HEALTH CARE FACILITY INFECTION CONTROL PROGRAM An …
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HEALTH CARE FACILITY
INFECTION CONTROL
PROGRAM
AN EMPLOYEE HEALTH PERSPECTIVE
Kenneth R. Keller, DO
Employee Health Physician
Medical Director Occupational Health Services
McCullough-Hyde Memorial Hospital
[email protected]
EMPLOYEE HEALTH & INFECTION
CONTROL OBJECTIVES
Minimize communicable disease transmission from
employee to patient and patient to employee.
Reduce the need for treatment and absenteeism
containing costs
Review immunization program
Review major risks of occupational exposure to Infectious
Disease
Review counseling, follow up, and work restriction
recommendations for communicable diseases and following
exposure
Review strategies to accomplish these functions
IMMUNIZATION PROGRAM
Begin with thorough pre-placement
evaluation
Assure immunity to minimize employee
to patient and patient to employee
communicable disease transmission
Must be consistent with the most current
ACIP guidelines
Barriers to success
PRE-PLACEMENT EVALUATION
Immunization record review
Health history review (pregnancy, current health status,
hepatitis, skin condition, TB/ exposure/ skin test conversion,
immune deficient conditions)
Physical examination (less important than history for
infection control purposes)
Lab tests (other than immune titres) and x-ray are generally
of no value)
One of our best opportunities to individually explain
the benefits of our immunization program, not just
for patients, but for the employee, as well.
CDC/ACIP HEALTHCARE PERSONNEL
VACCINATION RECOMMENDATIONS
Hepatitis B – 3 dose series ( now, 1 month, 6 months) IM. Obtain anti- HBs serology 1-2 months
Influenza - 1 dose annually. Inactivated influenza injection IM ( SAFE in pregnancy),Live
MMR (measles, mumps, rubella) - without serologic evidence of immunity or prior
Varicella (chickenpox) - no serologic proof of immunity, prior vaccination or PROVIDER
Tdap ( tetanus, diphtheria, pertussis) - if not previously given, IM ( SAFE in
Meningococcal – one dose to microbiologists routinely exposed to N. meningitidis, IM, SC.
TB skin test ( PPD) - 2 step ( 7-10 days apart), ID, SAFE in pregnancy. Chest x-ray NOT
after dose 3. (SAFE in pregnancy)
attenuated vaccine ( LAIV) intranasaly (NOT SAFE in pregnancy)
vaccination, 2 doses, 4 weeks apart SC. NOT SAFE in pregnancy- recommend protected intercourse 4
weeks post vaccination.
documented disease, 2 doses, 4 weeks apart, SC (NOT SAFE in pregnancy )
pregnancy)
routinely recommended for prior converters- only if symptomatic ( cough, hemoptysis, fevers, weight
loss, other constitutional symptoms ).
MAJOR OCCUPATIONAL INFECTIOUS
DISEASE EXPOSURE RISKS
Bloodborne Pathogens
Tuberculosis
Meningococcus
Selected disease risk to and from patients (Handout)
Selected disease risk from patients to providers (Handout)
Special populations (pregnancy, immunosuppression) (Handout)
For unusual non-major, as well as major, ID concerns immediately involve Infection Control, Employee Health
Officer, Local and State Health Departments.
Ensure your notification follows your policy and any applicable Local or State Health
Department Reporting Requirements.
BLOODBORNE PATHOGENS
29 CFR 1910.1030 – OSHA Bloodborne
Pathogen Standard
Limits occupational Exposure to blood and
other potentially infectious material (OPIM)
Protect workers against exposure that can lead
to disease and death
KEY ELEMENTS
OF THE STANDARD
Record Keeping
Multi-Employer Worksites
Who is covered under the standard
Exposure Control Plan
Compliance
HBV Vaccination, Post-Exposure Evaluation & Follow-Up
Employee Information & Training
RECORD KEEPING
Bloodborne Pathogen Exposure is an Injury
Usually recorded in the OSHA 300 Log
Healthcare Employers must Establish a Separate Sharps Log
(incident description, location, type and brand of device – at
minimum)
MULTI-EMPLOYER WORKSITES
Agency Contractors (Non-Employees)
cannot be Cited in an Exposure
The Contracting Facility (Hospital, etc) is Cited in an Exposure.
Home Health cannot be Cited for Site-Specific Hazards
WHO IS COVERED
UNDER THE STANDARD?
Any employee (full time, part, time,
temporary) with potential for blood or OPIM exposure
Excluding: students, state, county, municipal, and
construction workers.
