LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Discuss New York State's requirements for infection control training.
• Spell out professional responsibilities for monitoring infection control practices and interventions for compliance and safety.
• Explain the chain of infection and describe the way infection control concepts are applied.
• Define engineering controls, work practice controls, and environmental controls and give examples.
• Identify barriers and personal protective equipment (PPE) for protection from exposure to potentially infectious material.
• Explain the importance of reprocessing methods (cleaning, disinfection, and sterilization) to ensure the safety and integrity of patient-care equipment.
• Identify occupational health strategies for preventing the transmission of bloodborne pathogens and other communicable diseases through healthcare workers.

Preventing the spread of infection and communicable disease has been a key component of healthcare since the work of Semmelweiss in the 1840s. Infection control is a critical concern for clients, healthcare workers, facility administrators, and government agencies. Infection control measures are designed to combat everything from the spread of colds and flu to hepatitis B and C, SARS, HIV/AIDS, and other potentially life threatening diseases.

In 1999 the patient safety movement began with the publication of To Err Is Human by the Institute of Medicine. This brought much-needed attention to the problem of medical errors and healthcare-associated infections (HAIs, formerly called nosocomial infections). The CDC estimates that 88,000 Americans per year may die of HAIs.

Since September 11, 2001, the threat of bioterrorism has heightened awareness of infection control. In 2003 the epidemic of severe adult respiratory syndrome (SARS) focused global attention on the need for infection control.

Currently, methicillin-resistant Stapholococcus aureus (MRSA) is the subject of attention as its transmission becomes a wider problem both inside the healthcare system and in the community.

We do not know what challenges of infection prevention the future may bring, but the principles of preventing transmission of infection are likely to remain unchanged.

INFECTION CONTROL TRAINING

New York State Requirements

Since 1994 healthcare workers licensed, registered, or certified in New York State have been required to receive training on infection control and barrier precautions every four years unless otherwise exempted. This requirement was established in 1992 by Chapter 786 of the Laws of 1992, and amended in 2008.

New York requires the following professionals to get infection control training every four years:

• Dental Hygienists
• Dentists
• Licensed Practical Nurses
• Optometrists
• Physicians
• Physician Assistants
• Podiatrists
• Registered Professional Nurses
• Specialist Assistants
• Medical Residents
• Medical Students
• Physician Assistant Students
• Specialist Assistant Students

Physicians, physician assistants (PAs), and specialist assistants (SAs) must submit documentation of course completion to the Department of Health (DOH). However, individuals holding privileges, or affiliated with, or employed by, DOH-regulated healthcare facilities, including home healthcare agencies, need not submit documentation of course completion to the department. The following paragraphs are taken directly from the regulations of New York State.

All DOH-regulated healthcare facilities, including home healthcare agencies, must maintain documentation in credentialing or employment files of such infection control training and education of physicians, PAs, and SAs (Subpart 92-1.8, Title 10 [Health] of the Official Compilation of Codes, Rules and Regulations of New York). Exemptions from such training may be granted by the DOH to physicians, PAs, and SAs when the professional demonstrates to the department's satisfaction that:

• No need exists to complete the course work or training due to the nature of his/her practice, or
• He or she has completed equivalent course work of training.
• Health professionals work in settings where they
  • do not provide direct patient care
  • do not have responsibility for supervising staff who provide direct patient care or reprocess used patient care equipment, or
  • do not perform services to which these standards would be expected to apply.
• When the professional does not practice in New York State.

Those exempted from training due to nature of practice are required to reapply for their exemption every four years.

A physician, PA, or SA who has been granted an exemption must notify the department in writing of any change in the nature of his or her practice within 30 days of the occurrence of such change. The physician, PA, or SA must then obtain necessary course work or training within 90 days of the change in practice (Subpart 92-1.9, Title 10 [Health] of the Official Compilation of Codes, Rules and Regulations of New York).

Equivalent training or course work is that training or coursework that covers concepts of disease transmission, scientifically accepted principles and practices for infection control, and engineering and work practice control as detailed in the syllabus. Equivalent course work or training must emphasize the bidirectional aspect of disease transmission—that is, patient to healthcare worker and vice versa (Subpart 92-1.10, Title 10 [Health] of the Official Compilation of Codes, Rules and Regulations of New York).

Training Goals

The goals of infection control training are to:

• Ensure that health professionals understand how bloodborne and other pathogens can be transmitted in the work environment: patient to healthcare worker, healthcare worker to patient, and patient to patient.
• Apply current scientifically accepted infection control principles as appropriate for the specific work environment.
• Minimize opportunity for transmission of pathogens to patients and healthcare workers.
• Familiarize professionals with the law requiring this training and the professional misconduct charges that may result from failure to comply with the law.

This course explores the six core elements of infection control in depth.

INFECTION CONTROL PRINCIPLES AND PRACTICES

Approximately 1.7 million hospital patients each year get an infection while being treated for another illness or injury and almost 99,000 of them die as a direct or indirect cause of their infection. (Klevens, 2007). Healthcare-associated infections (HAIs) not only inflict suffering and death but also cost the United States almost $5 billion each year due to the extra days or weeks of hospitalization needed to treat the infection (McKibben, 2005).

Patients in nursing homes and in home care are also at risk for developing HAIs, particularly if they have invasive medical devices such as urinary catheters or central venous catheters. Nearly 1 million infections occur annually in nursing homes (CDC 2008).

Acute infections account for 27% of transfers of nursing home residents to hospitals (Longo et al., 2002) and complications of infections and their treatment can lead to functional decline among nursing home residents. Infection control programs have helped reduce the human and economic toll associated with infections. According to the CDC, HAIs in hospitals that report their findings to the CDC declined 30% between 1990 and 2000 (CDC, 2000).

The New York State Education Department Rules of the Board of Regents, Section 29.2(a) (13), states that unprofessional conduct should include failing to use scientifically accepted infection prevention techniques appropriate to each profession for the cleaning and sterilization or disinfection of instruments, devices, materials, and work surfaces, utilization of protective garb, use of covers for contamination-prone equipment, and the handling of sharp instruments. Such techniques shall include but not be limited to the following:

1. Wearing of appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, nonintact skin, blood-soiled items or bodily fluid–soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and decontamination procedures;
2. Discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient and washing hands prior to performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids;
3. Wearing of appropriate masks, gowns or aprons, and protective eyewear or chin-length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur;
4. Sterilizing equipment and devices that enter the patient's vascular system or other normally sterile areas of the body;
5. Sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient's body, or using high-level disinfection for equipment and devices that cannot be sterilized prior to use for a patient;
6. Using appropriate agents, including but not limited to detergents for cleaning all equipment and devices prior to sterilization or disinfection;
7. Cleaning, by use of appropriate agents, including but not limited to detergents, equipment and devices that do not touch the patient or that only touch the intact skin of the patient;
8. Maintaining equipment and devices used for sterilization according to the manufacturer's instructions;
9. Adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques;
10. Placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers until appropriately cleaned and sterilized;
11. Maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation;
12. Refraining from all direct patient care and handling of patient care equipment when the healthcare professional has exudative lesions or weeping dermatitis and the condition has not been medically evaluated and determined to be safe, or capable of being safely protected against, in providing direct patient care or in handling patient care equipment;
13. Placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking; and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide.

Failing to use these techniques not only jeopardizes the health and safety of patients and other healthcare colleagues but also constitutes unprofessional conduct in the professions of medicine, acupuncture, physical therapy, physician assistant, specialist assistant, chiropractic, dentistry, dental hygiene, pharmacy, podiatry, optometry, ophthalmic dispensing, psychology, social work, massage, occupational therapy, speech pathology, audiology, nursing (registered professional nurse, licensed practical nurse).

Any licensed healthcare professional who fails to use appropriate infection control techniques to protect patients or fails to ensure that healthcare workers under his or her supervision do so may be subject to charges of professional misconduct. Substantiation of professional misconduct charges can result in disciplinary action, revocation of professional license, and/or professional liability.

Any patient or employee complaint regarding lax infection control practices in a private medical or dental office will prompt an investigation by the departments of health and/or education. Substantiated lapses in infection control in a private practice setting may result in charges of professional misconduct against any licensed professional in the practice who was directly involved, was aware of the violation, or had responsibility for ensuring that the office staff were adequately trained and following patient protection measures.

Health professionals are responsible for monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques (Part 92, Subchapter N of Title 10 of the Official Compilation of Codes, Rules and Regulations of the State of New York).

New York State law mandates that all hospitals:

• Train their staff in infection control techniques
• Provide appropriate protective equipment and safety devices
• Enforce use of universal barrier precautions in situations involving potential exposure to blood or other body fluids.

All licensed healthcare facilities are responsible for monitoring and enforcing proper use of infection control practices and Standard Precautions by healthcare personnel functioning under their jurisdiction. Failure to comply with this requirement will result in a DOH citation, potential fines, and other disciplinary action against the institution.

PREVENTING INFECTION

The Chain of Infection

The spread of infection is best described as a chain with six links:

1. A pathogen or causative (infectious) agent
2. The reservoir
3. A portal of exit from the reservoir
4. A mode of transmission
5. A portal of entry into a host
6. A susceptible host

If you can break any link of the chain of infection, you can prevent the occurrence of new infection. Infection control measures are designed to break the links and thereby prevent new infection. The chain of infection is the foundation of infection prevention, so we will look at each link and at actions we take to break it.

CAUSATIVE AGENTS

Bacteria, viruses, fungi and protozoa ("germs") are very common in the environment, and most of them are beneficial to people. Creating an environment with no organisms is not a realistic goal outside of highly specialized laboratories.

Bacteria are single-celled organisms, some of which can cause disease. We all live with numerous bacteria—referred to as our "normal flora" or "resident bacteria"—which usually do not cause disease unless their balance is disturbed. Most bacteria require an infectious dose to cause disease; that is, it usually takes thousands to cause disease, not just one or two. Bacteria vary in infectivity (how easy they are to catch) and virulence (the level of danger from the infection they cause).

Viruses are intracellular parasites, meaning they can only reproduce inside a living cell. Viruses such as HIV/AIDS and hepatitis B and C have the ability to enter and survive in the body for years before symptoms of disease occur. Other viruses, such as the influenza viruses, quickly announce their presence through characteristic symptoms.

