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POLICIES MANUAL FOR [Company Name] ADVANCED/BASIC LIFE SUPPORT SERVICE Original DateRevised Dates- January 1991 January 1994 January 1997 January 2000 January 2003 January 2006 Appreciation and acknowledgement to Ephrata Community Hospital Advanced Life Support Service for providing these electronic Sample License Policies 1 Table of Contents Policy 1 Policy 2 Policy 3 Policy 4 Policy 5 Policy 6 Policy 7 Policy 8 Policy 9 Policy 10 Policy 11 Policy 12 Policy 13 Policy 14 Policy 15 Policy 17 Policy 18 Policy 19 Management of Personnel Safety Substance Abuse in the Workplace Placement and Operation of Ambulances Patient Management Use of Lights and Warning Devices Weapons and Explosives Completion of EMS Patient Care Reports Satisfying Documentation Requirements Satisfying Ambulance Standards Satisfying Equipment and Supply Requirements Satisfying Personnel Requirements Communicating with PSAPs Accident Injury and Fatality Reporting Medical Command Notification Dissemination and Protection of Patient Information Participation in Statewide and Regional Quality Improvement Programs Drug Use Control and Security Exposure Control Plan Infection Control Plan Policy 1- Management of Personnel Safety Policy 1-1 Caution with Emergency Response and Horse Drawn Vehicles Policy 16 Pages 3-7 Page 8 Page 9 Page 10 Pages 11-15 Page 16 Page 17-19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Pages 30-48 Pages 49-68 Policy-It is mandatory that care be exercised at all times during an emergency response. However, due to the high incidence of horse drawn vehicles within the response zone, special care must be taken. ProcedureWhen a horse drawn vehicle is observed, discretion is to be used as to whether or not the siren should be turned off so as not to frighten the horse causing an accident. 2 Policy 1-2 Cooperation with Ancillary Services Policy- It is the policy of [Company Name]to work closely with ancillary services to provide optimum patient care through use of the expertise and skills of all levels of certification and ancillary services present. This strengthens patient care and provides additional safety to both patients and crewmembers. Procedure- Upon arrival on scene, acknowledgement of the Advanced/Basic Life Support Service, Rescue and fire services and police are to occur. Their evaluation is paramount in the success of the team concept of patient care and crew safety. Each should continue to function in their realm, cooperating to give expedient quality care and safety to all personnel. Policy 1-3 Fire and Rescue Assistance Policy- In order to provide safety to the crew and the patient, it is mandatory that appropriate support services be present. Procedure- If appropriate services are not dispatched and deemed necessary, appropriate services are to be requested. Policy 1-4 Hazardous Situations Policy- It is of the utmost importance that the crew looks toward the safety of themselves and the unit when arriving at the scene of an incident, then the safety of other persons on scene and finally patients on scene Policy 1Policy 1-4 Management of Personnel Safety Hazardous Situations Procedure: Policy 1-5 1. Upon arrival, the scene is to be surveyed for any potentially dangerous situations. 2. Clearance is to be obtained from fire and/or rescue services on location prior to entering a vehicle and/or scene. 3. Vehicles are to be checked for stabilization and fire potential. 4. Protective gear is to be work as indicated. 5. Police are to be requested to enter and clear residences or scenes prior to crew entry if the situation appears suspicious. 6. Unknown substances are to be identified via placards if available or by manifest. 7. If in doubt as to the situation, do not approach a scene until appropriate authorities have given clearance. Driving Policy- By Pennsylvania law, no emergency vehicle may exceed the accepted posted speed. Therefore, at all times staff should abide by the law governing motor vehicles in the State of Pennsylvania. In addition, under Statewide BLS Protocols, use of lights and sirens are defined for life threatening conditions when transporting patients. 3 Procedure: 1. Excessive speed and/or reckless is not to be tolerated. Any member of the crew has the right to request a reduction in speed. 2. If the driver does not comply with the request, the crew member will direct the driver to decrease the speed immediately. Such action will require a written statement to be given to the Advanced/Basic Life Support Unit Manager and Advanced/Basic Life Support Coordinator explaining the circumstances. 3. A second written complaint within six (6) months of the first will result in suspension from driving the unit for not less than ten (10) shifts. A third infraction will cause suspension from driving for not less than thirty (30) days. 4. All drivers will observe relevant traffic laws. Policy 1- Management of Personnel Safety Policy 1-5 Driving Procedure: 5. Drivers will not be addicted to, or will not drive under the influence of drugs or alcohol. 6. Drivers must be free of any physical or mental disease that may impair his/her ability to drive an emergency vehicle. 7. Drivers may not have been convicted within the last four (4) years of driving under the influence of alcohol or drugs, and within the last two (2) years, has not been convicted of reckless driving or had a driver’s license suspended under the point system. 8. Any driver convicted as stated in #7 above will successfully complete an emergency vehicle operator’s course of instruction after their conviction. 9. All drivers must have a valid Pennsylvania drivers license and be twenty-one (21) years of age or older. 10. It is recognized that each incident must be considered in its own setting and disciplinary action taken accordingly. 11. All new crewmembers will receive instruction during driving training. 4 12. In the event of an accident, the driver shall be suspended from driving until completion of the accident investigation. 13. In the event a driver has been consistently approached by crew regarding driving problems, the Unit Manager and/or Advanced/Basic Life Support Coordinator has the authority to suspend driving privileges. 14. All crewmembers will comply with Pennsylvania Law governing the use of seatbelts. 15. Specific situations identifies as life-threatening are those in which the unit may respond emergency to the hospital with a patient on board. (See BLS Statewide Protocol 123) Policy 1-6 No Smoking in the Ambulance Policy- Due to the hazards present with smoking in an enclosed space with oxygen present, no smoking will be allowed in the Pennsylvania State Certified/Recognized. EMS Vehicle. Policy 1- Management of Personnel Safety Policy 1-6 No Smoking in the Ambulance Procedure: Policy 1-7 Infractions are to be reported with appropriate action taken when necessary by the Unit Manager and/or Operations Chief. Scene Control Policy: In compliance with the Pennsylvania Health Services guidelines, the service recognizes that control of all aspects of patient management at an emergency scene shall be the responsibility of the individual from the dispatched service in attendance who has the highest level of EMS certification/recognition and is affiliated or dispatched with a service whose response area includes the incident scene. Procedure: Individuals shall be recognized based on the following hierarchy of certification/recognition; 1. Health Professional 2. EMT-Paramedic 3. Emergency Medical Technician 4First Responder 5Ambulance Attendant Policy 1-8 Emergency Response 5 Policy: EMS will respond on emergency situation under the criteria as established by Act 45, Act 82 and EMD Priority Dispatch. Procedure: 1. Advanced/Basic Life Support and Basic Life Support responding to an incident scene or to an emergency care facility may use emergency lights and audible warning devices for cases involving patient with life threatening illnesses or injuries as dispatched. Use of emergency lighting on scene is permissible for safety purposes. 2. Advanced/Basic Life Support and Basic Life Support responding to an incident scene or to an emergency care facility may not use emergency lights and audible warning devices for cases involving patient that do not have life threatening illnesses or injuries. Policy 1- Management of Personnel Safety Policy 1-9 Driver Designation Policy: To provide safety for the crew and other motorists, all drivers will complete a driver orientation/evaluation program. This program will be the responsibility of the Unit Manager/ Operations Chief. A driver/trainer may be appointed who holds state EVOC instructor certification. Additionally, all current drivers will be evaluated annually per the Unit Manager. Appropriate forms for documentation of driving skills will be completed. Procedure: 1. All new members, upon approval of application, will be given an orientation packed to include driver orientation material. 2. The driver/trainer will arrange to meet with the new crewmember for unit orientation and review of driving policies. 3. As much as possible, the new crewmember will be assigned to a crewmember for driving evaluation. 4. It will be the responsibility of the Unit Manager to advise the onduty crew of the driver in training. 5. No driver in training will be allowed to serve as the sole driver until completion of this program. 6. Appropriate evaluation forms will be completed and upon satisfactory completion of this program, the new staff member will be elevated to driver. 