Also Excluding: “Good Samaritan” (helping co-worker with a
nose bleed, etc)
EXPOSURE CONTROL PLAN
Always reviewed by Compliance Officers
Sample Bloodborne Pathogen Standard Model Exposure Control Plan
available on the OSHA Website
Required for any Employer with one ore Employees wit Potential
for Exposure
Required Yearly Update
Facility Specific
Must Solicit Input From Non-Management
Must be Readily Available to Employees
Must contain Procedures for Investigation/Evaluation of Exposure
Incidents
COMPLIANCE
Universal Precautions
Engineering Controls: Sharps Protection
Hand Washing Facilities: Present & Effective
No Cost PPE
Proper Disposal of Contaminated Waste & Sharps
HBV VACCINE, POST-EXPOSURE
EVALUATION & FOLLOW-UP
HBV vaccine (three shot series ) provided at no cost and
outlined in the exposure control plan (ECP)
Obtained signed declination if refused, vaccine remains
available to them at any time
Beware of current CDC vaccination guidelines
No need to vaccinate if proof of prior vaccination or
immunity (positive titer)
Any unvaccinated employee has vaccine availability to them
within 24 hours of exposure incident
Every effort should be made (and documented) to test the
exposure source
EMPLOYEE INFORMATION
& TRAINING
Initial & Annual Training on Blood &
OPIM Exposure & Protective Measures
Training Conducted & Recorded by Qualified Instructor
Appropriate Biohazard Labeling of Containers &
Refrigerators
TRAINING ELEMENTS
Copy & Explanation of BBP
Standard
Hepatitis B Vaccine
Epidemiology & Symptoms
Emergency Reporting &
Response
Modes of Transmission
Exposure Incident
Employer & Site-Specific ECP
Post-Exposure Evaluation &
Follow-Up
Exposure Determination
Signs & Labels
Hazard Recognition/Risk
Identification
Live Question & Answer
Engineering Controls, Word
Practices & PPE
MAIN CONCERNS
Hepatitis B Virus
Hepatitis C Virus
HIV Virus
HEPATITIS B
Potentially Fatal & Preventable by Effective Vaccination
Over 1 Million Americans are Chronically Infected with Hepatitis B
5,000- 6,000 Deaths Annually due to Liver Disease or Cancer Related
to Hepatitis B
At Risk: IV Drug Users, Multiple Sex Partners (A Sexually Transmitted
Disease) Hemodialysis Patients
Hearty Virus: Can Live in Dried Blood for up to 2 Weeks
High Transmission Risk
1/3 of Patients have No Symptoms
CDC Reports 60,000 New HBV Cases a Year
HEPATITIS C
Most Common Chronic Bloodborne Infection in the U.S.,
Nearly 3,000,000 Active Infections
Chronic Infection may not have Symptoms for up to 2 Decades
Symptoms Similar to Hepatitis B
Chronic Liver Disease Occurs in 70% with 8,000-10,000 Deaths
Annually
Not as Hearty a Virus as Hepatitis B
Lower Transmission Risk, but No Vaccine
HIV VIRUS
Development of AIDS may take Years from Actual Infection with
HIV
40,000 New Cases of HIV / Year per CDC
Virus is Not Hearty & Does Not Survive Well Outside the Body
with Lower Transmission Risk
Less than 100 Reported Cases of Infection due to Occupational
Exposure (Nearly all deep needle sticks)
Risk of Transmission even from Needlestick only 1:300
EXPOSURE INCIDENT
DEFINITION
Contact of Blood or other Potentially Infectious
Material (OPIM) by Sharps Stick, Mucous Membrane
Exposure or Non-Intact Skin Exposure
WHAT IS OPIM?
Practical Definition: All Bodily Fluids
Universal Precautions Refers to Protection from All
Bodily Fluids
WHAT TO DO
IF AN EXPOSURE OCCURS?
Wash with Soap & Water
Report Incident to Superior
Medical Evaluation & Arrangement of Follow-Up ASAP
WHAT HAPPENS IN
THE POST-EXPOSURE PERIOD?
Documentation of the exposure type
Attempt to obtain source testing if applicable
Testing of exposed employees if applicable
Risk counseling of the exposed employee in prophylactic
treatment as indicated per USPHS and CDC guidelines
EXPOSURE RECORD-KEEPING
REQUIREMENT
Employee Name & SS#
Hepatitis B Immune Status
Applicable Test Results & Post-Exposure Follow-Up
Healthcare Provider Written Opinion
Maintain Confidential Records for Duration of
Employment & 30 years
THE BEST WAY TO MANAGE BP
EXPOSURE IN THE WORK PLACE?
PREVENTION!
PREVENTION!
PREVENTION!
PERSONAL PROTECTIVE
EQUIPMENT
Non Latex Gloves
Clothing/Footwear
Eye Protection / Faceshield
FIRST AID PRECAUTION
Gloves
Eye/Faceshield if Splash/Spray Hazard
Universal Precautions – Consider all Bodily
Fluids OPIM
Wash Hands!