Fungi are prevalent throughout the world but only a few cause disease in humans, and most of them commonly affect the skin, nails, and subcutaneous tissue. Candida is a fungus that causes yeast infections. These infections can be life-threatening in critically ill patients. Fungi such as Pneumocystis carinii can be life-threatening to the person with HIV/AIDS.

Prions are a form of infectious protein believed to be the cause of Creutzfeldt-Jakob disease (CJD).

Protozoa are single- or multi-celled microorganisms that are larger than bacteria. Examples of disease-causing protozoa include amoebas and giardia, which cause diarrhea, and plasmodium species, the cause of malaria. They may be transmitted via direct or indirect contact or an arthropod vector (an infected carrier) such as a mosquito.

Parasites are larger organisms that can infect or infest people. Infestation with arthropods, such as lice and scabies, occurs by direct contact with the arthropod or its eggs. Helminths include roundworms, tapeworms, and flukes. They infect humans principally through ingestion of fertilized eggs or when the larvae penetrate the skin or mucous membranes.

We eliminate the causative organism by several methods, including:

• Sterilizing surgical instruments and anything that touches sterile spaces of the body
• Using good food safety methods
• Providing safe drinking water
• Vaccinating people so they do not become reservoirs of illness
• Treating people who are ill

RESERVOIRS

Like other organisms, germs require water to grow and reproduce, so reservoirs are commonly wet. In general, if an area is wet it is probably a reservoir unless something specific has been done to prevent bacterial growth. The bacteria may not be pathogens. Sometimes the reservoir contains our own normal flora; that is, we get our own germs in the wrong place.

In some cases the environment can serve as the reservoir. For example, water supplies may carry Legionella spp. Inadequate air exchange can allow pathogens such as Mycobacterium tuberculosis and varicella-zoster virus to contaminate air supplies. Appropriate environmental infection-control measures and engineering controls can prevent these environmental reservoirs.

Common reservoirs in healthcare facilities include:

• Ill people.
• Well people. Our normal flora (the germs we live with) include bacteria that can be pathogens if they get into the wrong part of the body. For example, our mouths contain many different kinds of bacteria.
• Soil; has rich microbial life which may include pathogens.
• Raw meat; may harbor pathogens.
• Water from fish tanks or flower vases; may contain pathogens, especially for compromised patients.

Actions we take to eliminate reservoirs include:

• Treating people who are ill
• Vaccinating people
• Handling and disposing of body fluids responsibly
• Storing equipment dry
• Handling food safely
• Monitoring soil and contaminated water in sensitive areas of the hospital and washing hands carefully after contact with either

HUMAN RESERVOIRS AND TRANSMISSION OF INFECTIOUS AGENTS

Reservoir	Transmission Vehicle	Infectious Agent
Blood	Blood, needle stick, other contaminated equipment	Hepatitis B and C; HIV/AIDS, S. aureus, S. epidermidis
Tissue	Drainage from a wound or incision	S. aureus,, E. coli, Proteus spp
Respiratory tract	Droplets from sneezing or coughing	Influenza viruses, Strep spp., S. aureus
Gastrointestinal tract	Vomitus, feces, bile, saliva	Hepatitis A, Shigella spp, Salmonella spp
Urinary tract	Urine	E. coli, enterococci
Reproductive tract and genitalia	Urine and semen	N. gonorrhoeae, T. pallidum, Herpes simplex virus type 2, Hepatitis B

PORTAL OF EXIT

The portal of exit is the way the causative agent gets out of the reservoir, and it is the link of the chain that we can do the least about. Any break in the skin, including natural anatomical openings and draining lesions, may be the portal of exit from a person. Any bodily fluid may carry microorganisms out of the body. Some potent germs such as MRSA live on the patient's skin, and thus can easily exit their reservoir.

Actions we take to reduce risk from portals of exit include:

• Covering coughs and sneezes with a tissue
• Handling body fluids with gloves, then doing hand hygiene
• Keeping draining wounds covered with a dressing
• Not working when you have exudative (wet) lesions or weeping dermatitis

MODES OF TRANSMISSION

The mode of transmission is the weakest link in the chain of transmission, and it is the only link we can hope to eliminate entirely. Therefore, a great many of the efforts of Infection Control are aimed at avoiding carrying germs from the reservoir to the susceptible host. Transmission can occur by a number of mechanisms.

Direct contact is person-to-person transmission of pathogens through touching, biting, kissing, or sexual intercourse.

Indirect contact is the spread of pathogens by a person or an inanimate go-between, an intermediary between the portal of exit from the reservoir and the portal of entry to the host. Transmission by unwashed hands is a form of indirect contact. Inanimate objects such as patient-care equipment, cooking or eating utensils, handkerchiefs and tissues, soiled laundry, and door knobs that can transmit infection are sometimes called fomites. Gloves that touch two or more patients have been shown to carry pathogens. (This practice will result in disciplinary action in most facilities!)

Droplet transmission can spread diseases such as influenza, pertussis (whooping cough), and some forms of bacterial meningitis. Droplets are produced when the infected person coughs, sneezes, or speaks, and they travel only about three to six feet before drying out or falling to the ground.

Airborne transmission can occur when respiratory droplets evaporate, leaving behind droplet nuclei that are so small they remain suspended in the air. Very few diseases are transmitted by the true airborne route since most organisms cannot survive drying. Diseases transmitted by the airborne route include tuberculosis, chickenpox, measles, possibly SARS, and smallpox.

Modes of transmission that are not common in hospitals include:

• Common-source vehicles such as blood, serum, plasma, water, food, and milk. For example, food can be contaminated by E. coli if food handlers do not practice appropriate hand washing techniques after using the bathroom. If the food is eaten by a susceptible host, such as a young child or a person with HIV/AIDS, the resulting infection can be life-threatening.
• Vector-borne transmission by an animate intermediary—an animal, insect or parasite that transports the pathogen from reservoir to host. Transmission takes place when the vector injects salivary fluid by biting the host, or deposits feces or eggs in a break in the skin. Mosquitoes are vectors for malaria and West Nile virus. Rodents can be vectors for hantavirus.

Actions we take to eliminate the mode of transmission include:

• Hand hygiene
• Wearing gloves to minimize contamination of hands and discarding them after each patient
• Maintaining Contact, Droplet and Airborne Precautions as indicated.
• Cleaning, disinfection, or sterilization of equipment used by more than one patient
• Cleaning of the environment, especially high-touch surfaces

PORTAL OF ENTRY

The portal of entry can be thought of as the break in the skin that allows the germ to get into the body and cause disease. Pathogens cannot cause disease if they cannot get into the body.

Examples of portals of entry include:

• Mouth, nose, and eyes
• Other anatomical openings
• Skin breaks (cuts, rashes)
• Surgical wounds
• Intravenous sites
• Anatomical openings with tubes in place (more susceptible than those without)
• Needle puncture injuries

Actions we take to protect portals of entry (our own and our patients) include:

• Dressings on surgical wounds
• IV site dressings and care
• Elimination of tubes as soon as possible
• Masks, goggles and face shields
• Keeping unwashed hands and objects away from the mouth
• Actions and devices to prevent needlesticks
• Food and water safety

SUSCEPTIBLE HOSTS

Susceptibility can be reduced in several ways. For some diseases we have effective vaccines. Some diseases produce lasting immunity after illness. We have better resistance to disease when we are well-rested, well-fed, and relatively stress-free. People who have healthy immune systems are often able to resist infection even when bacteria do invade.

Host factors that influence the outcome of an exposure include the presence or absence of natural barriers, the functional state of the immune system, and the presence or absence of an invasive device.

Natural barriers to infection include:

• Intact skin and mucous membranes
• Cilia (small, hairlike projections that line the respiratory system) that filter inhaled air and trap microorganisms
• Lung macrophages—large white blood cells that ingest microorganisms, other cells and foreign particles—in a process called phagocytosis
• Antibodies (humoral immunity) resulting from immunization or previous disease
• Acidic environment in the stomach, urine, and vaginal secretions
• Normal flora provide competition to pathogens. An upset to the balance of normal flora can allow pathogens to cause infection, such as when a yeast infection follows a course of antibiotics.
• The immune system is a complex network of cells, tissues, and organs that interact to defend the body against infections. Defense mechanisms can be nonspecific or specific and include humoral immunity (antibodies that circulate in the blood), cell-mediated immunity (white blood cells), and the inflammatory response, which brings an increase in these infection-fighting defenses to the site of infection.

A person with normal immune system function is described as immunocompetent. Someone whose immune system is impaired by illness or age-related factors is said to be immunocompromised. For example, a person with HIV/AIDS is immunocompromised.

The very young and the very old are also at risk for compromised immune function. Infections are a major cause of death among newborns. Although babies receive certain temporary immunities from their mothers through the placenta and in breast milk, their immune systems are still developing, making them vulnerable to infection. Nutritional status is a key factor in immune function.

People with chronic disease may also be immunocompromised. People with diabetes mellitus or peripheral vascular disease are at high risk for infection because of impaired circulation.

Certain medications can impair immunity. For example, cancer drugs and anti-inflammatory medications such as corticosteroids can interfere with normal immune function.

Any surgical procedure carries the risk of infection because it penetrates the skin. Diagnostic or therapeutic procedures that involve an invasive device such as a urinary catheter or an intravascular (IV) catheter also increase the risk of infection. Caring for patients with these devices demands strict attention to infection control standards and continuous monitoring for any sign of infection. To reduce risk of infections associated with these devices, the device should be discontinued as soon as the patient no longer needs it.

Any foreign body, even a joint prosthesis, can act as a focus for infection and increase the risk of infection. Examples of susceptible hosts include:

• People who are already ill
• People with invasive devices or tubes in place
• Malnourished people
• The very old and very young
• People who are tired or under high stress
• People with skin breaks such as surgical wounds or IV sites
• People undergoing steroid therapy or treatment for cancer
• People with HIV infection
• People who are well and healthy (no one is immune to all disease)

Actions we take to minimize risk to susceptible hosts include:

• Vaccinating people against illnesses to which they may be exposed
• Preventing new exposure to infection in people who are already ill, are receiving immunocompromising treatment, or are infected with HIV
• Maintaining good nutrition
• Maintaining good skin condition
• Covering skin breaks
• Encouraging rest and balance in our lives

The nature of healthcare settings makes them vulnerable to the spread of infections because they bring together many ill people who are both reservoirs and susceptible hosts. Staff are also both reservoirs and susceptible hosts, so we cannot eliminate those two major links of the chain of infection. That is why we make such efforts to eliminate the mode of transmission, and that is why hand hygiene is still the single most important procedure to prevent the spread of infection.

