/sharps injuries.
  • Employer should provide a confidential medical evaluation and follow-up to the exposed employee, immediately following the report of an exposure incident [29 CFR 1910.1030(f)(3)]. It is recommended that the follow-up include identifying injury patterns and accident analysis to determine if other training, procedures, or safer needle devices should be used to prevent future accidents.

    • Post-exposure evaluation and follow-up should include:

  • Maintain a log of injuries from contaminated sharps [29 CFR 1910.1030(h)(5)].

  • The National Institute for Occupational Safety and Health (NIOSH) recommends that if an employee experiences a needlestick/sharps injury or is exposed to blood or other body fluid during the course of work that the following steps be taken immediately:

    • Wash needlestick and cuts with soap and water.
    • Flush splashes to the nose, mouth, or skin with water.
    • Irrigate eyes with clean water, saline, or sterile irrigates.
    • Report the incident to your supervisor.
    • Seek medical treatment immediately.
  • Questions about appropriate medical treatment for occupational exposures to blood is available 24 hours from the Clinicians' Post Exposure Prophylaxis Hotline (PEPline) (1-888-448-4911).

Thursday, October 24, 2013

Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B & Hepatitis C

National Institute for Occupational Safety and Health (NIOSH) Workplace Safety and Health Topic

Exposures to blood and other body fluids occur across a wide variety of occupations. Health care workers, emergency response and public safety personnel, and other workers can be exposed to blood through needlestick and other sharps injuries, mucous membrane, and skin exposures. The pathogens of primary concern are the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Workers and employers are urged to take advantage of available engineering controls and work practices to prevent exposure to blood and other body fluids.

Universal Precautions for Preventing Transmission of Bloodborne Infections

 There are two tiers of Healthcare Infection Control Practices Advisory Committee (HICPAC)/CDC precautions to prevent transmission of infectious agents, Standard Precautions and Transmission-Based Precautions. Standard Precautions are intended to be applied to the care of all patients in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel. Transmission-Based Precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. Since the infecting agent often is not known at the time of admission to a healthcare facility, Transmission-Based Precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or a transmissible infectious etiology is ruled out. Examples of this syndromic approach are presented in Table 2. The HICPAC/CDC Guidelines also include recommendations for creating a Protective Environment for allogeneic HSCT patients.

The specific elements of Standard and Transmission-Based Precautions are discussed in Part II of this guideline. In Part III, the circumstances in which Standard Precautions, Transmission-Based Precautions, and a Protective Environment are applied are discussed. See Tables 4 and 5 for summaries of the key elements of these sets of precautions.

Standard Precautions

Standard Precautions combine the major features of Universal Precautions (UP) 780, 896 and Body Substance Isolation (BSI) 640 and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered (Table 4). These include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g. wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient).

The application of Standard Precautions during patient care is determined by the nature of the HCW-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g., performing venipuncture), only gloves may be needed; during other interactions (e.g., intubation), use of gloves, gown, and face shield or mask and goggles is necessary. Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence when HCWs are faced with new circumstances 655, 681-686. An example of the importance of the use of Standard Precautions is intubation, especially under emergency circumstances when infectious agents may not be suspected, but later are identified (e.g., SARS-CoV, N. meningitides). The application of Standard Precautions is described below and summarized in Table 4. Guidance on donning and removing gloves, gowns and other PPE is presented in the Figure. Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands or via equipment used during patient care.

Friday, October 18, 2013

Hazard Recognition

The CDC estimates that 5.6 million workers in the health care industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. All occupational exposure to blood or other potentially infectious materials (OPIM) place workers at risk for infection with bloodborne pathogens. OSHA defines blood to mean human blood, human blood components, and products made from human blood. Other potentially infectious materials (OPIM) means: (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. The following references aid in recognizing workplace hazards associated with bloodborne pathogens.

Bloodborne Pathogens Standard

As mandated by the Needlestick Safety and Prevention Act, OSHA revised the Bloodborne Pathogens Standard [29 CFR 1910.1030], effective April 18, 2001. Definitions for bloodborne pathogens, other potentially infectious materials (OPIM), and occupational exposure are found in 29 CFR 1910.1030(b).

Potential Hazard
  • Employee exposure to blood and OPIM [29 CFR 1910.1030(b)] due to ineffective Exposure Control Plan (ECP).
Possible Solutions
  • Identify employees who have occupational exposure to blood or OPIM [29 CFR 1910.1030(b)], and then establish and implement a written Exposure Control Plan (ECP), designed to eliminate or minimize employee exposure [29 CFR 1910.1030(c)(1)].