HOUSEKEEPING PRECAUTIONS
Gloves for Any Contaminated Object – Including Laundry
Wash Hands ASAP After Removing Gloves
Collect broken Glass, Any Sharp Contaminant with Broom/Dust
Pan
Do Not Touch other Surfaces with Contaminated Gloves
No Food/Drink in Contaminated Area
No Smoking
Wash Hands!
DISPOSAL & DECONTAMINATION
Gloves!
Disinfect with ¾ Cup Bleach to 1 Gallon Water
Spill Clean-Up: Soak Up with Paper Towel, Disinfectant Wipe
Down, Red Bag all Wipes
Wash Hands!
SUMMARY
An Exposure is Blood or OPIM Contact by Sharps Stick,
Mucous membrane or Non-Intact Skin Contact
The Most Important Bloodborne Pathogen is Hepatitis B –
Potentially Fatal & Preventable by Effective Vaccine, Hearty
Organism with High Transmission Risk & the Only Pathogen
Specifically Included in the OSHA ECP
Universal Precautions Requires Considering All Blood &
Body Fluids as OPIM & Taking the Appropriate First Aid &
Housekeeping Precautions
Personal Protective Equipment is Needed for any Potential
Exposure
TUBERCULOSIS
At Risk Population
Annual Facility Risk Assessment
Surveillance/Screening
Annual Training
Steps in Exposure
Managing TB Skin Test (TST) Positives/Conversion
Counseling/Treatment
AT RISK
POPULATION FOR TB
Patient Populations: Foreign Nationals from High Risk
Areas, Alcoholic, IV Drug use, Prison Inmates, Homeless,
Immunosuppression, HIV History
Healthcare Workers (Especially Respiratory Care, those who
Intubate)
Staff Training to Identify those At Risk on Admission for
Triage to Negative Pressure Room in the ED or on a
Medical Floor
ANNUAL FACILITY
TB RISK ASSESSMENT
Moderate or High Risk will Require
Annual Surveillance
May have up to 3 Year Surveillance
Interval if Low Risk
SURVEILLANCE / SCREENING
OSHA Requirement
Must Include Employees, Volunteers, Students & Physicians
New Hire: 2 Step TST Mantoux Technique (0.1 ML -5 Tuberculin
Units – of Purified Protein Derivative Intermediate Intradermal) –
2 Step Required to Prevent Misinterpretation of a Boosted
Response from Recent Infection
If 1 Step 0-9 MM Induration, can Proceed to 2nd Step 1-3 Weeks
After
If Negative TST in Last 3 Months, Only Need 1 Step
If Positive TST ( >= to 10 MM Inuration), Obtain Chest X-Ray
If Prior Positive TST, Do Not Do TST, Chest X-Ray only if
Symptomatic
TB ANNUAL TRAINING
OSHA Required
Epidemiology of TB
Difference Between Latent TB Infection & Disease
Signs, Symptoms & Recognition
Purpose & Interpretation of TST
Multi-Drug Resistant TB & Treatment Problems
PPE & Respiratory Isolation Review (N95, FIT Test,
PAPR)
STEPS TAKEN
Unprotected Exposure (Other than Initial
Encounter) Should be Rare
Baseline PPD ASAP After Exposure
unless One in Previous 3 Months
2nd Step at 10 Weeks Post-Exposure
Referral for TB Evaluation if Positive
TST Response or Symptoms
IN
EXPOSURE
TB COUNSELING & TREATMENT
New TST Converters will Get a Chest X-Ray &
Referral (PCP, Pulmonologist, Health Department)
for Evaluation
They may not Return to Patient Care Until Cleared
by this Evaluation
MENINGITIS EXPOSURE
Neisseria Meningitidis is Spread by Droplet,
not Aerosol
Close Contact – Intubation or Nasotracheal
Suctioning – Required for Occupational
Transmission
Ceftriaxone 125 MG IM X 1 or Rifampin 600
mg every 12 Hours for 4 Doses
Consider No Patient Contact for 24 Hours
After Treatment
STRATEGIES
FOR
SUCCESSFUL
IMPLEMENTATION
Annual Training: OSHA required (hand washing, standard/universal
precautions, PPE, safe sharps handling, spills, biohazard) but also employee
responsibility with communicable disease and any other evolving issues
Cross Talk: Between Employee Health, Infection Control, Health and
Safety, Physician Services (Bylaws, Rules and Regulations) and Volunteer
Services committees and policies
Reporting & Real Time Action Structure: For TB surveillance, employee
or patient communicable or reportable disease.
Secure Employee Health Records: With access on as needed basis.
Preplacement Evaluation: Immunization review
Plan for all Associate Compliance: Thousand mile journey begins with
first step
Remember the Primary Objective: You will need it.
QUESTIONS