The reservoir and the susceptible host may reside in the same person, if the individual's normal flora get into the "wrong" part of the body and cause disease. Examples of this situation include:

• Oral flora in the lungs, causing aspiration pneumonia
• Skin flora in an IV site, causing a site infection or even a bloodstream infection
• Fecal flora in the urinary tract, causing a urinary tract infection (UTI)

So we take care to avoid providing the mode of transmission between different body sites of the same patient, changing gloves and washing hands when we must go from a contaminated area to a cleaner one.

Preventing the Spread of Infection

Preventing the spread of infectious organisms includes:

• Hand hygiene before and after every patient contact, including dry skin contact.
• Using Standard Precautions with every patient so that precautions are used with unknown carriers of most diseases.
• Prompt isolation of the patient when indicated, using the appropriate type of precautions.
• Early identification of the infectious organism and initiation of appropriate treatment

HAND HYGIENE

Hand hygiene is the single most important procedure for preventing the spread of infection. This is because healthcare facilities bring many reservoirs (the patients and staff) into close contact with many susceptible hosts (the patients and staff). We cannot eliminate the reservoirs and susceptible hosts, so we must eliminate the mode of transmission. We must not carry germs from reservoir to susceptible host!

Hand hygiene includes both using alcohol-based hand hygiene products and washing with soap and water. Alcohol-based hand hygiene products are preferred over soap and water when hands are not visibly soiled. Alcohol-based products are better in three ways:

• They kill the germs better.
• They leave skin in better condition.
• They are quicker and easier to use, so people use them more. (CDC 2002)

Use alcohol-based hand hygiene products only on dry hands. Use enough of the product so that hands are dry again in 15 seconds, and rub hands together until they are completely dry. If hands are visibly soiled, wash with soap and water, using friction, for at least 15 seconds. (Sing "Happy Birthday" twice.)

The CDC hand hygiene guideline specifies: Do not wear artificial fingernails or extenders when having direct contact with patients at high risk. Check with your facility for their policy. Nails should be unpolished and less than one-quarter inch long. Chipped nail polish, long nails, artificial fingernails, or nail extenders may tear gloves and can harbor pathogens, even after careful hand washing or the use of surgical scrubs.

CDC-RECOMMENDED PRECAUTIONS

The following section on types of precautions is based on the CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. CDC Guidelines are not regulations, but they are evidence-based recommendations. The 2007 Guidelines provide recommendations for patients in ambulatory settings, long-term care, and residential settings, in addition to those in acute care hospitals. Refer to your facility's policies for specific procedures.

The Centers for Disease Control (CDC) describe four types of precautions, based on the mode of transmission of the organism known or suspected to be present. In addition to Standard Precautions, they identify three precautions that are transmission-based: Contact, Droplet, and Airborne Precautions.

Standard Precautions

Standard Precautions are to be used with all patients, regardless of diagnosis. Standard Precautions, formerly known as Universal Precautions, were initially designed to minimize risk to staff from unknown carriers of bloodborne pathogens, such as hepatitis B, hepatitis C, or HIV. In addition to protecting staff, Standard Precautions also protect patients from organisms shed in the body fluids of other patients. Standard Precautions are required by good science and by federal law under the OSHA Bloodborne Pathogens Standard.

Long-established Standard Precautions include hand hygiene, use of personal protective equipment (gloves, mask and eye protection/face shield, gowns), protective procedures for handling of patient-care equipment and patient placement, and environmental and occupational health controls. In 2007 three new elements were added to Standard Precautions: respiratory hygiene, safe injection practices, and lumbar puncture procedures.

Hand hygiene. Wash hands with plain soap or alcohol-based product after touching blood, body fluids, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. Avoid unnecessary touching of surfaces near the patient to prevent contaminating clean hands and to prevent transmission of pathogens from contaminated hands to surfaces. (See additional detail on hand hygiene, above).

Gloves. Wear clean gloves when touching blood, body fluids, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and do hand hygiene immediately.

Mask and eye protection/face shield. Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during activities that are likely to generate splashes or sprays of blood or body fluids (such as suctioning, irrigation, or delivery of the newborn).

Gown. Wear a gown to protect skin and to prevent soiling of clothing during activities that are likely to generate splashes or sprays of blood or body fluids. Select a gown that is appropriate for the amount of fluid likely to be encountered. Remove the soiled gown as promptly as possible and do hand hygiene. (See additional details on personal protective equipment under Element IV.)

Patient-care equipment. Handle used patient-care equipment soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Clean or reprocess reusable equipment before using it for the care of another patient. Ensure that single-use items are discarded properly.

Environmental control. Follow hospital procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces.

Linen. Handle, transport, and process used linen soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms to other patients and environments.

Occupational health and bloodborne pathogens. Take care to prevent injuries when using or disposing of needles, scalpels, and other sharp instruments or devices. Never recap used needles using both hands or use any other technique that involves directing the point of a needle toward any part of the body. Do not manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers that are located as close as practical to the area in which the items were used. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.

Patient placement. Place a patient who contaminates the environment or who does not assist in maintaining appropriate hygiene (children, patients with altered mental status) in a single-patient room. If a single-patient room is not available, consult with infection control professionals regarding patient placement or other alternatives. If it is necessary for an infected patient to share a room with a noninfected patient, it is important that roommates are selected carefully and that patients, personnel, and visitors take precautions to prevent the spread of infection.

Respiratory hygiene is a relatively new concept introduced after the SARS outbreak in 2003, comprising vigilance and prompt implementation of infection control measures at the first point of encounter within a healthcare setting (reception and triage areas, outpatient clinics, and physician offices). It is directed to patients and family members with signs of respiratory illness such as cough, congestion, or increased respiratory secretion. Components include:

• Educate healthcare workers on the importance of source-control methods to contain respiratory secretions, especially during outbreaks of respiratory illness such as influenza.
• Post signs at entrances in languages appropriate to the population served asking patients and family members to cover the mouth and nose when coughing or sneezing or to wear a mask, and to do hand hygiene after contact with respiratory secretions.
• Provide tissues, masks, hand hygiene products, and waste receptacles convenient to patients entering the facility, and assign responsibility for maintaining the supplies.
• Maintain separation, ideally by at least 3 feet, between ill persons and others. Move ill patients to rooms promptly to remove them from common waiting areas.
• Healthcare personnel should use Droplet Precautions (wear a simple mask) and do hand hygiene when caring for any patient with symptoms of respiratory infection unless those symptoms are known due to a noninfectious cause.
• Healthcare workers with respiratory infection should avoid patient contact if possible, and should wear a mask of contact cannot be avoided.

Safe injection practices. Infection control problems identified in the course of outbreak investigations sometimes indicate the need for reinforcement of existing infection control recommendations to protect patients. Failure to adhere to recommendations for safe injection practices has resulted in several outbreaks of hepatitis B and C. Lack of oversight of personnel and failure to follow up on reported breaches of practice have contributed to these outbreaks.

The CDC recommends that these practices be incorporated into institutional policies that are monitored for adherence:

• Use aseptic technique to avoid contamination of sterile injection equipment.
• Do not administer medications from a syringe to multiple patients, even if the needle or cannula is changed. Needles, cannulae, and syringes are single-patient-use items.
• Use IV bags, tubings, and connectors for one patient only.
• Do not use bags of IV solution as common source of supply for multiple patients.
• Consider a syringe or needle/cannula contaminated after it has entered an IV bag or set.
• Use single-dose vials whenever possible.
• Do not use one single-dose vial for several patients or combine contents of several vials.
• If multidose vials must be used, both the needle/cannula and syringe used to access them must be sterile.
• Do not keep multidose vials (such as insulin) in the immediate patient care area. Store as recommended by the manufacturer, and discard if sterility is compromised.

Lumbar puncture practices. Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space.

Equipment Needed for Standard Precautions

Routinely, hand hygiene products, gloves, safety sharps, sharps disposal boxes, and disinfectant wipes or equivalent. Occasionally, gowns, face masks, eye protection or face shields.

TRANSMISSION-BASED PRECAUTIONS

In addition to Standard Precautions, which are used with all patients, some patients require additional precautions, known as Transmission-Based Precautions. There are three types of transmission-based precautions: Contact, Droplet, and Airborne. (Isolation precautions have disadvantages to the hospital, patients, personnel, and visitors, including the cost of specialized equipment and environmental controls, inconvenience to healthcare workers, and forced solitude for patients. However, these disadvantages must be weighed against the hospital's mission to prevent the spread of serious infection in the hospital.)

Contact Precautions

Contact Precautions are designed to minimize transmission of organisms that are easily spread by contact with hands or object. The CDC Isolation Guidelines of 2007 made changes to recommended practices for Contact Precautions. Among these changes is the direction to "Wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Don gown upon entry into the room or cubicle."

Droplet Precautions

Droplet Precautions are designed to prevent transmission of diseases easily spread by large-particle droplets produced when the patient coughs, sneezes, or talks, or during the performance of procedures.

Airborne Precautions

Airborne Precautions are designed to prevent transmission of diseases spread by the true airborne route. These organisms are released from the patient in respiratory droplets, which evaporate shortly after release. Most organisms die when they dry out, but the organisms of these few diseases—tuberculosis, chickenpox, measles, SARS, and smallpox—can survive drying out. The droplet nuclei (small-particle residue of evaporated droplets) remain suspended in the air and can be dispersed widely by air currents within a room or even over a long distance.

ENGINEERING AND WORK PRACTICE CONTROLS

Healthcare-associated disease transmission is transmission of infectious agents that results in the development of HAIs. Healthcare-associated infections (HAIs) are infections associated with healthcare delivery in any setting (eg, hospitals, long-term care facilities, ambulatory settings, or home care.) Patients may acquire them during the course of receiving treatment for other conditions—they are not present or incubating at the time of entry into the healthcare process. Healthcare-associated infections are one of the top ten leading causes of death in the United States (CDC 2008).