7. The schedule will indicate the driver in training with a D.T. noted by the individual’s name. 8. All Advanced/Basic Life Support drivers will have yearly checks completed by the Hospital’s Insurance Carrier regarding validity of license and clearance of infractions. 6 Substance Abuse in the Workplace Policy 2 Policy: As a healthcare provider, the Advanced/Basic Life Support Services refuses to allow the mixture of intoxicating beverages or drugs while functioning on the units. The Human Resource Policy regarding this abuse will be strictly followed. The possession, consumption or “being under the influence” of intoxicating beverages or drugs either while on duty or while at station is grounds for immediate dismissal. The use of either intoxication beverages or drugs prior to reporting to duty so that such use can be detected by physical criteria such as smell, slurred speech or unsteady demeanor may result in immediate disciplinary action up to and including dismissal and a request for complaint investigation to the Regional Council. Procedure: 1. Immediate activation of Human Resource Policy regarding substance abuse in the Workplace. 2. If such a situation is suspected, each crewmember is responsible for reporting the offense immediately to the Unit Manager and/or Advanced/Basic Life Support Coordinator. 3. Any crewmember suspected of such abuse should be removed as driver and direct patient care giver pending investigation. 7 Policy 3 Placement and Operations of Ambulances Policy: The Advanced/Basic Life Support Services will be located at the stations indicated in the license application and will primarily responds from that area to provide optimum patient care response. Units will become available when they are the closest unit to the dispatch and/or within their response area. Procedure: 1. etc. 2. 3. 4. The PSAP will be notified if a unit is stationed at another location e.g. stand-by at community event, sports event, All units will operate under required licensure equipment, staffing and response modes. Approved trip reports will be completed on all responses. These will include required patient information and will be completed within twenty-four (24) hours of the call. Initial reports will be given to the receiving facility at the time of patient arrival. 8 Policy 4 Patient Management Policy: The Advanced/Basic Life Support member in charge of the crew will be responsible for all patient care and for assuring that each patient has the appropriate level of provider delivering patient care. Procedure: 1. It will be the responsibility of the crewmember to make sure an adequate number of appropriate level of providers are available and that additional providers are requested to the scene if needed. 2. All necessary equipment and supplies are to be available to provide the appropriate care. 3. All patients are to be managed within the Statewide BLS and ALS Protocols. 4. Patients are to be taken to the appropriate receiving facility as defined by Protocol. 9 Policy 5 1) Use of Lights and Warning Devices Policy: Intent Operators of EMS vehicles are afforded the privilege of using emergency lights and sirens (L&S) to decrease their response time to life-threatening or potentially lifethreatening conditions. Operating emergency vehicles with L&S increases the potential for emergency medical vehicle crashes (EMVCs). Studies have shown that L&S may only decrease transport time by a couple of minutes in most systems and by less than one minute in many systems. Every decision to use L&S response/transport must be based upon the patient’s clinical condition, the estimated time saved by an L&S response/transport, and the increased risk of an EMVC during L&S response/transport. This Policy is in accordance with the EMS Act of 1985, as amended, and further defines section 1005.10(g). In addition, this protocol is secondary to, and does not contradict, the Pennsylvania Motor Vehicle Code (75 Pa C.S.) and BLS Statewide Protocol 123. 2) SCOPE a) This applies to all licensed Advanced/Basic Life Support, basic life support and quick response vehicles b) The following procedures are mandatory: i. L&S may only be used when responding to or transporting a patient with life-threatening or potentially life-threatening condition ii. The EMS vehicle driver is responsible for the mode of response to the scene based upon information available at dispatch and regional medical dispatch (EMD) protocols iii. It is almost never appropriate to transport the patient using emergency warning lights without using the siren when exercising any moving privileges granted to EMS vehicles. iv. Mode of transport for inter-facility transfers will be based upon the medical protocol and the direction of the referring physician who provides the orders for patient care during the transport v. All EMS vehicle operators must be restrained by a seat belt before the vehicle is placed in motion vi. No L&S will be used when advanced life care is not indicated (I.E. Advanced/Basic Life Support cancelled by basic life support or Advanced/Basic Life Support released by medical command) 10 Policy 5 Use of Lights and Warning Devices L&S may be indicated in some situations where Advanced/Basic Life Support is indicated but not available or cancelled, because they cannot rendezvous with the basic life support ambulance prior to transport to the closest appropriate receiving facility. vii. The EMS Practitioner primarily responsible for patient care during transportation will determine the mode of transportation based upon the medical condition of the patient. c) The following procedures are suggested: i. L&S will both be used when exercising any moving privilege granted to EMS vehicles responding in an emergency mode as defined by the Pennsylvania Motor Vehicle Code (75 Pa. C.S.) ii. Low-beam headlights will be on (functioning as day-time running lights) at all times while operating EMS vehicles during L&S and non-L&S driving iii. Seatbelts or restraints will be securely fastened to the following individuals when the vehicle is in motion: 1. All non-EMS passengers in the cab and patient compartment 2. All patients 3. All EMS providers when patient care allows 4. All infants and toddlers should be transported in a child seat if their condition allows 3) DISPATCH RESPONSE PROTOCOL a) General Statement The EHSF, with the approval of the Pennsylvania Department of Health, has adopted the Medical Priority Dispatch (MPD) Program for the region. All PSAP’s have trained personnel and program materials to conduct the MPD Program The Medical Priority Dispatch Program is a comprehensive, nationallyrecognized program for emergency medical dispatch. The MPD Program defines the appropriate EMS resources and response mode for emergency medical calls. Policy 5 Use of Lights and Warning Devices Based on program criteria, the PSAP telecommunicator will instruct dispatched EMS services on the response mode. 11 b) Protocol Criteria The following protocol criteria will define when an EMS service responds with L&S is appropriate: i. EMS services dispatched by the PSAP will respond to the emergency call, as instructed by the telecommunicator, based on the MPD Program criterion and response mode. ii. Changes in the response mode can occur, as directed, by the PSAP telecommunicator or based on additional information available to the EMS service. If a change occurs justification for response mode change must be documented on the patient care report and/or EMS service incident report iii. The response mode has been modified to reflect the regional EMS system. The modification has been reviewed, and approved by the Regional Medical Director, as follows: 1. Class 3 – Closest Basic Life Support Ambulance without L&S 2. Class 2 – Closest Basic Life Support Ambulance with L&S 3. Class 2 – Closest Basic and/or Advanced/Basic Life Support Ambulance with L&S 4) TRANSPORTATION PROTOCOL a) General Statement Emergent transport should be used in any situation in which the most highly trained EMS Practitioner believes that the patient’s condition will be worsened by a delay equivalent to the time that can be gained by emergent transport. A medical command physician may be used to assist with this decision. The justification for using this criterion should be documented on the Patient Care Report. Note; In most cases (up to 95% of EMS calls), EMS can perform the initial care required to stabilize the patient’s condition to a point where the small amount of time gained by L&S transport will not affect the patient’s medical condition or outcome. Policy 5 Use of Lights and Warning Devices b) Protocol Criteria The following medical criteria will define when patient transportation to a receiving facility with L&S is appropriate: i. Vital signs (outside listed limits with possibly related illness or injury) 1. Systolic BP< 90mmHg with possibly related disease or trauma 2. Systolic BP> 200 mmHg with possibly related disease or trauma 3. Respiratory rate > 32 per minute with patient as relaxed as possible 12 4. Respiratory rate <10 per minute 5. Pulse rate <50 beats per minute 6. Pulse rate > 150 beats per minute with patient relaxed as possible ii. Airway 1. Inability to establish or maintain patent airway 2. Upper airway strider iii. Respiratory 1. Severe respiratory, distress unresponsive to standard basic or Advanced/Basic Life Support treatment. Objective criteria may include oxygen saturation less than 90%, retractions, strider, or respiratory rate >32 per minute or < 10 per minute iv. Cardiac 1. Cardiopulmonary arrest (including persistent ventricular fibrillation, hypothermia, overdose/poisoning, pediatric arrest). Patients in asystole that have not responded to standard Advanced/Basic Life Support intervention may not warrant the risks associated with L&S transport 2. Severe uncontrolled hemorrhage of any source 3. Diastolic BP > 130 mmHg with possibly related disease or trauma Policy 5 Use of Lights and Warning Devices v. Trauma 1. Penetrating wound to head, chest, or abdomen except for obviously superficial wounds 2. Penetrating or blunt neck trauma except obviously superficial or mild wounds 3. Two or more suspected proximal long-bone fractures 4. Suspected pelvic fracture 5. Flail chest vi. Neurologic 1. Glasgow Coma Score of <13, only if acute change of any cause 2. Generalized seizure activity not controlled by standard basic or Advanced/Basic Life Support intervention vii viii Obstetric 1. Potentially complicated birth including, but not limited to, cord prolapse, premature labor, and delayed delivery Pediatrics 13 1. 