  • Exposure Control Plan requirements include:
    • Documenting an annual review and update of the written plan that reflects changes in technology for safer medical devices. [29 CFR 1910.1030(c)(1)(iv)(A)] Employers must also document consideration and implementation of the safer medical devices annually. [29 CFR 1910.1030(c)(1)(iv)(B)]

    • Employer must get input for the devices from those responsible for direct patient care. [29 CFR 1910.1030(c)(1)(v)] This input must also be documented.
  • Employer should ensure that the Exposure Control Plan (ECP) is accessible to all employees. [29 CFR 1910.1030(c)(1)(iii)] They should also review and update it at least yearly. [29 CFR 1910.1030(c)(1)(iv)]

  • Employer should ensure that employees with occupational exposure to bloodborne pathogens receive appropriate training, at no cost to employee, and during working hours. [29 CFR 1910.1030(g)(2)(i) and 29 CFR 1910.1030(g)(2)(vii)]

Friday, October 11, 2013

Quick Reference Guide Part 3

  • Does the revised Bloodborne Pathogens standard apply to medical or dental offices that have fewer than 10 employees?

    OSHA's Bloodborne Pathogens standard applies to all employers with employees who have occupational exposure to blood or other potentially infectious materials (OPIM), regardless of how many workers are employed. However, the offices and clinics of medical doctors and dentists are exempt from the requirement to keep a log of occupational injuries and illnesses and thus exempt from maintaining a sharps injury log. (See Appendix A to Subpart B of 29 CFR Part 1904.) All other applicable provisions of the Bloodborne Pathogens standard still apply.

  • What information do I need to include in my written Exposure Control Plan (ECP)? How often do I need to update it?

    The required elements of an ECP are:
    • The exposure determination which identifies job classifications with occupational exposure and tasks and procedures where there is occupational exposure and that are performed by employees in job classifications in which some employees have occupational exposure;
    • The procedures for evaluating the circumstances surrounding exposure incidents;
    • A schedule of how other provisions of the standard are implemented, including methods of compliance, HIV and HBV research laboratories and production facilities requirements, hepatitis B vaccination and post-exposure evaluation and follow-up, communication of hazards to employees, and recordkeeping;
      Methods of compliance include:
      • Universal Precautions;
      • Engineering and work practice controls, e.g., safer medical devices, sharps disposal containers, hand hygiene;
      • Personal protective equipment;
      • Housekeeping, including decontamination procedures and removal of regulated waste.

    • Documentation of:
      • the annual consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure, and
      • the solicitation of non-managerial healthcare workers (who are responsible for direct patient care and are potentially exposed to injuries from contaminated sharps) in the identification, evaluation, and selection of effective engineering and work practice controls.

    The ECP must be reviewed and updated at least annually, and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

  • Are employers responsible for providing sharps containers for employees who are diabetic and need insulin shots in a non-healthcare related facility?

  • The employer would not be required to provide a sharps container to an employee using insulin syringes for personal therapeutic reasons. To eliminate potential exposures to other workers, however, the employer could require that the employee provide his or her own workplace sharps container.

  • What does OSHA currently accept as "appropriate" disinfectants to prevent the spread of HIV and HBV

    OSHA's position is that EPA-registered tuberculocidal disinfectants, diluted bleach solutions and EPA-registered disinfectants that are labeled as effective against both HIV and HBV as well as Sterilants/High-Level Disinfectants cleared by the FDA, meet the requirement in the standard and are "appropriate" disinfectants to clean contaminated surfaces, provided that such surfaces have not become contaminated with agent(s) or volumes of or concentrations of agent(s) for which higher level disinfection is recommended.

    It is important to emphasize the EPA-approved label section titled "SPECIAL INSTRUCTIONS FOR CLEANING AND DECONTAMINATION AGAINST HIV-1 AND HBV OF SURFACES\OBJECTS SOILED WITH BLOOD\BODY FLUIDS." These instructions require:

    • that personal protective equipment be provided for the worker performing the task;
    • that all the blood must be cleaned up thoroughly before applying the disinfectant;
    • that the disposal of the infectious waste be in accordance with federal, state, or local regulations; and
    • that the surface be left wet with the disinfectant for 30 seconds for HIV-1 and for 10 minutes for HBV.

  • Is a Hepatitis B (HBV) post-vaccination titer required?

    29 CFR 1910.1030(f)(1)(ii)(D) takes into consideration the changing nature of medical treatment relating to hepatitis B. OSHA requires use of the U.S. Public Health Service (USPHS) guidelines current at the time of the evaluation or procedure. The most current guidelines regarding hepatitis B is the Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis in MMWR, Vol. 50, No.11, June 29, 2001. The hepatitis B vaccination must be given in the standard dose and through the standard route of administration, as recommended in the guidelines. Employees who have ongoing contact with patients or blood and are at ongoing risk for percutaneous injuries must be tested for antibody to hepatitis B surface antigen, one to two months after the completion of the three-dose vaccination series. Employees who do not respond to the primary vaccination series must be revaccinated with a second three-dose vaccine series and retested. Non-responders to the second series must be medically evaluated.