The OSHA Bloodborne Pathogens Standard requires the use, in this order, of:

1. Engineering controls
2. Work practice controls
3. Personal protective equipment

These precautions are built into the isolation precautions guidelines of the CDC.

Engineering controls isolate (contain) or remove the bloodborne pathogens hazard from the workplace. Examples include sharps disposal containers, self-sheathing needles, and sharps with engineered sharps injury protection and needleless systems. For example, the puncture-resistant containers required by Standard Precautions for the disposal and transport of needles and other sharps are an engineering control. Splatter shields on medical equipment associated with risk-prone procedures such as locking centrifuge lids isolate or contain the hazard. Hand hygiene is also an engineering control, since it removes the microorganisms from the workplace.

Work practice controls reduce the likelihood of exposure to bloodborne pathogens by altering the manner in which a task is performed, such as prohibiting recapping of needles using a two-handed method. These are the workplace procedures that tell you how to do the job safely. Be sure you know where to find the procedure manuals for your workplace and be sure those procedures are current and complete if that falls within your scope of practice..

Personal protective equipment provide barriers to the transmission of infectious organisms., thereby protecting both the healthcare professional and the patient.

Safe injection practices are a set of measures taken to provide injections in a manner that is optimally safe for patients, healthcare personnel, and others. A safe injection does not expose the patient to harm, does not expose the provider to avoidable risks, and does not produce waste that is dangerous for the community. Injection safety includes practices intended to prevent transmission of bloodborne pathogens between one patient and another or between a healthcare worker and a patient, and also to reduce risk of needlestick injury to others.

High-risk practices and procedures that increase the opportunity for healthcare worker and patient exposure to potentially infectious materials include:

• Sharps injuries with contaminated sharps, which can result from sharps being left undiscarded when a procedure has been completed, failure to activate safety sharps after use, recapping used needles using both hands, and removing scalpel blades from their handles by hand.
• Procedures which involve sharps used under conditions of poor visualization, such as "blind" suturing, having the non-dominant hand close to a contaminated sharp, and procedures in which sharp bone or metal fragments are produced. Situations involving use of sharps with poor visualization should be minimized or eliminated when possible. These situations pose a risk to both worker and patient, since there is potential for patient exposure to the blood of the worker.
• Procedures which may expose the mucous membranes of eyes, nose, mouth or other mucous membranes to spray or splatter of blood or other potentially infectious materials (such as irrigation or suctioning), contact with contaminated hands or gloves, or contact with open skin lesions or dermatitis.
• Accidental injection of infectious material via shared blood glucose monitoring devices, such as glucometers or lancets, administration of injectable medication or infusion of contaminated fluids.

Following guidelines carefully is not only effective but also an expression of good professional practice, whereas neglecting to follow guidelines could lead to a charge of professional misconduct.

Engineering Controls

Giving injections, disposing of syringes with needles, or reprocessing needles and other sharps all hold potential risk for exposure to pathogens. An estimated 600,000 to 800,000 percutaneous injuries occur annually in U.S. hospitals. These figures represent only part of the picture because they do not include nonhospital settings, which employ more than half of all healthcare workers (NIOSH, 1999).

Every area of the healthcare facility and every type of patient care holds the potential for exposure to pathogens but some settings and practices hold greater risk than others. High-risk settings include:

• Intensive-care units (surgical, medical, coronary, pediatric)
• Operating rooms
• Delivery rooms
• Newborn nurseries
• Isolation units
• Clinical laboratories

Engineering controls used to prevent transmission of airborne infections include:

• Isolation rooms with appropriate air exchanges (negative pressure and/or direct exhaust)
• HEPA filtration
• Ultraviolet irradiation

Many of the practices described in the section on safe injection practices include engineering controls that protect patients from exposure to bloodborne pathogens. When safe injection practices are used, bloodborne pathogens are contained to the patient who carries them and their equipment, isolated from other patients. The hazard is then removed from the facility when the carrier patient departs.

Safety sharps devices and containers are another type of engineering control, since they isolate or contain the hazard—used sharps. The Occupational Safety and Health Administration (OSHA) requires the use of safety sharps when feasible. Healthcare workers may be exposed percutaneously (through the skin) by sharps or needle sticks to HIV, hepatitis B and C, and other bloodborne pathogens.

In 2000 both New York State and federal laws were enacted to protect healthcare workers against needle sticks; these laws require that healthcare facilities evaluate and provide safe needles. OSHA has revised their guidelines on bloodborne pathogens to require that employers:

• Use engineering controls or work practices that "eliminate or minimize exposures" (OSHA 2001, CPL2-2.44D)
• Involve employees in the selection process
• Provide effective safe needles and sharps
• Provide training covering personal protective equipment, how to use safe-needle devices, and limitations of such devices

Always use safety sharps and other devices when available. Always activate the safety feature. Never try to work around or disable it.

Employers must provide and workers must use safer devices whenever possible to prevent sharps injuries. Those devices must be evaluated and chosen to give preference to

• Passive protection that does not depend on the worker to activate it
• Mechanisms that provide protection without delay
• Safety mechanisms that are integrated into (built into) the device, not an add-on

Other considerations to minimize risk of sharps injuries include

• All staff who will use a specific device should receive education on its use.
• Some facilities have chosen to eliminate non-safety alternatives wherever possible.
• Specific safety devices may be needed for specialty areas or settings.

When using a safety sharp device, be sure to activate the safety feature before discarding. The stick you prevent may be your own! (This directive was adopted by the NYS Department of Labor's Public Employee Safety and Health program (PESH) and thus applies to all public employees in New York.)

Puncture-resistant containers must be used for the disposal and transport of needles and other sharp objects.

• Information on selection, evaluation and placement of containers for sharps disposal is available from NIOSH at http://www.cdc.gov/niosh/sharps1.html.
• The New York State Department of Health recommends "Household Sharps—Dispose of them Safely," available at http://www.health.state.ny.us/publications/0909.pdf.

In addition to sharps safety, other kinds of engineering controls contain or remove other kinds of hazards. For example, some kinds of medical equipment which may have risk of splatter, such as lab centrifuges, should be equipped with splatter shields.

The average risk of transmission from a single needlestick contaminated with HIV has been estimated to be approximately 0.3%. (MMWR, 2005)

The risk of transmission from a single needlestick contaminated with hepatitis B ranges from 1% to 30%, depending on the infectivity of the source. (MMWR, 2001)

The risk of transmission from a single needlestick contaminated with hepatitis C is 1.8 %. (MMWR, 2001)

Hepatitis B is definitely the greatest risk for transmission, and we are fortunate that there is a safe and effective vaccine against it. Employers whose employees may have exposure to hepatitis B on the job are required to offer hepatitis B vaccine free to employees who may be exposed. There is also postexposure prophylaxis (PEP) that can be used following exposure to hepatitis B to reduce risk of infection.

There is no vaccine against HIV at this time, but medication may reduce risk of transmission. There is neither vaccine nor preventive medication against Hepatitis C. Prevention is the only means of reducing risk of transmission (MMWR, 2001).

Poor visualization during certain procedures also poses a hazard to both patient and healthcare worker. These procedures include blind suturing, a nondominant hand opposing or next to a sharp, and removal of bone or metal fragments. Situations involving use of sharps with poor visualization should be minimized or eliminated when possible.

Work Practice Controls

Work practice controls to eliminate or reduce the likelihood of exposure to potentially infectious material include general practices such as the following:

• Hand hygiene protects both patients and workers. Choices regarding use of alcohol-based hand sanitizers versus soap and water are addressed in Element II.
• Avoid unnecessary use of needles and other sharps.
• Use care in handling and disposing of needles and other sharps.
  • Avoid recapping unless absolutely medically necessary and use a mechanical device or one-handed technique when recapping is necessary.
  • Sharp instruments should not be passed hand to hand. A designated "safe zone" should be used.
  • When used sharps such as scalpels must be disassembled, forceps or other instrumentation should be used.
• Facilities should provide safe procedures to minimize risk of injury.
  • Use forceps, suture holders, or other instruments for suturing.
  • Avoid holding tissue with fingers when suturing or cutting.
  • Avoid leaving exposed sharps of any kind on procedure work surfaces. In many facilities, the person who uses the sharp is responsible to dispose of it safely. If this is not done, the person who leaves the sharp should report its presence to the person who will discard it.
• Use safety devices as designed.
  • Always activate safety features which require activation.
  • Never circumvent (defeat or destroy) safety features.
• Proper procedures for cleaning of blood and body fluid spills begins with wearing appropriate personal protective equipment; gloves at the least; then initial removal of bulk material using disposable absorbent material (such as paper towels) as needed, followed by disinfection with either
  • An EPA-registered tuberculocidal agent
  • A germicide with specific label claims for HIV or HBV
  • Freshly diluted 1:100 sodium hypochlorite. (CDC 2008) (1/4 cup bleach to 1 gallon of water)
  • Proper selection, donning (putting on), doffing (taking off), and disposal of personal protective equipment as described in Element IV. Specific directions may be found at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html on pages 129–130.
  • In routine times, gloves should be put on last, covering gown cuffs, and removed first.
  • When dealing with a disease transmitted by both airborne and contact routes, seek specific timely instruction or refer to the CDC reference.
• In some settings, for example, dental work areas, work surfaces may be protected with appropriate barriers. Refer to CDC Guideline for Disinfection and Sterilization, 2008, pages 88–89 for specific details.
• Prompt cleanup of blood and body fluid spills with appropriate disinfectant
• Proper disposal/handling of blood and body fluid, including contaminated patient-care items. Facility procedures should comply with local regulations.
• Safe handling of used linen and waste

Work practice controls also include specific practices to avoid exposure and injury by modifying procedures and use of equipment. Percutaneous exposures can be prevented by:

• Avoiding unnecessary use of needles and other sharps
• Using care in the handling and disposal of needles and other sharps
• Not recapping unless absolutely medically necessary and then using one-hand technique or safety device to recap
• Passing sharp instruments by use of designated "safe zones"
• Disassembling sharp equipment by using forceps or other devices
• Closing and replacing sharps containers when they are full (rather than overfilling) according to the manufacturer's instructions
• Using forceps, suture holders, or other instruments for suturing
• Not holding patient tissue with fingers when suturing or cutting
• Having the patient wear a surgical mask
• Instructing the patient to cover the mouth with tissue when coughing or sneezing
• Early identification and isolation of patients suspected to have diseases requiring isolation.
• Transportation of potentially infectious patients

Work practices used when patients potentially or actually infected with virulent or epidemiologically important microorganisms are transported include:

• Appropriate barriers (eg, masks, impervious dressings) should be worn or used by the patient to reduce transmission of infection to other patients, personnel, and visitors, and to avoid contamination of the environment.
• Personnel in the area to which the patient is to be taken should be notified of the impending arrival of the patient and precautions to be used to reduce the risk of transmission.
• Patients are informed of ways in which they can assist in preventing the transmission of their infection to others.

