Download Preventing Transmission of Bloodborne Pathogens In Health Care

Preventing Transmission of Bloodborne Pathogens In Health Care Settings
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Purpose: To ensure that employees in health care settings are provided with essential tools to
prevent transmission of bloodborne pathogens.
ANA’s Position: Although the risks of transmission of bloodborne pathogens in health care
settings are real and growing – both to patients and health care professionals – such
transmission is preventable. Basic principles of public health and occupational safety require that
health care settings provide workers with swift and meaningful access to essential tools to
prevent transmission of bloodborne pathogens. It is the position of the American Nurses
Association that employers in the health care field should implement policies designed to promote
safety and reduce the risks of transmission of bloodborne pathogens and laws and regulations
promoting safety in health care settings are vigorously enforced on an ongoing basis.
History/Previous Position Statements:
Supportive Material: In the early 1990s, when the risk of transmission of bloodborne pathogens
in health care settings first attracted significant public attention, information was limited regarding
the magnitude of the risk and the effectiveness of particular prevention strategies. More than a
decade later, however, a substantial body of data provides clear guidance regarding formulation
of policy to prevent such transmission. Despite the wealth of information now available regarding
strategies to promote occupational safety in health care settings, the National Institute for
Occupational Safety and Health reports that rates of occupational injury to health care workers
have actually risen in the last decade, underscoring the need for greater attention to safety issues
in health care settings and more rigorous enforcement of applicable regulations.
Sharps injuries account for the majority of cases of transmission of bloodborne pathogens in
health care settings. Pathogens of particular note include HIV, hepatitis C (HCV), and hepatitis B
(HBV).
• Risk of Transmission. Per-episode risk of transmission to health care workers from a
needlestick injury involving an HIV-infected patient is). 3% for HIV, 1.8% for HCV, and 630% for HBV. Factors influencing likelihood of transmission include the pathogen
involved, nature of exposure, amount of blood involved in the episode, and viral load of
the infected individual. Risk of HIV transmission is about one-third lower for exposures
involving the eye, nose or mouth than for percutaneous exposure. Exposure of intact
skin is believed to pose no risk at all, although a risk of exposure could exist in cases of
prolonged exposure or when the skin has been damaged.
• Universal Precautions. The most effective means of avoiding exposure to bloodborne
pathogens in health care settings is adherence to universal precautions, which regards
all individuals as potentially infectious. Universal precautions apply to blood and a wide
range of body fluids specified in recommendations promulgated by the Centers for
Disease Control (CDC). Universal precautions require use of protective barriers such as
gloves, gowns, aprons, masks and protective eyewear. Following implementation of
universal precautions in the 1980s, the frequency of potential exposures to bloodborne
pathogens significantly declined.
• Safe Devices. Prevention measures to reduce the risk of bloodborne exposures in health
care settings have long included safe injection practices (e.g., prohibition on re-use of
injection equipment) and mechanisms for safe sharps disposal. In recent years, a
number of important technological developments have significantly improved the ability
of health care settings to protect workers and patients from the risk of bloodborne
exposures. Such technologies include safer injection equipment (e.g., needle guards,
needleless injection mechanisms, retractable needles), improved delivery systems for
intravenous medications, safer intravenous insertion equipment, improved mechanisms
for blood collection, blunt suture needles, safety scalpels and safer lancets.
• Pre-Exposure Vaccination. A vaccine does not exist for either HIV or HCV. OSHA requires
that all healthcare workers at risk of occupational exposure to blood or body fluids are
offered the Hepatitis B vaccine within 10 working days of initial assignment after the
employee has received training. The vaccine is to be offered at no cost to the employee.
• Post-Exposure Prophylaxis. Studies suggest that administration of antiretroviral therapy
following a percutaneous blood exposure reduces the risk of transmission of HIV. The
U.S. Public Health Service recommends a four-week course of two drugs or more drug
PEP regimen from the five classes of antiretroviral agents available with the initiation of
the post-exposure regimen to begin as soon after exposure as possible (preferably
within hours). Post-exposure regimens for HIV can result in notable, although typically
manageable, side effects, underscoring the importance of medical monitoring during the
four-week course of treatment. Employees who have not been vaccinated for HBV and
who experience a potential blood exposure should be swiftly vaccinated for HBV.
Recommendations:
Employers in the health care field:
Federal law obligates employers in the health care field to implement policies deigned
to promote safety. Mandates to generate a list of job classifications where employees
are at risk of occupational exposure by skin, mucous membranes, eye or parenteral
contact with blood or other potentially infectious materials that may result from the
performance of the employee’s work duties. In addition, employers must generate a
list of all tasks and procedures or groups of closely related tasks and procedures in
which occupational exposure occurs. Employers must generate clear safety policies
and procedures, provide necessary training and re-education to employees, monitor
the workplace to ensure compliance with policies, and redesign the workplace to
reduce the risk of disease transmission.
It is recommended that employers in the health care field:
• Promulgate clear policies and procedures, in compliance with federal and state legal
mandates and regulations, to promote worker safety and reduce the risk of transmission
of blood borne pathogens.
• Provide employees with equipment needed for adherence to universal precautions,
including gloves, gowns, goggles, and other technologies that comply with state-of-theart quality standards.
• Develop, implement and evaluate comprehensive educational and training programs and
training to for all employees regarding universal precautions, use of safer medical
devices, and pre- and post-exposure prophylaxis options. All new employees should
receive comprehensive infection control training before being placed in situations where
a blood borne exposure is possible.