2. ix. Upper airway strider All patients <8 years of age should be evaluated individually based upon the history, degree of distress, and the EMS Practitioner’s experience with patients of this age; when in doubt, seek advice from a medical command physician Behavioral 1. Any patient exhibiting aggressive behavior or who might otherwise jeopardize the safety of self or EMS Practitioners When in doubt, contact a medical command physician for advice and guidance Policy 6 Weapons and Explosives Policy: In accordance with EMS legislation, no crewmember will wear on their person, nor carry aboard any ambulance, any firearms, weapons or explosives. This policy does not apply to law enforcement officers who are serving in an authorized law enforcement capacity and are governed by the policies and procedures of their respective police department. 14 Policy 7 Policy 7-1 Completion of EMS Patient Care Reports Charting Policy: Because of the medical/legal issues involved in pre-hospital care, complete and thorough documentation of the situation, assessment and treatment are to be completed. All calls should undergo complete audit and deficiencies noted. Procedure: 1. All data is to be recorded: a. Location of incident b. Date and times as indicated c. Units responding d. Patient information i. Name ii. Date of birth iii. Age iv. Attending physician v. Parent or guardian, if patient is a minor vi. Power of attorney, if indicated vii. Chief complaint as patient statement viii. Past medical history ix. Current drug therapy x. Allergies xi. Vital signs and assessment xii. Social security number and/or Medicare number. xiii. Treatment and identification number of provider(s). xiv. Examination and assessment findings xv. Response to treatment xvi. Condition on arrival receiving facility. xvii. Mileage 15 xviii. Accurate times xix. Requested receiving facility xx. Documentation of receiving facility xxi. Information as indicated. e. Crew identification and certification numbers, signatures as indicated. Policy 7 Policy 7-1 Completion of EMS Patient Care Reports Charting Procedure: f. g. Disposition Police, fire, rescue, ancillary services, BLS service, coroner, etc. 2. Narrative should have certification number of crewmember completing at the end of the report with date and time of completion. Policy 7-2 Initial Patient Report Policy: The Advanced/Basic Life Support Service provides the initial care in the prehospital setting. The care is important for healthcare personnel at the receiving facility. It is vital that patient care activities performed by prehospital personnel be provided to the healthcare personnel upon arrival of the patient at the receiving facility. This policy will identify the vital information that must be provided by prehospital personnel at the time of patient transfer at the receiving hospital. Procedure: Transfer of information protocol1. All EMS practitioners will provide the following information when a patient is transported to a receiving facility: a. Patient Name b. Age c. Chief complaint d. Past medical history e. History of present illness f. Medication (s) g. Treatment h. Response to treatment 2. An EMS practitioner must remain with the patient and may not release patient to the receiving facility until the transfer of information is complete. 16 Policy 7 Policy 7-3 Completion of EMS Patient Care Reports Completion of EMS Patient Care Reports Policy: Complete, detailed and accurate documentation must occur on all patients for legal and medical reasons. This is done through use of Pennsylvania Approved Electronic Data System. In addition, all HIPAA regulations will be followed. Procedure: 1. All trip sheets will be numbered to identify sequence of calls and patient information. 2. All information will be completed as soon as possible and MUST be done within twenty-four (24) hours of the call. 3. Location of the call is the address, including zip code, of the dispatch. 4. The nature of the call as dispatched should be indicated. 5. Crewmembers are to be identified by certification number. 6. All crewmembers should sign the completed trip sheet. 7. The crewmember completing the narrative should indicate their certification number at the end of the narrative along with date and time completed. 8. Police, fire, rescue and physicians on location should be identified at the bottom of the narrative portion. 9. Radio problems, if present, are to be identified as indicated. 10. Full physical assessment is to be documented. 11. Response to treatments and review of treatments should be documented. 12. Frequent assessment of vital signs and condition are to be recorded. 13. Remember, this is a legal document. Nothing incriminating is to be stated and only that which is witnessed and can be verified is to be documented. Avoid judge mental statements as assumptions. Document any on-scene problems as indicated. 14. Patient comments should be documented as quotes 15. Patient request for receiving hospital are to be documented. 16. Diverts are to be documented with the appropriate reason for divert. 17 Policy 8 Satisfying Documentation Requirements Policy: A complete documentation review of all trip sheets will occur in order to identify areas of weakness in documentation and to improve the method in which documentation occurs. Review will occur through the Privacy Officer and will follow all HIPAA Regulations. Procedure: 1. All calls will be reviewed for accurateness of information and completion of required information. 2. Major documentation errors will be reviewed with the crew involved. 3. General review of documentation errors will be provided to staff members. 4. Areas of need will be identified and appropriate continuing education review given in the identified areas of deficiency. 18 Policy 9 Satisfying Ambulance Standards Policy: At all times the Advanced/Basic Life Support Service will comply with ambulance standards. Procedure: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. The following standards will be followed: Staffing Satisfying equipment and supply requirements Continuing education of providers State wide quality assurance program Patient reporting Driving Response Communication with PSAP Infection control Management of personnel safety Substance abuse in workplace Placement and operations of ambulances Patient management Use of lights and warning devices Weapons and explosives Completion of EMS patient care reports Satisfying documentation requirements Satisfying personnel requirements Accident, injury and fatality reporting Dissemination and protection of patient inform State Wide BLS Protocol Regional ALS Protocol 19 Policy 10 Satisfying Equipment and Supply Requirements Policy: At all times the Advanced/Basic Life Support vehicles will comply with licensure equipment and supply requirements. It will be the responsibility of association members to make sure all supplies and equipment are present and all equipment and supplies used during patient care are replaced upon return to quarters. Procedure: 1. Vehicle checks will be performed as scheduled with documentation of the compliance with requirements in equipment and supplies. 2. All crewmembers are responsible for replacing supplies and equipment used upon return to quarters. 3. Equipment left at the receiving facilities will be replaced with back-up equipment and documentation will be posted as to what equipment has been left at which receiving facility. 4. Stock levels will be defined and posted. 20 Policy 11 Satisfying Personnel Requirements Policy: The Advanced/Basic Life Support Service, in compliance with the Pennsylvania State Department of Health guidelines and the Emergency Health Services Federation of South Central Pennsylvania will adhere to the Advanced/Basic Life Support Squad Staffing Requirements. Procedure: 1. Basic crew structure will be no less than one Advanced/Basic Life Support certified crewmembers. 2. All crewmembers will be designated drivers. 3. Crew structure can be expanded to two ALS providers, One ALS provider and one EMT-Driver. 4. Crew structure will be provided twenty-four (24) hours per day, seven (7) days per week in accordance with required licensure staffing patterns. 21 Policy 12 Communication with PSAPs Policy: In order to provide appropriate care, the Advanced/Basic Life Support Staff will communicate to the PSAPs the status of the association and the vehicles. Procedure: 1. The association will advise the PSAPs when a vehicle is unavailable for prehospital dispatch, e.g. out for maintenance, out on a stand-by, not staffed, etc. 2. On response, the ambulance driver will advise the PSAPs of response. 3. In addition, the ambulance driver will advise the PSAPs of the following- on scene, transporting to receiving facility, arrival at receiving facility, returning to quarters and in quarters. 4. All requests for additional assistance will be directed to the PSAPs either directly or through incident command. 