Safe Injection Practices

Safe injection practices and procedures are described by the CDC as an addition to Standard Precautions in the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Many of these practices are not new. They were added to Standard Precautions after several outbreaks of disease due to bloodborne pathogens were traced back to compromised aseptic technique associated with injection therapy, often in outpatient settings.

These lapses have resulted in

• Transmission of bloodborne viruses, including hepatitis B and C to patients;
• Notification of thousands of patients to possible exposure to these pathogens and recommendation that they be tested for hepatitis B, hepatitis C, and HIV;
• Referral of providers to licensing boards for disciplinary action, and
• Malpractice suits filed by patients.

These practices are designed to prevent disease transmission from patient to patient and from healthcare worker to patient.

Pathogens for Hepatitis B, hepatitis C, HIV and other diseases can be present in sufficient quantity to cause disease in the absence of visible blood, clouding of fluid, or other visible evidence of contamination. Used syringes, IV tubing, multidose medication vials and blood glucose monitoring devices may have no visible blood or sign of contamination but still carry potentially infectious agents. All used injection supplies and materials are potentially contaminated and must be discarded!

The following practices are required of all providers of injection and/or intravenous (IV) therapy:

• Ensure proper hand hygiene before handling medications.
• Maintain aseptic technique throughout all aspects of injection preparation and administration.
  • Medications should be prepared ("drawn up") in a designated clean medication area that is not adjacent to areas where potentially contaminated items are placed. For example, a cart with both blood glucose testing devices (contaminated) and syringes and insulin (supplies for injection) would not meet this requirement.
  • Use a new sterile syringe and needle to draw up medications, preventing contact between the injection materials and the non-sterile environment.
  • If a medication vial has already been opened, the rubber septum should be disinfected with alcohol prior to piercing it.
  • Never leave a needle or other device (eg, "spikes") inserted into a medication vial septum or IV bag/bottle for multiple uses, since this provides a direct route for contamination.
  • Medication vials should be discarded on or before the manufacturer's expiration date, the date set by facility expiration policy, or any time there are concerns regarding the sterility of the medication.
• Never administer medications from the same syringe to more than one patient, even if the needle is changed.
• Never use the same syringe or needle to administer IV medications to more than one patient, even if the medication is administered into IV tubing, regardless of the distance from the IV insertion site.
  • All of the infusion components from the infusate (IV fluid) to the patient's catheter are a single interconnected unit.
  • All of the components are directly or indirectly exposed to the patient's blood and cannot be used for another patient.
  • Syringes and needles that enter any port in the IV system are contaminated and cannot be used for another patient OR used to re-enter a non-patient-specific multi-dose vial.
  • Separation from the patient's IV by distance, gravity, and/or positive infusion pressure does not ensure that small amounts of blood are not present in these items.
• Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient.
• Dedicate vials of medication to a single patient.
  • Medications packaged as single-use must never be used for more than one patient.
    • Never combine leftover contents for later use.
    • Medications packaged as multi-use (such as insulin) should be assigned to a single patient whenever possible.
    • Never use bags or bottles of intravenous solution as a common source of supply for more than one patient.
• Never use peripheral capillary blood monitoring devices (such as lancets or platforms) packaged as single-patient use on more than one patient.
  • Restrict use of peripheral capillary blood sampling devices to individual patients.
  • Never reuse lancets. Consider selecting single-use lancets that permanently retract upon puncture.

Safe injection practices designed to prevent disease transmission from patient to healthcare worker are described by OSHA (http://www.osha.gov/):

• Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted below. Shearing or breaking of contaminated needles is prohibited.
• Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such an action is required by a specific medical or dental procedure.
• Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or one-handed technique.
• Immediately or as soon as possible after use, contaminated REUSABLE sharps shall be placed in appropriate containers until properly reprocessed. Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the container.

Each employer having employee(s) with occupational exposure (reasonably anticipated skin, eye, mucous membrane, or parenteral (piercing) contact with blood or other potentially infectious materials that may result from the performance of the employee's duties) shall establish a written Exposure Control Plan designated to eliminate or minimize employee exposure. Among the requirements for this Exposure Control Plan is identification of which employee groups may be at risk for exposure. In general, any worker who has contact with patients or with body fluids is at risk for exposure.

All sharps devices can cause injury and disease transmission if not used and disposed of properly.

• Devices with a hollow bore, such as needles for injection, can contain blood and carry higher risk to transmit infection.
• Some devices, such as "butterfly" needles, devices with recoil action and lancets may be more likely to cause injury.
• Employers should track which devices are associated with blood exposures areas and settings where exposures occur.
• Post-exposure management is described in Element VI.

Environmental Controls

Environmental control measures also help prevent the transmission of infection. These measures include:

• Environmental cleaning (housekeeping)
• Waste management
• Linens (textiles) and laundry management

HOUSEKEEPING

Appropriate housekeeping and sanitation practices are essential to reduce the spread of infection, particularly in high-risk areas such as nurseries, operating rooms, and intensive-care units. The CDC guidelines include the following recommendations:

• Keep housekeeping surfaces (eg, floors, walls, tabletops) visibly clean on a regular basis and clean up spills promptly.
• Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in patient-care areas.
• Follow proper procedures for effective uses of mops, cloths and solutions.

WASTE MANAGEMENT

There are two categories of hospital waste: regulated medical waste and unregulated waste. According to the CDC (2000), most hospital waste is no more infective than ordinary residential waste, nor is there evidence that current hospital waste management practices have caused disease in the community.

Regulated medical waste ("red bag" waste) requires special precautions in handling and disposal. Regulated medical waste includes:

• Microbiology laboratory waste
• Pathology and anatomy waste
• Bulk blood or blood products
• Sharps items such as used needles or scalpel blades (CDC, 2003)

These items require special handling, transport, and storage procedures. The CDC (2003) recommends the following guidelines:

• Personnel responsible for waste management must receive appropriate training in handling and disposal methods in accordance with hospital policy.
• Waste generated in isolation areas should be handled using the same methods used for waste from other patient care areas.
• Disposable syringes with needles, including sterile sharps that are being discarded, scalpel blades, and other sharp items, should be disposed of in puncture-resistant containers located as close as practical to the point of use.
• Do not bend, recap, or break used syringe needles before discarding them into a container.
• Sanitary sewers may be used for safe disposal of blood, suctioned fluids, ground tissues, excretions, and secretions, provided that local sewage discharge requirements are met and that the state has declared this to be an acceptable method of disposal.
• Store regulated medical wastes awaiting treatment in a properly ventilated area inaccessible to vertebrate pests. Use waste containers that prevent development of noxious odors.
• If treatment options are not available at the site where the waste is generated, transport regulated medical waste in closed, impervious containers to the on-site treatment location or to another facility for treatment as appropriate.
• Regulated medical waste must be treated by a method (steam sterilization, incineration, interment, or an alternate treatment technology) approved by the appropriate authority (eg, the state, Veterans Administration, Indian Health Service) before disposal in a sanitary land fill. (CDC, 2003)

LINENS AND LAUNDRY

According to CDC (2003), except for soiled textiles from patients in isolation, the risk of actual disease transmission from soiled laundry is negligible. Thus commonsense hygienic practices for handling, processing and storage of textiles are recommended. These practices include:

• Not shaking the items or handling them in any way that may aerosolize the infectious agents.
• Avoid contact of one's own body and personal clothing with the soiled items being handled.
• Containing soiled items in a laundry bag or designated bin at the location where it was used, minimizing leakage.
• No sorting or rinsing of textiles in the location of use.
• Labeling or color-coding bags or containers for contaminated waste.
• If laundry chutes are used:
  • Ensure that laundry bags are securely closed before they are placed in the chute.
  • Do not place loose items in the laundry chute.
• Textiles heavily contaminated with blood or other body fluids should be bagged and transported in a manner that will prevent leakage.
• Do not use dry cleaning for routine laundering in healthcare facilities.
• Clean textiles should be handled, transported, and stored by methods that will ensure their cleanliness.

Note: Employers are responsible for laundering reusable personal protective equipment (PPE). Work clothes such as uniforms are not considered to be PPE. Provided gowns or other PPE should be used to prevent soiling of uniforms. (OSHA, 2001).

Training healthcare workers who are responsible for housekeeping and management of linen and waste in appropriate infection control for their particular duties is essential for safe patient care.

PROTECTING AGAINST HAZARD

Personal Protective Equipment

Personal protective equipment (PPE) is specialized clothing or equipment worn by a healthcare worker for protection against a hazard. OSHA guidelines state that PPE will be considered "appropriate" only "if it does not permit blood or other potentially infectious materials to pass through or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used." (OSHA, 2001).

Use of PPE is built into the descriptions of all four kinds of isolation precautions (Standard, Contact, Droplet, and Airborne) described by the CDC. Use appropriate barriers and/or PPE whenever you may have contact with the blood or body fluids of any patient and to prevent exposure to the droplets of patients with respiratory symptoms.

A barrier is a material object that separates a person from a hazard. The type of PPE selected should be based on the procedure and reasonably anticipated events such as:

• Blood or body fluid splash
• Contact with minimal bleeding/drainage/body substance
• Contact with large volume bleeding/drainage/body substance that is likely to soak through the contact area
• Respiratory droplet pathogens
• Airborne pathogens

Some barriers are used to protect the patient, including:

• Sterile barriers for invasive procedures
• Masks for the prevention of droplet contamination

Personal protective equipment includes:

• Gloves
• Cover garb (gowns, aprons, fluid-resistant laboratory coats)
• Face shields
• Masks
• Eye protection
• Caps and hoods

GLOVES

Gloves should be worn when contact with blood or body fluids, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated patient care equipment is anticipated.

