I. Let’s Start With Universal Precautions/ Standard Precautions And OSHA’s Final Rule
A. Background
The concept of Universal precautions was developed in the mid 1980’s as a result of the human immunodeficiency virus (HIV) epidemic. The Center for Disease Control and Prevention (CDC) recognized that there was an urgent need to create strategies to protect healthcare personnel from infections carried in blood. Why? Because personnel were experiencing needlesticks and skin contamination with patients blood, and, there were reports of hospital personnel becoming infected with HIV from such events. Researchers were also learning that many patients with bloodborne infections are symptom free and are not recognized as infectious.
In 1985 the CDC officially introduced the application of Universal Precautions to all persons regardless of their presumed infection status. In 1991, The Occupational Safety and Health Administration (OSHA) published the Final Rule to improve working conditions and promote safety for you, the healthcare worker (HCW), when caring for patients infected with bloodborne pathogens. The new law required compliance to the published federal guidelines by all healthcare facilities. This law is a very important part of our approach to healthcare today. All healthcare workers should be familiar with the requirements in order to comply and to carry out safe practices for themselves and all co-workers (either present or downstream).
B. Exactly what are these bloodborne pathogens?
Bloodborne pathogens are 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), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).
C. Current definition
In 1996 the definition and recommendations for Universal Precautions was revised and given the new name of Standard Precautions. Today, Standard Precautions is the primary strategy to be used to reduce the risk of transmission of pathogens from moist body substances and applies to all patients regardless of their diagnosis or presumed infection status. Healthcare workers must avoid all contact with moist body substances by the use of Personal Protective Equipment (PPE), work practices and engineering controls.
Standard Precautions apply to:
1. Blood
2. All body fluids, secretions, and excretions (except sweat) regardless of whether or not they contain visible blood
3. Non-intact skin
4. Mucous membranes
D. What are the requirements for Standard Precautions in everyday nursing practice?
1. Hand washing
a. All HCWs should wash their hands thoroughly with soap and water when visibly soiled.
b. All HCWs should wash their hands:
1. Before and after patient contact
2. After contact with any source of microorganism (all body fluids or moist surfaces and also inanimate objects found in the patient’s environment)
3. Immediately after removing gloves
c. How long should you wash?
The recommended time to wash hands is 10-15 seconds using soap, water, and friction.
d. Which soap should you use?
1. Plain non-antibacterial soap is best for general patient care preferably in liquid form. It is advisable to check the policy on hand washing in your facility. Note: As liquid dispensers have the potential to become contaminated when refilled or “topped” off, they should be used only once and discarded or be washed and thoroughly dried before refilling.
2. Alcohol based gels/rubs are acceptable when a sink is not readily available. The application of gels should not be used when there is visible or gross soilage.
3. Antimicrobial soaps are recommended for performing invasive procedures such as surgery or placement of IV catheters, indwelling urinary catheters or other invasive devices.
A special tip: today’s informed consumers (patients) want to see you washing your hands.
2. Personal Protective Equipment/Attire (PPE)
PPE is defined as Attire designed for HCWs that provides protection against exposure to bloodborne pathogens. PPE includes protective gowns, gloves, masks, eye protection, head covers, and footwear. The amount and extent of protective attire is related to the activity involved. For example:
To insert a routine Intravenous catheter (IV), protective attire would be a pair of unsterile gloves.
To participate as the scrub nurse during a Cesarean Section, full coverage with protective attire is required.
Also included in protective attire are mouthpieces, pocket masks, and other ventilation devices.
Your employer should provide the appropriate attire for the task and also ensure that you (the HCW) Use the equipment provided!!! Appropriate sizes and alternate supplies are to be readily available for persons with special needs (allergies, dermatitis, etc.)
3. Engineering And Work Practice Controls
Tasks performed by HCW’s that require the handling of contaminated devices are to be evaluated and altered to reduce the likelihood of exposures. Examples include the puncture resistant and leakproof sharps disposal containers and the prohibition of two handed recapping of needles.
New products appearing in the work place such as safety syringes and needles should be used when provided. Clinicians must be conscious of new safety products and be willing to learn to alter or to use new techniques in order to adapt the safety devices into everyday use. The goal, of course, is to ensure HCW safety. By federal law, each healthcare facility MUST provide employees with safety products if they are available on the market. (The OSHA Directive emphasizing safety devices was published in November 1999 and became effective immediately)
4. Education
Any employee in a healthcare facility whose job has been identified as one potentially subject to occupational exposure must receive education upon employment and annually thereafter. In addition, employers must provide education/training when new procedures are introduced or new devices are implemented.
The training content includes precisely the information you are learning in this module plus information regarding the identity and symptoms of bloodborne diseases. The records of employee training sessions and the topics presented are to be kept for three years. Training is to be conducted by a qualified person. All persons attending the training must sign their name and job title. Employees should have the opportunity to ask questions of the person conducting the training session.
5. Housekeeping/Waste Disposal/Laundry
(Say, is all this information in the OSHA standard? -You bet it is!!)
The HCW should expect to work in a clean and sanitary environment. Employers are responsible to ensure that all equipment and environmental surfaces within the worksite are cleaned and decontaminated according to a written schedule and as necessary when areas are contaminated between routine cleaning times. Cleaning is to be done with appropriate detergents and disinfectants selected to address the nature of the soilage.
Regulated waste (defined as containing liquid or semi liquid blood or body fluids) is to be placed in containers that are labeled or color coded red to indicate a biohazard. Clinicians are responsible for placing such waste in the appropriate containers when a procedure or activity has generated it where it has been produced. Sharps, which include scalpels, suture needles, syringes, IV catheters, etc. are to be handled (as mentioned in engineering controls) by placing in sharps disposal boxes. ALL regulated waste is subject to State and National regulations regarding types of containers, proper labeling, storage and transporting.
Soiled and contaminated laundry is to be handled as little as possible and with a minimum amount of agitation. Always bag linen at the location where it was used. Laundry bags are to be fluid resistant and are to be transported in solid containers to prevent leakage of fluids. HCWs should avoid holding soiled linens against their uniforms. Your employer is responsible for the laundering of uniforms, lab coats and other work attire in the event that they are soiled with blood or body fluids.
6. Hepatitis B Vaccine
All employees whose job duties may involve exposure to blood or body fluids are to be offered the hepatitis B vaccination series at no cost.
Employees have the option to decline the vaccination by signing a statement, which is then to be kept in the workers’ employee health file. The same worker may later decide to accept the vaccination series. If so, the employer must provide it when requested.
7. Employee Exposure Protocol
Each institution/employer must have an exposure protocol set up in the event of an employee exposure (needlestick, mucous membrane splash, or exposure to non-intact skin). The protocol should go into effect immediately after the employee makes it known that there was an exposure. Please Take Note: the recommendations from the CDC state that the injured employee should be seen, evaluated, and treated within a two hour period of time- beginning from the time of the exposure. You, the HCW, need to report the injury at once to the designated person in your facility (supervisor, manager, or similar title). Protocol should then be followed to ensure an immediate and confidential medical evaluation with appropriate testing of the employee and the source patient (if known). If HIV testing is indicated and requested by the employee, all State and Federal laws must be observed to protect both employee and patient’s rights.
8. Records And Written Plans
Employee medical records are confidential and are not to be disclosed to any person without the employee’s written consent except as required by law. HCW medical records are to be maintained by the employer for the duration of employment plus 30 years.
Each employer must have a written Exposure Control Plan outlining a specific plan to eliminate or minimize employee exposures to bloodborne pathogens. Employees must have access to the plan. Plans should be reviewed and updated annually.