22 Policy 13 Accident Injury and Fatality Reporting Policy: The Advanced/Basic Life Support Coordinator or Unit Manager will report to the Emergency Health Services Federation, on the appropriate forms, any ambulance vehicle accident that is reportable under 75 Pa.C.S., and an accident or injury to an individual that occurs in the line of duty of our association that results in a fatality, or medical treatment at a facility. The report will be made within twenty-four (24) hours after the accident or injury. The report of a fatality shall be made within eight (8) hours after the fatality. 23 Policy 14 Medical Command Notification Policy: The Advanced/Basic Life Support Staff are encouraged to contact medical command whenever there is a question as to patient care, need to provide patient assisted medications, need for additional assistance, when protocol dictates contact and whenever a patient is refusing medical care. Procedure: 1. The crew member in charge of the call will contact the receiving hospital. 2. A request for medical command will be given. 3. A brief patient report and request for assistance will be communicated. 4. Documentation of time and request will occur on the patient trip report as well as documented of the command physician. 5. Documentation of the command physician’s response will also be provided on the patient care report. 6. If requested by the command physician, assistance will be provided for the command physician to talk directly to the patient. 7. Where appropriate and documented through ALS protocol, ALS notification may be given to the receiving hospital. 24 Policy 15 Dissemination and Protection of Patient Information Policy: Compliance with all State and HIPAA requirements regarding storage of documents both on computer and as hard copy will be strictly followed. All information will be kept confidential and access to the documents will be restricted. Procedure: 1. Access to creating trip sheets will be limited to ALS Staff with secure passwords into system. 2. Electronic trip sheets will be completed and sent to the receiving facility via designated fax numbers with twenty-four (24) hours of the call. 3. Printed copies of the trip sheet will be secured in the association office for reference and billing purposes and will be reviewed only by those individuals responsible for these purposes. 4. The association will maintain these documents in a secure place. 5. NO ASSOCIATION MEMBER NOT ON THE CALL WILL BE PERMITTED TO OBTAIN INFORMATION REGARDING THE CALL EXCEPT FOR QI REVIEW. 6. NO ASSOCIATION MEMBER SHALL DISCUSS PATIENT CONFIDENTIAL INFORMATION. 7. All patients will be advised of their rights under HIPAA and appropriate forms completed. 25 Policy 16 Participation in Statewide and Regional Quality Improvement Programs Policy: [Company Name] will comply with all Statewide and Regional Quality Improvement Programs. Procedure: 1. All information requested will be submitted to the appropriate agency. 2. All patient data will be submitted to the Regional Council as directed. 3. All association calls will be reviewed for appropriateness of documentation and care. 26 Policy 17 Drug Use Control and Security Policy: In compliance with the Controlled Substance Act and the Harrison Narcotics Act, it is the responsibility of the ALS Staff to verify narcotics and controlled substances on the vehicle and sign the narcotic sheet at the beginning of each shift. Procedure: 1. 2. 3. 4. 5. 6. 7. A staff member is to verify drugs at the beginning of his/her shift. The record will be located in the drug cabinet. Any drugs used will be signed out on both the Advanced Life Support form and with the narcotics in the Emergency Department. Narcotics are to be replaced as soon as possible from the Emergency Department. Valium is not to be replaced from Emergency Department Stock. Replacement will be from the Pharmacy. The ALS Units are to be kept locked at all times when the crew members are not in attendance. The drug cabinet is to be locked as well. The narcotics sheet will be taken to the pharmacy when completed. 27 Policy 18 A. Exposure Control Plan Purpose of the Plan One of the major goals of the Occupational Safety & Health Act (OSHA) is to regulate services, where work carried out, to promote safe work practices in an effort to minimize the incidence of illness and injury experienced by staff. Relative to this goal, OSHA has enacted the Bloodborne Pathogens Standard, codified as 29 CFR 1910.1030. The purpose of the Bloodborne Pathogens Standard is to “reduce occupational exposure to Hepatitis B (HBV), Human Immunodeficiency Virus (HIV), and other bloodborne pathogens” that staff may encounter in their workplace. The Advanced/Basic Life Support Service supports the following general principles in working with bloodborne pathogens. It is prudent to minimize all exposure to bloodborne pathogens Risk of exposure to bloodborne pathogens should never be underestimated. The Advanced/Basic Life Support Service will institute as many environmental and work place practice controls as possible to eliminate or minimize staff exposure to bloodborne pathogens. The Advanced/Basic Life Support Service has implemented this Exposure Control Plan to meet the letter and intent of OSHA Bloodborne Pathogens Standard. The objective of this plan is two fold: B. To protect staff from the health hazards associated with bloodborne pathogens To provide appropriate treatment and counseling should a staff be exposed to bloodborne pathogens. Responsible Persons 1) Designated Officer (Infection Control Coordinator) The “Designated Officer” will be responsible for the overall management and support of The Advanced/Basic Life Support Service Bloodborne Pathogens Compliance Program. Activities which are delegated to the Designated Officer typically include but are not limited to: 28 Overall responsibility for implementing the Exposure Control Plan for the entire service Working with the Service Administrators and other employees to develop and administer any additional bloodborne pathogens related policies and practices needed to support the effective implementation of this plan. Identifying opportunities to improve the Exposure Control Plan, as well as review and/or revise the bloodborne pathogens safety and health information Collecting and maintaining a suitable reference library on the Bloodborne Pathogens Standard and bloodborne pathogens safety and health information Acting as service liaison Conducting periodic audits to maintain up-to-date Exposure Control Plan Personal Protective Equipment (P.P.E.) and availability of P.P.E. within the service. Maintaining an up-to-date list of staff requiring training Developing a suitable education/training program Scheduling periodic training seminars for staff Maintaining appropriate training documentation such as “Sign in Sheets”, “Quizzes”, etc. Annual review of the training programs to include appropriate new information 2) Staff Staff has the most important role in a bloodborne pathogens compliance program. Ultimate execution of much of the Exposure Control Plan rests with the staff. In this role, they must do the following: C. Know what tasks they perform that have occupational exposure Attend bloodborne pathogens training session Plan and conduct all operations in accordance with our work practice controls Develop good personal hygiene habits Availability of Exposure Control Plan to Staff To assist the staff with their efforts, the Advanced/Basic Life Support Service Exposure Control Plan must be available to all staff at any time. Staff is advised of this availability during their training sessions. Copies of The Advanced/Basic Life Support Service Exposure Control Plan are kept in the following locations: D. Each service vehicle Staff Quarters Service Offices Review and Update of the Plan 29 The Advanced/Basic Life Support Service recognizes that it is important to keep the Exposure Control Plan up-to-date. To ensure this, the plan will be reviewed and updated under the following circumstances: E. Annually Whenever new or modified tasks and procedures are implemented which affect occupational exposure of staff Whenever staff jobs are revised such that new classifications are developed or new instances of occupational exposure are identified Exposure Determination The exposure determination is made without regards to the use of personal protective equipment. One of the keys to implementing a successful Exposure Control Plan is to identify exposure situations staff may encounter. To facilitate this success the following lists have been prepared: Job classifications in which all staff have occupational exposure to bloodborne pathogens Job classifications in which some staff have occupational exposure to bloodborne pathogens Tasks and procedures in which occupational exposure to bloodborne pathogens occur F. Implementation Schedule and Methodology OSHA requires that this plan contain a method of implementation of the various requirements of the standard. The elements of the standard include the following Exposure Determination Universal Precautions Handwashing Disposal of sharps Eating, drinking, smoking, applying cosmetics and handling contact lenses Storage of food and drink Leak-proof containers Contaminated equipment Sharps containers Closable leak-proof containers 30 2. Red bags for regulated waste Handwashing facilities Antiseptic towelettes Personal protective equipment Disposable gloves Hypoallergenic gloves Utility gloves Face protective: o Masks o Goggles Protective body clothing Foot wear and head wear Respiratory equipment Hepatitis B Vaccine Post Exposure