• Wear gloves with fit and durability appropriate to the task, such as disposable exam gloves for patient care and disposable or reusable gloves for cleaning.
• Remove gloves in a manner than minimizes risk of hand contamination.
• Do not wear the same pair of gloves for the care of more than one patient.
• Do not wash disposable gloves.
• Change gloves during the care of one patient if moving from a contaminated body site to a cleaner one. (CDC 2007)

Gloves are available in several materials including latex, nitrile, or rubber (utility/housekeeping). Some healthcare workers have developed an allergy to latex and should use gloves made of nitrile or other latex-free alternative.

The 2007 CDC Guidelines for Isolation Precautions do not recommend the use of double-gloving. However, some studies have found that, for some procedures, wearing two pair of gloves helps reduce the risk of contamination with blood and body fluids. One clinical study found that wearing a single pair of surgical gloves resulted in a failure rate (loss of glove integrity) of 51%. Double-gloving reduced the failure rate to 7% (Quebbeman et al., 1992).

Another study recommended double-gloving for surgical procedures in which the patient is known or suspected to be infected with a transmissible virus and for all procedures expected to last more than two hours. If double-gloving is not done, healthcare workers should frequently check for blood penetration and should change gloves every 1 to 3 hours (Raahve, 1996).

Latex or nitrile gloves are preferable over vinyl gloves for clinical procedures, since several studies have shown that vinyl gloves have higher failure rates in use (CDC, 2007).

Always use nitrile or other appropriately protective gloves when handling chemotherapy or other chemicals. Both examination (nonsterile, clean) gloves and surgical (sterile) gloves must be available for specific healthcare tasks. Avoid use of petrolatum-based lotions or creams when using latex gloves since these products may affect the integrity of the gloves.

Gloves are the first line of PPE, and can prevent heavy contamination of hands during patient care and transmission of pathogens. However, wearing gloves does not provide complete protection against acquiring viral infections, particularly hepatitis B and herpes simplex viruses.

Wearing gloves does not replace the need for hand washing because gloves may have small, unnoticeable defects or may tear during use, and hands can become contaminated during glove removal. Hands should be washed with soap and water after glove removal if hands are visibly soiled or if the glove has torn. In the absence of visible hand contamination, hand hygiene with alcohol hand rubs is appropriate after glove removal (CDC, 2007). Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks, even with the same patient.

GOWNS

Gowns are available in both sterile (surgical) and nonsterile (clean) versions and in fabrics of varying permeability (impervious, fluid-resistant, permeable). Gowns protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to involve contact with or generate splashes or sprays of blood or body fluids. Choose the type of gown which will provide adequate protection for the task planned.

When using Standard Precautions, an isolation gown is worn only as needed to protect the wearer from contact with blood or body fluid. Wear a gown for direct patient contact if the patient has uncontained body fluids.

When Contact Precautions are in use, both gown and gloves should be worn on entry into the room to reduce unintentional contact with contaminated surfaces. Do not reuse gowns, even for repeated contacts with the same patient (CDC, 2007).

RESPIRATORY AND EYE PROTECTION

Masks, respirators, and powered air-purifying respirators (PAPRs) protect the healthcare worker, the patient or both from transmission of pathogens. Different types of respiratory protection are available for different tasks and purposes, including:

• Single-use disposable masks are used for Droplet Precautions. They are also used ON patients with respiratory symptoms as part of respiratory hygiene or ON patients known or suspected to have TB. Simple masks contain the droplets coming out of the person wearing the mask (covering their portal of exit).
• Single-use disposable mask with eye shield should be used when splash splatter is anticipated, such as in the OR. These must be changed if wet or soiled. These protect the patient and sterile field from the exhaled droplets of the surgical staff as well as protecting the eyes of surgical staff.
• N-95 respirators are required for staff sharing air space with the patient known or suspected to have tuberculosis. They must make a tight seal against the face, and must be fit tested. This type of respirator protects the person wearing it from possible pathogens in the air of the room, protecting their portal of entry. Some N-95 respirators have an exhalation valve, and these do not prevent contamination of a sterile field and so should not be worn alone in the OR.
• PAPRs are used in many facilities in addition to or instead of N-95 respirators. They do not require fit testing and they can be used by people with facial hair that precludes wearing of an N-95. PAPRs do require training and maintenance. Check your facility's policy if you may need to use them.

All types of respiratory protection should cover both the mouth and the nose. If the mask or respirator has a metal strip, it should be fitted securely over the bridge of the nose to prevent inhalation or exhalation of pathogens and to prevent fogging of eyeglasses. If glasses are worn, the upper edge of the mask should fit under the glasses to prevent fogging.

When wearing a mask with strings, tie both strings securely to prevent strings from coming loose during the procedure. Tie the upper strings at the back of the head and the lower strings at the neck.

Masks with eye shields or face shields and other eye protection (goggles, safety glasses) are essential to protect the mucous membranes of the eyes, nose, and mouth during procedures that are likely to generate splashes or sprays of blood or body fluids. Although percutaneous injuries (needle sticks) are the most common route for transmission of bloodborne viruses, splashes or sprays to the mucous membranes are the second most common route.

Eye protection includes masks with eye shields, goggles, and face shields. Eyes should be protected whenever splash or splatter of blood or body fluids may be anticipated. When eye protection is worn, a mask must also be worn (OSHA, 2001).

N-95 respirators must be worn as specified on the product package or protection may not be provided. Specifically, if the respirator has two straps, they must be placed as directed, not left dangling or placed together.

BARRIERS FOR PATIENT PROTECTION

Some barriers and PPE are worn to protect the patients from the germs of healthcare professionals, especially in the OR. Sterile drapes are used to create a sterile field in which the operative procedure can take place. Surgical masks reduce risk of droplet contamination of the operative field. Caps and hoods are worn to reduce shedding and promote environmental control. The Association of Operating Room Nurses recommends that a cap or hood be worn that fully covers all hair on the head and face when in restricted and semi-restricted areas of the surgical suite.

Barriers and PPE are most effective when appropriately selected, properly fitted, worn according to manufacturer's instructions, inspected frequently to verify integrity of the barrier, and changed between patients. The cost of barriers and PPE are far less than the cost of treating preventable infections of patients and personnel.

ENVIRONMENTAL SAFETY PRACTICES

The potential for contamination exists in every area of the hospital or other healthcare facility. Contaminated patient-care equipment (wet or soiled dressings), invasive devices that were used in diagnosis and treatment (surgical instruments or endoscopes), and environmental surfaces (doorknobs, floors, toilets) can act as vehicles for the transmission of infection to healthcare workers and/or patients.

Understanding and applying appropriate procedures for cleaning, disinfection, and sterilization are essential to maintaining a safe patient-care environment.

Cleaning

The healthcare environment may be contaminated with microorganisms, and recent concerns regarding MRSA and Clostridium difficile (C. diff) have focused new attention on the importance of effective environmental cleaning. Environmental surfaces such as floors and tabletops should be cleaned or disinfected on a regular basis, when spills occur, and when they are visibly soiled. The disinfectant manufacturer's instructions for dilution, use, and contact time should be followed. Refer to the updated Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf for further detail.

Except in rare and special instances (as mentioned below), items that do not ordinarily touch the patient are not involved in disease transmission and generally do not necessitate disinfection between uses on different patients. These items include crutches, bed boards, and a variety of other medical accessories. Consequently, depending on the particular piece of equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed.

Keep in mind that all disinfectants and sterilizing chemicals have a degree of toxicity necessary to kill the microorganisms. In general, the lowest level of product that will do the job should be used, to minimize exposure to toxic chemicals.

Care must be taken to use the right disinfectant for the purpose, consistent with its FDA or EPA registration.

Disinfection

LOW-LEVEL DISINFECTION

Low-level disinfection includes the following:

• Use EPA-registered disinfectants in accordance with manufacturer's directions. In general, this is the disinfectant found on the housekeepers' carts.
• Keep environmental surfaces visibly clean on a regular basis and clean up spills promptly.
• Clean high-touch surfaces (monitor controls, doorknobs, bed rails, light switches) often.
• Avoid cleaning methods that produce aerosols or disperse dust.
• Use barrier protective coverings as appropriate for high-touch surfaces such as computer keyboards.
• Do not use high-level disinfectants for environmental cleaning due to toxicity.
• Refer to the CDC Guidelines for Environmental Infection Control in Healthcare Facilities, 2003, for additional detail.

INTERMEDIATE-LEVEL DISINFECTION

Intermediate-level disinfection is used primarily for cleaning of blood spills and other significant environmental cleaning. These disinfectants are typically labeled as "tuberculocidal" to give evidence that they exceed requirements to kill hepatitis B and HIV. They may be available as a liquid or as disposable wipes.

Blood spills should be cleaned without delay:

• Wear gloves and other personal protective equipment as needed.
• Proper procedures for cleaning of blood and body fluid spills begins with initial removal of bulk material using disposable absorbent material (such as paper towels) as needed, followed by disinfection with either
  • An EPA-registered tuberculocidal agent
  • A germicide with specific label claims for HIV or HBV
  • Freshly diluted 1:100 sodium hypochlorite (1/4 cup bleach to 1 gallon of water) (CDC 2008)

Some situations, such as care of the patient in Contact Precautions, may require specified patient-care items to be either dedicated to one patient or patient cohort, or subjected to low-level disinfection between patient uses.

• Patients infected with methicillin-resistant Stapholococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile (C. diff) or other drug-resistant microorganisms judged by the infection control program, based on current state, regional, or national recommendations, to be of special or clinical or epidemiologic significance
• Patients infected with highly virulent microorganisms, eg, viruses causing hemorrhagic fever (eg, Ebola or Lassa)

HIGH-LEVEL DISINFECTION

High-level disinfection is used for reprocessing of reusable patient equipment that touches mucous membranes, such as laryngoscopes or endoscopes when sterilization is not feasible.