Infection control education and training should be periodically reinforced (at least once
annually, but no greater than 12 months apart and more frequently in the case of
important new developments) for existing workers.
• Monitor incidents and injuries related to needlestick injuries related to needlestick injuries
on an ongoing basis. Implement strategies to decrease exposures and injuries. Assess
the effectiveness of new technology post implementation and to identify opportunities for
improvement.
• Continually monitor technological developments that promote the safety of workers and/or
patients. Employers should provide meaningful access to safer, state-of-the-art medical
devices and should reconfigure policies, procedures and physical spaces so as to
promote routine use of safer devices. Non-managerial employees responsible for direct
patient care who have risk of exposure to injuries from contaminated sharps should be
included in the identification, evaluation and selection of effective engineering and work
practice controls. Newly developed technologies that promote health care and workplace
safety should be rapidly integrated into workplace policies and procedures (including
applicable education and training protocols).
• Non-managerial employees responsible for direct patient care who have risk of exposure
to injuries from contaminated sharps should be included in the identification, evaluation
and selection of effective engineering and work practice controls. Newly developed
technologies that promote health care and workplace safety should be rapidly integrated
into workplace policies and procedures (including applicable education and training
protocols).
• Provide employees with meaningful opportunities to be vaccinated for HBV. Vaccination
should be provided free of charge, and employees should be periodically informed of the
availability and importance of HBV vaccination and have access to appropriate
counseling.
• Develop clear, enforceable protocols for post-exposure HIV, HBV and HCV exposure with
post exposure prophylaxis, as indicated. Such policies and procedures should be clearly
communicated to all employees who might reasonably be exposed to blood or body
fluids. Such policies and procedures must, at a minimum, include designation of an
official infection control supervisor within the institution, maintenance of sufficient
supplies of post-exposure regimens, and employee access to evaluation, treatment and
counseling 24 hours a day for blood exposures to facilitate rapid initiation of prophylactic
treatments.
Employee Obligations: Nurses and healthcare employees within health care organizations
should attend comprehensive infection control training and education provided by
employers before being placed in situations where a blood borne exposure is possible.
Additionally, all nurses and healthcare employees should remain current in infection
control procedures by attending education and training sessions at least annually and no
greater than 12 months apart and more frequently in the case of important new
developments.
Nurses and healthcare providers need to be vigilant in identifying situations that are high
risk and undertake appropriate precautions, to protect themselves and others from
needlestick injury. If an injury does occur, the nurse and/or healthcare employee should
report the injury and comply with post exposure protocols.
It is recommended that employees in the health care field:
• Attend education and training programs provided by employer
• Maintain and enhance knowledge base and competency related to infection control
techniques
• Comply with infection control protocols to reduce risk of exposure to bloodborne
pathogens
• Notify employer of high-risk situations so that systems can be monitored, evaluated
and enhanced to improve safety in the work environment.
• Utilize supplies and equipment appropriately to reduce risks posed by bloodborne
pathogens. Communicate equipment and supply needs to employer when needs
are identified.
• Maintain vigilance in the identification of high-risk situations to alert employers and
co-workers in an effort to reduce risk and enhance safety.
• In the event of an exposure and/or injury, report the exposure to the appropriate
personnel and comply with exposure protocols.
Law and Regulations Enforcement: It is recommended that laws and regulations
promoting safety in health care settings should be vigorously enforced on an ongoing basis.
Employers in the health care field that violate work safety measures should be subject to
severe fines and other enforcement measures. Enforcement authorities should receive
sufficient financing to monitor compliance with applicable workplace safety rules.
References:
D Cardo et al., A Case-Control Study of HIV Seroconversion in Health Care Workers After
Percutaneous Exposure, New Eng J Med 1997;337:1485-90.
Centers for Disease Control and Prevention, Guidelines for Prevention of Transmission of Human
Immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, MMWR
1989;38(S-6):1-36.
Centers for Disease Control and Prevention, Recommendations for Follow-Up of Health Care
Workers After Occupational Exposure to Hepatitis C Virus, MMWR 1997;46:603-606.
Centers for Disease Control and Prevention, Recommendations for Prevention of HIV
Transmission in Health-Care Settings, MMWR 1987;36(supp. No. 2S).
Centers for Disease Control and Prevention, Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis, MMWR 2001;50(No. RR-11).
Centers for Disease Control and Prevention, Update: Universal Precautions for Prevention of
Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in HealthCare Settings, MMWR 1988;37:377-88.
International Health Care Worker Safety Center, University of Virginia, Information on Safety
Devices in Health-Care Settings, available at
www.med.virginia.edu/medcntr/centers/epinet/products.html.
S Mast et al., Efficacy of gloves in reducing blood volumes transferred during simulated
needlestick injury, J Infect Dis 1993;168:1589-92.
National Institute for Occupational Safety and Health, Centers for Disease Control and
Prevention, Exposure to Blood: What Health-Care Workers Need to Know, available at
www.cdc.gov/niosh
.
L. Seeff et al., Type B hepatitis after needle-stick exposure: prevention with hepatitis B immune
globulin. Final report of the Veterans Administration Cooperative Study, Ann Intern Med
1978;88:285-93.
Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures
to HIV and Recommendtions for Postexposure Prophylaxis, MMWR September 30, 2005:50 (No.
RR-9)
U.S. Department of Labor, Occupational Safety and Health
Administration, Regulation (Standards-29 CFR) Bloodborne pathogens – 1910.1030;
1-33.