Evaluation and Follow-up Labels and signs Record keeping COMPLIANCE METHODS a. Universal Precautions The Advanced/Basic Life Support Service has observed the practice of Universal Precautions to prevent contact with blood and other potentially infectious materials. It is reviewed and revised annually and as necessary. The ALS Service treats all human blood and the following body fluids as if they are known to be infectious for HBV, HIV and other bloodborne pathogens: Blood and any other body fluid/tissue containing visible blood Semen Vaginal secretions Cerebrospinal fluid Amniotic fluid In circumstances where it is difficult or impossible to differentiate between body fluid types, we assume all body fluids to be potentially infectious. Personnel Hand washing Equipment Hand washing Facilities Location OSHA requires that these facilities be readily accessible after incurring exposure. Staff should be familiar with locations at receiving facilities Hand washing Antiseptic Towelettes: Policy 18 Exposure Control Plan 31 Antiseptic towelettes shall be provided for those times when hand washing facilities are not available. A sufficient amount or alternate antiseptic cleanser shall be available at all times in the patient compartment of the vehicle Hands are to be washed as soon as hand-washing facilities are available. Sharps Disposal Containers Containers should have the following characteristics: Puncture-resistant Red in color or labeled with a biohazard warning label Leak-proof on the sides and bottom Easily accessible Staff Work Practice Controls The following Work Practice Controls are in place; 1. Handwashing: Staff shall wash their hands immediately, or as soon as feasible, after removal of personal protective gloves or equipment. Staff shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If staff incurs exposure to their skin or mucous membranes, those areas shall be washed with soap and water or flushed with water as soon as feasible following contact. Antiseptic toweletts are used in areas where hand washing in not feasible until soap and water are available. Needles and Disposable Sharps Contaminated needles and other contaminated sharps shall not be bent, recapped, removed, sheared or purposely broken. Sharps Containers Contaminated, used sharps are to be carefully placed in appropriate container as soon as possible after use. This should be done with care. Work Area Restrictions In the work area where there is a reasonable likelihood of exposure to blood or other potentially infectious material, staff is not to eat, drink, apply cosmetics or lip balm, smoke or handle contact lenses. Policy 18 Exposure Control Plan All procedures will be conducted in a manner, which will minimize splashing, spraying, splattering, and generating droplets of blood or other potentially infectious wastes. Contaminated Equipment 32 Equipment which has become contaminated with blood or other potentially infections materials shall be decontaminated as necessary, unless the decontamination of the equipment is not feasible. Personal Protective Equipment Personal Protective Equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The personal protective equipment will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through or reach the staff’s clothing, 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. The Advanced/Basic Life Support Service assures that appropriate personal protective equipment in the appropriate size is readily accessible in the vehicles. All personal protective equipment will be cleaned, laundered, and /or disposed of as indicated. All garments, which are penetrated by blood, shall be removed immediately or as soon as feasible. All disposable protective equipment must be discarded in a red plastic bag and treated as contaminated waste. All personal garments are to be decontaminated prior to removal from the receiving facility. 1. Gloves: Gloves shall be worn whenever or wherever it is reasonably anticipated that employees will have had contact with blood, other potentially infectious materials, non-intact skin and mucous membranes. Gloves will be available to staff members in sufficient size, amount and type. Disposable gloves provided are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if Policy 18 Exposure Control Plan torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use if the integrity of the glove is not compromised. Discard utility gloves if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised. 2. Masks/eye protection Masks, in combination with eye protection devices, such as goggles or glasses with solid side shield or chin length face shields, are required to be worn whenever splashes, spray, splattering or droplets of blood or 33 other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated. 3. Others Appropriate protective clothing such as, but not limited to, gowns, coats, or similar outer garments shall be worn in occupational exposure situations. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated. 4. Personal Protective Equipment-Service specific – See attachment 5. Environmental Cleaning Maintaining service vehicles in a clean and sanitary condition is an important part of The Advanced/Basic Life Support Service Bloodborne Pathogens Compliance Program. Written schedule for cleaning and decontamination of various equipment and vehicle shall be posted. The following will be included in this schedule: a. b. c. d. Area or items to be cleaned/decontaminated Schedule or frequency of cleaning/decontamination Cleaners and disinfectants to be used Persons responsible for decontamination Using this schedule, staff will employ the following practices; Policy 18 Exposure Control Plan All equipment and surfaces are cleaned and decontaminated after contact with blood or other potentially infectious materials; a. Immediately (or as soon as feasible) when surfaces are overtly contaminated b. After any spill of blood or infectious wastes c. At the end of any response in which contamination may have occurred. 6. Regulated waste In handling regulated waste (including contaminated sharps, used bandages, and other potentially infectious materials), the following procedures are to be followed: a. All waste from the service that is possibly contaminated by infectious biological waste will be collected in impervious red double bags or containers that are: i. Closeable 34 ii. Puncture-resistant iii. Leak-proof iv. Red in color 7. b. Containers for this regulated waste will be located as close as possible to the waste source. c. Waste containers lined with red plastic bags are maintained upright, routinely emptied to prevent overfilling. They will be securely closed prior to removal. d. Staff will not transfer contaminated waste into another container and shall not sort through the contents of infectious waste without use of a mechanical device. Linen procedures Laundry, contaminated with blood or other potentially infectious materials will be handled as little as possible. Policy 18 Exposure Control Plan All staff who handles contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious material. 8. Hepatitis B Vaccination Post Exposure Evaluation and Follow-up The Advanced/Basic Life Support Service recognizes that even with good adherence to all of its exposure preventing practices, exposure incidents can occur. As a result, The Advanced/Basic Life Support Service has implemented a Hepatitis B Vaccination Program, as well as set up procedures for post-exposure evaluation and follow-up should exposure to bloodborne pathogens occur. a. Vaccination Program: To protect staff as much as possible from the possibility of Hepatitis B infection, the service has implemented a vaccination program. This program is available to all employees who have been identified as having exposure to blood or other potentially infectious materials, at no cost to the staff. The Vaccine is offered upon acceptance as a staff member. 35 The vaccination program consists of a series of three inoculations over a six-month period. Staff will receive information on this program upon acceptance with the association. The Designated Infectious Control Officer is responsible for setting up and operating this vaccination program. Vaccinations will be obtained through Ephrata Community Hospital Employee Health. 9. Post Exposure Evaluation and Follow-up When a staff member incurs an exposure incident which involves bloodborne pathogens, it is to be reported to the Designated Infection Control Officer immediately. Policy 18 Exposure Control Plan The Designated Infection Control Coordinator investigates all exposure incidents that occur and is responsible for maintaining records of the exposure incident. All staff that incurs an exposure incident will be offered a confidential medical evaluation and follow-up including * Date, time and location of incident 10. If possible, the identification of the source individual, and if possible, determination of the HIV and HBV status of the source individual. The blood of the source individual will be tested (after consent is obtained). All this will be done in conjunction with the Infection Control Nurse of the receiving facility based on the Exposure Control Plan of that facility. All counseling will be under the investigating facility. Training Having well informed and educated staff is extremely important when attempting to eliminate or minimize staff exposure to bloodborne pathogens. Because of this, all staff who has the potential for exposure to bloodborne pathogens is to attend a comprehensive training program. Staff will be retrained at least annually to keep their knowledge current. The training will be the responsibility of the Designated Infection Control Officer. 