Endoscopes can transmit pathogens to patients by contaminated internal channels even if the exterior has been disinfected, if the internal channels have not been adequately cleaned or if contact of the disinfecting solution with the internal channel is incomplete or does not last long enough.

• When handling and cleaning contaminated items, wear appropriate personal protective equipment, gloves and eye protection and/or gown as needed.
• Always clean items thoroughly before reprocessing. First rinse with cold water to remove blood or body fluids, then wash with hot soapy water and rinse again to remove the soap before disinfecting or sterilizing. Cleaning methods may be manual or mechanical and may require a rinse or presoak, depending on the nature and amount of blood or body fluids. Once cleaned, avoid cross-contamination by other articles or surfaces.
• For devices with internal lumens such as endoscopes, methods for verifying contact with all internal channels and components must be monitored.
• Always follow the recommendation of the device/equipment manufacturer's of BOTH the device to be disinfected and the disinfectant recommendations for reprocessing to ensure that the method chosen is compatible with the components and materials in terms of heat and pressure tolerance and time required for reprocessing.

Devices labeled "for single patient use only" should be discarded properly following use. Reuse of such devices is prohibited unless specific FDA regulations are followed and documented. Check with your facility's risk management department if reuse of devices so labeled is considered.

Sterilization

The CDC (2002) recommends the following principles concerning sterilization or disinfection of patient-care equipment:

1. The major sterilizing agents used in hospitals are:
• Moist heat by steam autoclaving (the gold standard, also minimally toxic)
• Ethylene oxide gas (highly toxic; use is decreasing)
• Peracetic acid (used in proprietary machines, often for endoscopes)
• Plasma (new method with little toxicity)
• Dry heat
2. Steam sterilization is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture (CDC 2008)

Reprocessing Equipment

Reprocessing of reusable patient-care equipment includes both high-level disinfection and sterilization. Both these processes must be preceded by decontamination and careful, thorough cleaning.

Industry guidelines and manufacturer recommendations (of both chemicals and equipment) should be used to develop and update reprocessing policies and procedures.

Written instructions should be available for each instrument, medical device, and equipment reprocessed.

Potential for contamination is dependent upon:

• Type of instrument, medical device, equipment, or environmental surface (material, configuration, or presence of hinges, crevices, or lumens,)
• Frequency of hand contact with the device or surface
• Potential for contamination with body substances or environmental organisms.
• Level of contamination: types and numbers of microorganisms and potential for cross-contamination.

REPROCESSING STEPS

• Pre-cleaning should be done as soon as possible after use, usually at the use location. This removes soil, debris and lubricants from internal and external surfaces.
• Cleaning may be manual (scrubbing with brushes) or mechanical, using an automated washer. Cleaning equipment must be used appropriately. For example, do not reuse disposable cleaning equipment. Cleaning solutions must be changed as directed by the manufacturer.
• Cleaning is followed by either disinfection or sterilization.
• Disinfection requires sufficient contact time of all internal and external surfaces with the solution.
• Sterilization requires sufficient exposure time to heat, chemicals or gases.

The choice of level of reprocessing (sterilization or high-level disinfection) depends on the intended use of the item (whether it will touch sterile spaces or intact mucous membranes). Remember that intermediate and low-level disinfection are used only for environmental cleaning and items that will touch intact skin.

The choice of reprocessing methods must also consider the manufacturer's recommendations for compatibility among equipment components and materials and the chemicals to be used, the heat and pressure tolerance of the equipment and the time and temperature requirements of the reprocessing methods. For example, steam sterilization would not be appropriate for equipment which cannot tolerate heat and moisture.

EFFECTIVENESS OF REPROCESSING

Effectiveness of reprocessing depends on a number of variables.

• Thorough cleaning is essential before either disinfection or sterilization.
• The right disinfectant product must be chosen. High-level disinfectants require immersion, while surface disinfectants are for environmental use.
• Presence of organic matter (inadequate cleaning) inactivates many disinfectants
• Presence of biofilm on the object. Biofilms are constructed by some bacteria, providing protection for the bacteria from hostile environments such as disinfectants. In general, biofilms are not readily removed by chemicals alone, but require mechanical scrubbing. An example of a biofilm is the film on our teeth in the morning, not removed by mouthwash, requiring brushing.

Monitoring of disinfection is essential to document the effectiveness of reprocessing. Factors to be documented include:

• Activity (concentration) of the disinfectant
• Contact time with internal and external components
• Record keeping and tracking of equipment usage and reprocessing
• Handling and storage after disinfection to prevent contamination
• For additional detail, refer to the CDC Guideline for Disinfection and Sterilization, 2008, pages 86–89.

Monitoring of sterilization requires different documentation for different methods. Steam sterilization is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture. (CDC, 2008)

Most sterilization methods require documentation of:

• Biologic monitors: test organisms that are exposed to the sterilization process then incubated to verify that the process killed them
• Process monitors, such as indicator tapes or strips, which change visibly to distinguish between packs that have or have not yet been processed
• Physical monitors (time, temperature, pressure) which document that the physical parameters for sterilization have been met
• Record keeping and a recall system for each item sterilized.
• Packaging, handling and storage after sterilization including definition of when reprocessing is needed (either by event or by time.)

When inadequately reprocessed patient care equipment has been used, this has usually been due to:

• Failure to reprocess or dispose of equipment between patients
• Inadequate cleaning before reprocessing
• Contamination of disinfectant or rinse solutions
• Inadequate disinfection or sterilization processes (failure to monitor the quality of the process)
• Improper storage or handling following reprocessing
• Inadequate/inaccurate record keeping of reprocessing requirements.

HANDLING AND STORAGE OF REPROCESSED ITEMS

Once devices/equipment have been disinfected, proper handling and storage are required to maintain these items in ready-to-use condition. See your facility's policies for specific details.

Proper handling and storage after sterilization, including package integrity and shelf-life or event-related sterility criteria, are required to maintain these items in a sterile state.

Event-related sterility means that sterilized items do not outdate by an arbitrary date, but are judged to be sterile unless an "event" has compromised sterility.  Compromising events include circumstances that break the integrity of the sterile packaging by creating holes or wetting the package, which could carry bacteria into it. This means that the once-sterile package that has come loose, has holes, or shows evidence of wetting, presently or in the past, cannot be used because sterility may have been compromised. The end user of the package is responsible for inspecting its integrity, verifying that no event has compromised sterility.

Every healthcare professional should recognize potential sources of cross-contamination in the healthcare environment and apply infection-control procedures to avoid cross-contamination. These sources include:

• Surfaces or equipment that require cleaning between patients
• Practices that contribute to hand contamination and potential for cross-contamination
• Consequences Implications of reuse of single-use/disposable equipment instruments, or medical devices or equipment. Any consideration of re-use of single-use devices should be reviewed by the facility's risk manager to assure that the requirements of the FDA for such re-use are met. These may be reviewed at http://www.fda.gov/cdrh/reprocessing/.

Lapses in infection control practices resulting in cross-contamination of instruments, medical devices or equipment have led to reported cases of disease transmission. Identified factors which have led to this cross contamination include

• Failure to reprocess or dispose of items between patients
• Inadequate cleaning
• Inadequate disinfection or sterilization
• Contamination of disinfectant or rinse solutions
• Improper packaging, storage and handling
• Inadequate or inaccurate record keeping of reprocessing requirements.

New York State Department of Health Expectations

The New York State Department of Health has stated its expectations with respect to differing levels of disinfection and sterilization methods and agents based on the area of professional practice, setting, and scope of responsibilities.

The area of professional practice dictates the level of responsibility for recognizing various levels of disinfection/sterilization methods and agents. Those health professionals who practice in settings where handling, cleaning, and reprocessing equipment, instruments, or medical and devices are performed elsewhere, such as a dedicated central Sterile Processing Department facility, should:

• Understand core concepts and principles including:
  • Standard/Universal Precautions, such as the wearing of personal protective equipment.
  • The steps of reprocessing and choice of reprocessing methods as described previously.
  • Appropriate application of safe practices for handling instruments, medical devices and equipment in the area of professional practice.
  • Designation of physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended by the NYSDOH.
• Verify with those responsible for reprocessing what steps are necessary before return for reprocessing, such as pre-cleaning and/or soaking. The methods for accomplishing these steps should be described in written procedures.

Professionals who have primary or supervisory responsibilities for equipment, instruments or medical device reprocessing (such as Sterile Processing Department staff or clinics and physician practices where medical equipment is reprocessed on-site) should:

• Understand core concepts and principles including:
  • Standard/Universal Precautions, such as the wearing of personal protective equipment.
  • The steps of reprocessing and choice of reprocessing methods as described previously.
  • Appropriate application of safe practices for handling instruments, medical devices and equipment in the area of professional practice.
  • Designation of physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended by the NYSDOH.
• Determine appropriate reprocessing practices and selection of appropriate methods, considering:
  • Antimicrobial efficacy
  • Time constraints and requirements for various methods
  • Compatibility among equipment/materials, including corrosiveness, penetrability, leaching, disintegration, heat tolerance and moisture sensitivity
  • Toxicity issues, including potential for patient toxicity/allergy, risks to staff, environmental hazards and potential abatement methods, and monitoring of exposures.
  • Residual effects of methods considered, including potential for patient toxicity/allergy and antibacterial residual.
  • Ease of use, including the need for specialized equipment and/or special training requirements.
  • Stability of the materials to be used, including concentration, potency, efficacy of use and the effect on the process of organic material.
  • Odor
  • Cost
  • Monitoring frequency and impact of FDA regulations.

PREVENTING INFECTIOUS DISEASE IN HEALTHCARE WORKERS

Prevention of infectious diseases in healthcare workers (HCWs) means protecting them from infections they do not already have. Management of infectious diseases in HCWs means protecting others from the diseases the worker already does have. This protection must work in both directions!

Protecting healthcare workers from disease is accomplished in many ways, including:

• Use of Standard Precautions with all patients
• Use of additional isolation precautions to protect workers as well as patients
• Influenza vaccine is offered annually and staff are encouraged to accept it as a method for protecting patients. Vaccinating staff against influenza is associated with lower patient death rates from influenza (Carman et al., 2000)

If you suspect that you have been exposed on the job to a communicable disease, let your supervisor and your infection control practitioner know without delay. This will allow evaluation of the circumstances to prevent exposure of others, management of the exposure, and appropriate follow-up of your health as needed. For some diseases, post exposure prophylaxis (preventive medication) is available.

