Download HEALTH CARE FACILITY INFECTION CONTROL PROGRAM An …

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


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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
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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


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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
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Hand Washing Facilities: Present & Effective
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No Cost PPE
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Proper Disposal of Contaminated Waste & Sharps
HBV VACCINE, POST-EXPOSURE
EVALUATION & FOLLOW-UP
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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
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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
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Not as Hearty a Virus as Hepatitis B
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Lower Transmission Risk, but No Vaccine
HIV VIRUS


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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
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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
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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
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No Food/Drink in Contaminated Area

No Smoking

Wash Hands!
DISPOSAL & DECONTAMINATION
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Gloves!
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Disinfect with ¾ Cup Bleach to 1 Gallon Water

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Spill Clean-Up: Soak Up with Paper Towel, Disinfectant Wipe
Down, Red Bag all Wipes
Wash Hands!
SUMMARY

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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
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Counseling/Treatment
AT RISK
POPULATION FOR TB


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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

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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
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Signs, Symptoms & Recognition
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Purpose & Interpretation of TST
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Multi-Drug Resistant TB & Treatment Problems

PPE & Respiratory Isolation Review (N95, FIT Test,
PAPR)
STEPS TAKEN
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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

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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