36 Training topics: 1. Copy of the Bloodborne Pathogens Standard with an explanation. 2. Epidemiology and symptoms of bloodborne diseases. 3. Modes of transmission of bloodborne pathogens 4. Exposure Control Plan Policy 18 Exposure Control Plan 5. Appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials. 6. Control methods, which will be used to control exposure to blood or other potentially infectious materials. a. Work practice controls b. Personal protective equipment c. Universal precautions 7. Personal protective equipment a. b. c. d. e. f. g. Types available and selection Proper use Location Removal Handling Decontamination Disposal 8. Visual warnings of biohazards including labels, signs, and “color coded” containers 9. Information on the Hepatitis B Vaccine, including a. b. c. d. e. Efficacy Safety Method of administration Benefit of vaccination Staff vaccination program 10. Actions to take and persons to contact in an emergency involving blood or other potentially infectious materials. 11. Procedures to follow if an exposure incident occur, including incident reporting. 12. Information on the post-exposure evaluation and follow-up including medical consultation Methods used for training include several techniques as listed below: 37 Classroom type atmosphere with personal instruction Video tape programs Policy 18 Exposure Control Plan Training manuals/employee hand-outs Because staff needs an opportunity to ask questions and interact with instructor, time is specifically allotted for these activities in each training session. Record Keeping The Designated Infection Control Coordinator maintains comprehensive medical records on staff and is responsible for setting up and maintaining these records, which include the following information: 1. Name of staff member 2. Social security number of staff member 3. Copy of the staff member’s Hepatitis B vaccination status a. Dates of any vaccination b. Medical records relative to the staff member’s ability to receive vaccination 4. Documentation of any exposure incident and action taken as a result of that incident As with all information in these areas, The Advanced/Basic Life Support Service recognizes that it is important to keep information in these records confidential; therefore, no release of information will occur without staff member’s written consent. Training Records The Designated Infection Control Coordinator will maintain all training records of staff containing the following: Dates of all training sessions Contents/summary of the training sessions Names and qualifications of the instructors Names of staff attending the training sessions Individuals Bloodborne Regulations checklist will be kept in the staff members file. Availability Records shall be available upon request to an OSHA Representative Policy 18 Exposure Control Plan 38 Training records shall be provided upon request for examination and copying to staff or their representative The Advanced/Basic Life Support Service shall notify OSHA 3 months prior to disposal of staff medical records. Original Date: Reviewed: Revised: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Records will be kept secure with no access to anyone other than the Designated Infection Control Coordinator. DEFINITION OF TERMS The following definitions, taken from the OSHA Rules are provided for easy reference and apply throughout this plan. Blood: Human blood, human blood components, and products made from human blood. 39 Bloodborne Pathogens: Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Contaminated: The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. Contaminated laundry; Laundry which has been soiled with blood or other potentially infectious materials or may contain sharps Contaminated sharps: Any contaminated object that can penetrate the skin including, but not limited to, needles, broken glass, etc. Decontamination: The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are not longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal. Exposure incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of staff duties. Hand washing Facilities: A facility providing an adequate supply of running portable water, soap and single towels or hot air drying machines HBV; Means Hepatitis B Virus HIV: Means human immunodeficiency virus Occupational Exposure: Means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of a staff member’s duty. Other Potentially Infectious Materials: Means The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural (1) (2) (3) 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 the body fluids; Any unfixed tissue or organ (other than intact skin) from a human (living or dead), and; HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV 40 Parenteral: Means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions. Personal Protective Equipment: Is specialized clothing or equipment worn by an employee for protection against a hazard. General work cloths (e.g., uniform, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment (P.P.E.) Regulated Waste: Means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling: contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. Source Individuals: Means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to staff. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disables; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood components. Universal Precautions: Is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Work Practice Controls: Means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g. prohibiting recapping of needles by a two-handed technique) APPENDIX A The Advanced/Basic Life Support Service Staff positions in which all staff have occupational exposure to bloodborne pathogens: Advanced/Basic Life Support Providers Emergency Medical Technicians First Responders Emergency Care Providers Ambulance Attendants Staff positions in which some staff have occupational exposure to bloodborne pathogens: None Tasks and procedures in which occupational exposure to bloodborne pathogens occur (these tasks and procedures are performed by staff in the above lists) and all personal protective equipment required to perform the tasks and procedures listed: 41 Hand washing gloves Procedure Bandaging X Gown Mask X Eye Shoe Protection Covers * * * *__ Ventilation X X Assessment X *_____________________________________ Vital Signs X______________________________________________ All Patient Contact X______________________________________________ Control of bleeding X X * *__________ * * *_ Incontinent patients X X____________________________________ Trauma Patients X X OB Patient X Respiratory Pt. X X * * X * * * * * * * * * ________________________________________________________________________ Key: X = Routinely S = If soiling is likely * = If splattering is likely Personal Protective Equipment Personal Protective Equipment Location Cleaning reusable Discard Disposables Gloves On Unit N/A Dispose in red lined trash container in area of use Splash shields On Unit N/A Same as above Eye Protection On Unit N/A Same as above Fluid resistant gowns Disposable On Unit N/A Same as above Protective Suits On Unit N/A Same as above Sterile Procedure 42 Antiseptic Towelettes On Unit N/A Dispose in red lined trash containers in area of use Infection Control Policy and Procedure Manual Universal Precautions POLICY: It is the policy of [Company Name] to minimize contact with blood and body fluids by care given; Minimize likelihood of transmission of specific organisms, such as Hepatitis B, Human Immunideficiency Virus (HIV) Use consistent disposal practices Increase confidentiality for patients Have consistent application of infection control principles by Universal Precautions for any patient treated by our services PROCEDURES: A. Guidelines for “Universal Precautions” : (MMWR, August 21, 1987) 1. All staff should routinely use appropriate barrier precautions to prevent skin and mucous-membrane exposure when in contact with blood or other body fluids of any patient is anticipated. a. Gloves are to be worn when touching blood and body fluids, mucous membranes or non-intact skin of any patient, for handling items or surface 43 soiled with blood or body fluids. Also for performing any treatment that could result in contamination. Gloves are to be changed after contact with each patient. b. Masks and Protective Eyewear are to be worn during procedures that are likely to generate droplets of blood or body fluids such s in wound care, suctioning, etc. c. Gowns are to be worn during procedures that are likely to generate splashes of blood or body fluids 2. Hands and other skin surfaces are to be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed. 3. All health care workers should take precautions to prevent injuries caused by sharps, sharp instruments or devices during procedures, cleaning of equipment, during disposal of sharps. a. Adequate lighting should be used when performing procedures where there is a danger of injury from sharps, or contamination by bodily fluids B. 4. Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be strategically located and available for use in areas where the need for resuscitation is predictable. 5. Staff who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment until condition resolves Application of Universal Precautions According to the CDC updates, (MMWR, June 24, 1988) Universal Precautions should be used when contact with the following fluids/tissues is anticipated; 1. 2. 3. 4. 5. 6. 7. 