Protecting others from infections of health professionals is a responsibility of the facility and the individual healthcare worker. Employees should report to their supervisor or occupational health service any signs or symptoms of a communicable disease. Symptoms that should be reported and evaluated include:

• Fever
• Unusual rash
• Unexplained blisters
• Purulent skin lesions, such as boils
• Exudative (weeping) dermatitis
• Sore throat with fever
• Gastrointestinal symptoms (vomiting, diarrhea)
• Recent onset of unexplained cough or congestion suggesting an acute respiratory infection
• Jaundice
• Symptoms suggesting active tuberculosis (chronic productive cough with unexplained weight loss, fever, night sweats or hemoptysis [bloody sputum])

Employees who report symptoms of illness should be removed from duty and medically evaluated to determine their ability to work and the duration of work restrictions. Those found to have a legally reportable communicable disease should have their illness reported to the local health unit for follow-up (NYS DOH, 1994).

New York State law also recommends that:

• All healthcare workers whose job responsibilities involve contact with blood or sharp objects likely to be contaminated with blood should be offered and encouraged to receive the hepatitis B vaccine.
• All healthcare personnel should receive information about the risks associated with HIV, HBV, and HCV infection and the merits of knowing their status if they have personal occupational risks so they may benefit from medical management.
• All healthcare workers should be informed that if they have an impaired immune system due to HIV infection or other medical condition, they are at risk of acquiring potentially life-threatening infections, including TB, from patients.
• Information on the availability of voluntary, confidential, anonymous counseling and testing for HIV, HBV, and HCV must be made available to all healthcare workers. Employees must be offered the HBV vaccine and the NYS Department of Health strongly recommends that at-risk healthcare workers receive this vaccine.

The New York State Department of Health (1994) recommends that every health facility and home health agency incorporate the evaluation of personnel for a communicable disease into a broader occupational health program. Policies and procedures should be developed for reporting signs and symptoms of illness and diagnosis of or exposure to a communicable disease. All employees must receive initial and ongoing education regarding these policies and procedures.

Other occupational health strategies for preventing transmission of bloodborne pathogens and other communicable diseases include:

• Pre-employment evaluation to screen for:
  • Tuberculosis
  • Rubella (German measles) immunity
  • Measles immunity
• Annual assessment of staff (including surveillance for TB)
• Influenza immunization
• Removal from work or modification or limitation of work practices

IMMUNIZING AGENTS RECOMMENDED FOR HEALTHCARE WORKERS

Generic Name	Indications
Source: CDC, 1998.
Hepatitis B recombinant vaccine	Healthcare personnel at risk of exposure to blood and body fluids
Influenza vaccine (inactivated whole or split virus)	Healthcare personnel with contact with high-risk patients or working in chronic care facilities; personnel with high-risk medical conditions and/or ≥65 yr
Measles live virus vaccine	Healthcare personnel born in or after 1957 without documentation of (a) receipt of two doses of live vaccine on or after their 1st birthday, (b) physician-diagnosed measles, or (c) laboratory evidence of immunity; vaccine should be considered for all personnel, including those born before 1957, who have no proof of immunity
Mumps live virus vaccine	Healthcare personnel believed to be susceptible can be vaccinated; adults born before 1957 can be considered immune
Rubella live virus vaccine	Healthcare personnel, both male and female, who lack documentation of receipt of live vaccine on or after their 1st birthday, or of laboratory evidence of immunity; adults born before 1957 can be considered immune, except women of childbearing age
Varicella zoster live virus vaccine	Healthcare personnel without reliable history of varicella or laboratory evidence of varicella immunity

IMMUNIZING AGENTS FOR SPECIAL CIRCUMSTANCES

Generic Name	Indications
Source: CDC, 1998.
BCG vaccine (for tuberculosis)	Healthcare personnel in communities where (a) MDR-TB is prevalent, (b) strong likelihood of infection exists, and (c) full implementation of TB infection control precautions has been inadequate in controlling the spread of infection (Note: BCG should be used after consultation with local and/or state health department)
Hepatitis A vaccine	Not routinely indicated for U.S. healthcare personnel; persons who work with HAV-infected primates or with HAV in a laboratory setting should be vaccinated
Meningococcal polysaccharide (quadrivalent A, C, W135, and Y) vaccine	Not routinely indicated for healthcare workers in the United States
Polio vaccine	Healthcare personnel in close contact with persons who may be excreting wild virus and laboratory personnel handling specimens that may contain wild poliovirus
Rabies vaccine	Personnel who work with rabies virus or infected animals in diagnostic or research activities
Tetanus and diphtheria (Td)	All adults; tetanus prophylaxis in wound management
Typhoid vaccines: IM, SC, and oral	Personnel in laboratories who frequently work with Salmonella typhi
Vaccinia vaccine (smallpox)	Personnel who directly handle cultures of or animals contaminated with recombinant vaccinia viruses or orthopox viruses (monkeypox, cowpox, vaccinia, etc.) that infect human beings

Bloodborne Pathogens Training

Bloodborne pathogens training must include:

• Information on hazards associated with blood or other potentially infective material (OPIM)
• OPIM includes 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
• Protective measures to minimize risk of occupational exposure
• Information on appropriate actions to take if exposure occurs

New York State law requires retraining employees every four years, or when changes in procedures or tasks affecting occupational exposure occur.

All employees whose jobs involve participation in tasks or activities with exposure to blood/OPIM shall be offered the first of the hepatitis B vaccination series within 10 working days of employment and/or new assignment. The vaccination is free, safe, and highly recommended.

Serologic testing after vaccination (to verify that the vaccination was effective) is recommended for all persons with potential occupational exposures. The brief summary that follows is not meant to replace or supplant required bloodborne pathogens training.

Although HBV and HIV are specifically identified in the standard, "bloodborne pathogens" include any pathogen present in human blood/OPIM that can infect and cause disease in people exposed to the pathogen. Bloodborne pathogens may also include HCV, malaria, West Nile virus, 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-II, and viral hemorrhagic fever.

The risk of developing HIV infection from a needle stick with infected blood is about 1:300 without prompt antiretroviral treatment. As of December 2002 (latest statistics available), the CDC reported 57 documented and 139 possible cases of HIV seroconversion among healthcare personnel in the United States. Most were exposed to blood through percutaneous injuries, and eight of the workers were infected despite receiving postexposure prophylaxis (PEP) (Do et al., 2003). Twenty-six later developed AIDS.

To prevent transmission of bloodborne pathogens to healthcare workers, the CDC recommends that postexposure prophylaxis (PEP) begin within 1 to 2 hours after the exposure (MMWR, 2001). Specific guidelines are summarized in the box below.

The CDC recommends that healthcare facilities monitor the effects of PEP and track safety and acceptability of different PEP regimens that include new antiretroviral agents. Communication prior to treatment about possible side effects and follow-up during treatment with PEP increase compliance (see table below).

POSTEXPOSURE PROPHYLAXIS FOR HEALTHCARE WORKERS

Disease	Indication
Source: CDC, 1998.
Diphtheria	For healthcare personnel exposed to diphtheria or identified as carriers
Hepatitis A	May be indicated for healthcare personnel exposed to feces of infected persons during outbreaks
Hepatitis B	HBV-susceptible healthcare personnel with percutaneous or mucous-membrane exposure to blood known to be HBsAg seropositive
Meningococcal disease	Personnel with direct contact with respiratory secretions from infected persons without the use of proper precautions (eg, mouth-to-mouth resuscitation, endotracheal intubation, endotracheal tube management, or close examination of oropharynx)
Pertussis	Personnel with direct contact with respiratory secretions or large aerosol droplets from respiratory tract of infected persons.
Rabies	Personnel who have been bitten by human being or animal with rabies or have had scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or other potentially infective material (eg, brain tissue)
Varicella zoster virus	Personnel known or likely to be susceptible to varicella and who have close and prolonged exposure to an infectious healthcare worker or patient, particularly those at high risk for complications, such as pregnant or immunocompromised persons

The following standards are based on recommendations by the CDC (1998).

Healthcare workers who have or may have HBV or HIV should be evaluated for the ability to work safely. This evaluation should be based on the premise that HIV or HBV alone is not sufficient justification to limit the worker's professional duties. Case-by-case evaluation should be done to determine whether an individual healthcare worker poses a risk to patients that warrants job modification, limitation, or restriction. If a patient is exposed to the blood of a healthcare worker, that patient must be informed of the exposure and appropriate follow-up offered.

Periodic re-evaluation of a healthcare worker infected with HIV may be appropriate if the disease progression alters physical or mental functioning. Other factors that may affect the ability of healthcare workers to provide quality healthcare include:

• Lack of compliance with established infection control guidelines
• Appropriateness of techniques as related to performance of procedures
• Any health condition that would pose a significant risk to others

Healthcare facilities are required to establish a mechanism for evaluating healthcare workers with HIV or HBV infection. However, this does not include involuntary screening of employees for HIV or HBV. New York State law prohibits HIV testing of any citizen without written informed consent.

Institutional evaluation of individual workers known to be infected with HIV or HBV shall be based on DOH criteria and shall involve consultation with experts who can provide a balanced perspective. Such experts can include:

• An infectious disease physician and/or hospital epidemiologist with an understanding of HIV/HBV
• A representative from the infected healthcare worker's practice area
• The personal physician of the infected worker

All matters related to evaluation must be handled confidentially.

Any modification of work practice must seek to impose the least-restrictive alternative in accordance with federal disability laws. Workers who believe that their employment has been unfairly restricted or terminated may ask for a second opinion from a DOH review panel and/or file a complaint with the NYS Human Rights Commission.

All HIV-infected healthcare workers are entitled to protection under the New York State HIV Confidentiality Law, as are other citizens. Such workers are not required to disclose their status to patients or employers. For more information about Authorization for Release of Confidential HIV Related Information go to http://www.health.state.ny.us/nysdoh/hivaids/hivpartner/pdfs/authoriz.pdf.

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