  • Are workers who administer the vaccines in emergency situations (e.g., in a pandemic response) covered by the Bloodborne Pathogens standard

    The Bloodborne Pathogens standard covers all workers in the private sector as well as civilian employees of federal entities. State and local government employees are covered if they are in one of the 25 states and two territories that operate their own OSHA-approved state plans. In the remaining jurisdictions, where Federal OSHA has authority, hospitals operated by state, territorial or local governments are required to provide the protection of the Bloodborne Pathogens standard to their employees with enforcement by the Centers for Medicare and Medicaid Services (42 U.S.C. 1395cc(a)(1)(V) and (b)(4)).

    Additionally, the CDC recommends that all vaccination clinics comply with the Bloodborne Pathogens standard's provisions.

  • Where can I get information about what is expected of me?

    There are several resources available for employers and employees with regard to occupational exposures to blood and OPIM. First is the OSHA Bloodborne Pathogens standard (29 CFR 1910.1030). Also available are CPL 2-2.69 (November 2001) Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens, and many other related documents. This information can be found on OSHA's Bloodborne Pathogens and Needlestick Prevention Web Page. You may access additional information, such as information from OSHA's Consultation and State Plan State Offices, via OSHA's website or by phone at 1-800-321-OSHA (6742). CDC and the National Institute for Occupational Safety and Health (NIOSH), a CDC agency, also have documents related to the prevention of occupational exposure to blood and OPIM available.

Monday, October 7, 2013

Quick Reference Guide Part 2

  1. Do the Bloodborne Pathogens standard and the Needlestick Safety and Prevention Act apply to me?

    OSHA's Bloodborne Pathogens standard, including its 2001 revisions, applies to all employers who have an employee(s) with occupational exposure (i.e., reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (OPIM) that may result from the performance of the employee's duties). These employers must implement the requirements set forth in the standard. Some of the new and clarified provisions in the standard apply only to healthcare settings, but other provisions, particularly the requirements to update the Exposure Control Plan and to keep a sharps injury log, apply to non-healthcare as well as healthcare settings.

  2. What does the standard say about the use of safer medical devices?

    The standard states, "engineering and work practice controls shall be used to eliminate or minimize employee exposure." The 2001 revision defines engineering controls as "controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace." Employers who have employees exposed to contaminated sharps must consider and implement appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure. Also, employees with occupational exposure must be trained in the use and limitations of methods that will prevent or reduce exposure, including appropriate engineering controls, work practices and personal protective equipment. Therefore, training must include instruction on any new techniques and practices associated with new engineering controls.

  3. If I've never had an employee experience a needlestick, do I still need to use safer devices?

    Yes. OSHA standards are intended to be implemented as a means to prevent occupational injuries and illnesses. To most effectively avoid percutaneous injuries from contaminated sharps, employers must implement engineering controls, including safer medical devices, so that employees have them available to use.

  4. How many non-managerial employees do I need to include in the process of choosing safer medical devices?

    Small medical offices may want to seek input from all occupationally exposed employees when making their decisions. Larger facilities are not required to request input from all exposed employees; however, the employees selected should represent the range of exposure situations encountered in the workplace (e.g., pediatrics, emergency department, etc.). Regardless of the number chosen, in order to be included in the process the workers must be responsible for direct patient care and be potentially exposed to injuries from contaminated sharps. The solicitation of employees who have been involved in the input and evaluation process must be documented in the Exposure Control Plan.

  5. Does OSHA have a list of available safer medical devices?

    No. OSHA does not approve or endorse any product. It is the employer's responsibility to identify and implement appropriate, commercially available and effective safer medical devices for the specific medical procedures being conducted.

  6. What if a safer option is not available for the medical device that I use?

    A key element in choosing a safer medical device, other than its appropriateness to the procedure and its effectiveness, is its availability on the market. If there is no safer option to the medical device that you are using for a particular procedure, you are not required to adopt a device different from the one currently being used. During your annual review of devices, you must consider new or prospective safer options and document this fact in your written Exposure Control Plan. With advances in medical technology, more devices are becoming available for different procedures. If no engineering control is available, work practice controls shall be used and, if occupational exposure still remains, personal protective equipment must also be used.

  7. Do I have to keep a sharps injury log? Does it have to be confidential?

    If, as an employer, you are required to maintain a log of occupational injuries and illnesses under 29 CFR Part 1904, you must also establish and maintain a sharps injury log for recording percutaneous injuries from contaminated sharps. The sharps injury log must contain, at a minimum, the type and brand of device involved in the injury (if known), the department or work area where the exposure incident occurred, and an explanation of how the incident occurred. The log must be recorded and maintained in a manner that protects the confidentiality of the injured worker (e.g., removal of personal identifiers).