8. Blood and any other body fluid/tissue containing visible blood Semen and vaginal secretions Cerebrospinal fluid Synovial fluid Pleural fluid Peritoneal fluid Pericardial fluid Amniotic fluid The report further states that Universal Precautions need not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. (If there is any suspicion of blood in these fluids, use universal precautions.) Some of the above fluids and excretions represent a potential source for nosocomial and communityacquired infections with other pathogens, and recommendations for preventing the transmission of non-blood borne pathogens are addressed later. 44 Following Universal Precautions during emergency situations is especially important, since blood contact may be more likely. Each unit must maintain protective equipment needed to follow Universal Precautions. This equipment should be checked daily in order to insure an adequate supply. C. Use of gloves The use and selection of gloves will vary accordingly to the procedure involved. The use of disposable gloves is indicated for procedures where body fluids are handled. 1. Use of gloves i. The use of gloves is particularly important in the following circumstances 1. If the provider has cuts, abraded skin, chapped hands, dermatitis or the like. 2. During examination of the oral pharynx 3. When examining abraded or non-intact skin or patients with active bleeding 4. During invasive procedures 5. During all cleaning of body fluids and decontamination procedures 2. Selection of gloves There are no reported differences in barrier effectiveness between intact latex and intact vinyl used to manufacture gloves. The type of gloves selected should be appropriate for the task being performed. Latex should be used with caution due to increasing incidence of sensitivity among health care providers. The following general guidelines are recommended; a. Use sterile gloves for procedures involving contact with normally sterile areas of the body b. Use examination gloves for procedures involving contact with mucous membranes, unless otherwise indicated, and for other patient care which does not require sterile gloves. c. Use general-purpose utility gloves (e.g., rubber household gloves) for housekeeping chores involving potential blood contact and for decontamination purposes. Utility gloves may be decontaminated and reused but should be discarded if they are peeling, cracked, or discolored, or if they have punctures, tears, or other evidence of deterioration. d. Change gloves between patient contact e. Do not wash or disinfect surgical or examination gloves for reuse. 3. Waste disposal 45 Bulk blood, suctioned fluids, excretions, and secretions may be carefully poured down a drain connected to a sanitary sewer. 4. Linen All linens soiled with blood or body fluids are to be bagged appropriately. If the outside of the bag is soiled, a second bag should be added. 5. Cleaning and Decontaminating Spills of Blood or Other Body Fluids. Chemical germicides that are approved for use as disinfectants when used at recommended dilutions can be used to decontaminate spills of blood and other body fluids. Visible materials should first be removed and then the area should be decontaminated with appropriate solution. Gloves must be worn during the decontamination process. 6. Compliance The service will develop a monitoring procedure for the appropriate decontamination of patient areas and equipment. Sharps Disposal System POLICY: It is the policy of The Advanced/Basic Life Support Service to provide Sharps Disposal System. This precaution is taken to prevent injury to, or infection of, personnel in disposition of needles and syringes. Sharps containers within the Basic Life Support Service are to be utilized accordingly. PROCEDURE: 1. Sharps disposal containers will be easily accessible within the patient compartment 2. The container will be monitored and when full, will be appropriately sealed and disposed of. Hand washing Guidelines POLICY: 46 Hand washing is generally considered the most important single procedure for preventing infections. INDICATIONS: In general, indications for hand washing are: a. In the absence of a true emergency, staff should always wash their hands, a. Before performing invasive procedures b. Before and after contact with wounds c. Before contact with particularly susceptible patients and newborn infants d. After contact with a source that is likely to be contaminated Immediate recontamination of washed hands can be avoided by using a paper towel to turn off faucets. As an additional precaution, gloves should be worn when the risk of transmitting infection by patient contact is high. PROCEDURE: For most hand washing during routine patient care, vigorous washing with soap under a stream of running water for at least 10 seconds is recommended because this removes transient flora. When personnel want to reliably eliminate microorganisms with hand washing they should also remove hand jewelry and clean under their nails. Antiseptic (antimicrobial) hand washing is necessary when staff need to reliably eliminate microorganisms from their hands. Antiseptics are more irritating to skin than soap and water, and their frequent use often results in dry skin and dermatitis; paradoxically, this dermatitis can cause an increase in microbial skin colonization and also discourage frequent hand washing. Hand creams should decrease dermatitis and dry skin, but evidence suggests that contaminated creams can be associated with infections. Waterless systems as approved by the Advanced/Basic Life Support Infection Control Coordinator will be available in the Advanced/Basic Life Support Equipment. Food and Drink Restriction in Patient Care Area POLICY: Eating, drinking, smoking, applying cosmetics or lip balm, and handling of contact lenses are prohibited in work areas where there is a reasonable likelihood of exposure. Handling of Potentially Contaminated Equipment 47 POLICY: All staff shall adhere to Universal Precautions to guard against infection by bloodborne pathogens when working with or around equipment which may have been contaminated. All equipment with any possibility of being contaminated by blood or other infectious materials shall be thoroughly cleaned and decontaminated immediately prior to being placed back in service. PROCEDURE: A. Routine Cleaning of Equipment Because equipment is designed to be re-usable, it may be a source of environmental contamination unless properly cleaned or disinfected. 1. Staff engaged in cleaning equipment shall use personal protective equipment that will ensure there is no contact of potentially contaminated material with skin or personal clothing 2. A germicidal detergent may be used, avoiding splatter or dripping. 3. Clean spills around the equipment, cleaning area immediately 4. All cleaning materials and personal protective equipment shall be disposed of as infectious waste, 5. Wash hands after removal of personal protective equipment Availability and Accessibility of Personal Protective Equipment DEFINITIONS: Personal Protective Equipment includes, but is not limited to, gloves, gowns, face shields, masks, eye protection, mouthpieces, resuscitation bags, pocket masks and other ventilation devices. Appropriate equipment is that which does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, under garments, skin, eyes, mouth, or other mucous membranes under normal conditions and for the duration of use. POLICY: A sufficient quantity of appropriate personal protective equipment in appropriate sizes to insure that staff has it available when and where needed will be provided by Ephrata Community Hospital. 48 Staff shall replace supply as indicated. Each staff member is responsible for knowing the location and inventory level appropriate and properly sized protective equipment, and for advising management when an inadequate supply is not available. Each staff member is responsible for inspecting protective equipment before use and for replacing any that is defective. To reduce the risk of exposure, personal protective equipment should not be handled excessively for the purpose of inspection after use. Pieces observed to be damaged should be placed in a separate contaminated bag. Specific Use of Personal Protective Equipment DEFINITIONS: Appropriate equipment is that which does not permit blood or other potentially infectious materials to pass through or reach the crewmember’s work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes, under normal conditions and for the duration of use. POLICY: Mask, eye protection and face shield combinations shall be worn whenever splashes, spray, splatters, or droplets of blood or other potentially infectious materials may be generated and eye, nose or mouth contamination can be reasonably anticipated. Crewmembers shall wear gloves when it can be reasonably anticipated that the crewmember may have hand contact with blood, other potentially infectious materials, mucous membrane, and nonintact skin. Protective body clothing such as, but not limited to, gowns or similar outer garments, shall be worn in occupational exposure situations. The type and characteristics will depend upon the degree of exposure anticipated. 49 Crewmembers shall wear surgical caps or hoods and shoe covers or boots when there is a reasonable anticipation of gross contamination. PROCEDURE: Eye protection such as goggles, eyeglasses, or a face shield will be worn when indicated. To properly apply protection: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Wash hands Apply eye protectors Mask and glove Perform procedure Remove gloves Remove eye protectors and mask Dispose of mask into waste container with a red plastic bag Dispose of eye protectors if indicates, if non-disposable, wash with a germicidal solution and rinse Wash hands Keep non-disposable eye protectors in convenient, clean and dry area. To remove headwear, foot wears, gloves and gown: 1. 2. 3. Remove headwear, footwear and then gloves and discard into a waste container lined with a red plastic bag located within the area if possible. Remove gown, turning in inside out. Handle only the inside of the gown. Dispose of within the area if possible. Wash and flush mucous membranes if there is any possibility that membrane exposure to blood or other infectious fluids or materials occurred. When using additional protection, e.g. PAPR systems, staff are to follow the procedure for utilization and will have completed appropriate training and annual review in the use of this protection. 50 Trash and Infectious Waste POLICY: All biological waste, infectious waste, and potentially hazardous non-biological waste, including all disposals of medical products, are to be discarded into double red plastic bag before being secured and taken to appropriate waste handler. PROCEDURE: When working with trash, Universal Precautions shall be taken as the first line of defense against healthcare workers’ occupational exposure to bloodborne pathogens. All biological waste and any non-biological waste collected in medical procedures shall be considered infectious and handled accordingly. 1. 2. 3. 4. 5. Gloves will be worn at all times when gathering, containerizing, and transporting waste which has any chance of having been exposed to blood, body fluids, or tissue. Do not over fill containers so that they cannot be easily and tightly closed without stretching the red plastic bag. All bags will be tightly closed or sealed prior to being taken from the area in which the waste was created. Closed bags shall not be left in the area in which they were filled but removed immediately. If the outside of any bag which may contain biohazardous waste is observed to be punctured or damp from internal leakage, that bag shall be placed into another qualified bag by a gloved and protected crewmember before being removed from area. A two-person method of double bagging is preferred, and shall be used if a second crewmember is reasonably available and properly dressed for handling potentially infectious materials. a. The second crewmember should cuff the clean bag over the hands, opening it widely b. The crewmember handling the defective or contaminated container should place it carefully into the second bag 51 6. 7. c. The partner holding the bag then closes the clean red bag securely. Spills from hazardous waste containers shall be cleaned up with an EPA approved germicidal solution. Blood spills require particular attention and shall be cleaned up immediately using a tuberculocidal or 5.15% Sodium Hydroclorite (bleach) mixed 1 part to 10 parts water. Immediately after bagging potentially hazardous waste, cleaning spills from containers holding potentially hazardous waste or handling filled waste containers, crewmembers shall wash their hands in accordance with Universal Precautions and the hand washing policy and procedure. Laundry Handling Practices POLICY: In accordance with Universal Precautions and this policy, all used linen contaminated with blood or body fluids is considered contaminated and is to be handled as follows: PROCEDURE: 1. 2. 3. 4. 5. 6. 7. Soiled lined will be carefully removed and bagged. Soiled linen shall be placed carefully into a t appropriate container. The container should be non-absorbent, leak-proof and free of holes and tears. Any crewmember handling soiled linen shall wear protective gloves and a properly fitting gown if gross contamination is present. DO NOT OVERFILL BAGS If the first bag becomes wet or could reasonably be expected to become wet, a second bag should be utilized. When a bag is full, close it immediately. No soiled or used linen should be transported within a clean patient compartment. Hepatitis B Vaccination of Crew Members POLICY: To protect crewmembers as much as possible from the possibility of Hepatitis B infection, the service is to implement a vaccination program. This program is available to all crewmembers who have been identified as having exposure to blood or other potentially infectious material in the course of providing care. This is at no cost to the crewmember. The vaccine is offered within ten (10) working days of the crewmembers initial assignment to the crew. Crewmembers who have previously received the vaccination may wish to submit to an antibody test, which shows the crewmember to have sufficient immunity. The vaccination program consists of a series of three injections with a second and third administration at one and six month intervals, respectively, from the initial inoculation. Prior to vaccination, interested individuals will receive detailed vaccine manufacturer’s product 52 information, an inservice and be evaluated. Those receiving the vaccine will be required to sign the Hepatitis B Vaccine Consent Form. Those refusing or declining to receive the vaccine will be required to sign the refusal statement per OSHA’s regulations. Hepatitis B Vaccine administrations will be arranged by the Ephrata Community Hospital Employee Health Nurse. The Infection Control Coordinator will keep records of vaccination. Prophylaxis Protocol for Accidental Exposure to Blood/Body Fluids POLICY: It is the policy of the EMS Service to have the following prophylaxis protocol instituted in cases of: Percutaneous injury (accidental skin puncture or laceration from a potentially contaminated object e.g. needle stick, bite or cut) Perimucosal exposure (splash to eye, nasal mucosa, or mouth with blood or potentially infectious body fluids) Contact of skin with blood or potentially infectious body fluids (especially when exposed skin is chapped, abraded, or afflicted with dermatitis or the contact is prolonged or involving an extensive area) PROCEDURE: I. Crewmember’s responsibility A. B. C. Clean wound or area immediately as appropriate Notify Infection Control Coordinator and the EMS Coordinator Complete Crew member Incident Report Form 1. Fill in all pertinent information on forms 53 D. II. Crew Chief Responsibilities A. B. C. D. III. a. Source patient’s identification b. Hepatitis B vaccine status c. Tetanus immunization status d. How incident occurred, etc. Go to the Emergency Department or follow-up as directed by the Infection Control Coordinator and the EMS Coordinator Make sure crew has taken appropriate precautions to prevent exposure If exposure occurs, direct crew member appropriately Notify Designated Infectious Control Officer as soon as possible or immediately if actions to follow unclear. Make sure crew member is directed to complete appropriate forms Designated Infectious Control Coordinator A. B. C. D. Upon receipt of information, make sure crewmember is appropriately directed as to care, etc. Verify correct completion of forms Maintain all records in confidentiality Make sure crewmember receives appropriate follow up and counseling if indicated. 54 GUIDELINES FOR CREW MEMBERS WHO HAVE HAD SIGNIFICANT EXPOSURE TO BLOOD/BODY FLUIDS -Percutaneous (needle stick) exposure -Injury form items potentially contaminated by blood products -Accidental exposure to blood/blood products (splash to eye or mouth, etc.) -Cutaneous exposure involving large amounts of blood or prolonged contact with blood. (Especially when the exposed skin is chapped, abraded or afflicted with dermatitis.) -Human bites A. B. C. D. Receiving facility will be notified upon receipt of the patient, of the crew member’s exposure The receiving facility will then follow it’s exposure procedure The Infection Control Coordinator will follow up with the receiving facility as to the procedures followed. The crewmember will be advised as to follow-up procedure by the receiving facility. 55 Decontamination of Penetrated Personal Clothing POLICY: It is the policy of theEMS Service to provide guidelines for decontamination of personal clothing contaminated with blood or other potentially infectious materials. PROCEDURES: I. Assessing the contamination A. Content II. 1. Determine the source by identifying if the contamination was from blood or other potentially infectious materials. 2. Determine if the contaminated area is small enough to spot-clean by yourself or if it needs to be sent for laundering. Process for clothing A. As soon as the task is completed, remove contaminated personal clothing (including undergarments if they are contaminated) B. Receiving facility shall provide scrubs if indicated. C. Place clothing in a clear plastic beg for transport for decontamination D. Decontaminating of clothing 1. Wear gloves for cleaning 2. Pour hydrogen peroxide onto soiled area so that the area is saturated. Allow to remain in contact for 5 minutes 3. Rinse area under cold running water and then saturate the soiled area with one of the following germicides and allow to soak for 20 minutes. a. 1 : 10 bleach solution b. Lysol solution 4. Rinse area thoroughly under cold running water and blot dry with a towel 5. Place in plastic bag to be transported home 6. Normal laundering procedures at home may be used after utilizing this process III. Processing of Leather shoes/boots 56 A. As soon as task at hand is completed, remove shoes/boots for cleaning B. Wear gloves C. Spot cleaning shoes/boots 1. Wet paper towel or cleaning cloth with cold water 2. Apply small amount of antibicrobial liquid soap: allow to soak for 20 minutes 3. Rinse with cold water NOTE:-If exposure occurs to skin or mucous membranes, affected areas need to be washed or flushed with water as soon as feasibly possible following contact. 57 58
