The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit www.apic.org/ambulatorynewsletter. To learn more about APIC, visit www.apic.org.
Bloodborne Pathogens are diseases that are caused by exposure to the blood or body fluids of another person. These include hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV). There are others, but these are the big three that cause the most infections from exposures. The goals of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard are to prevent exposures of workers to bloodborne pathogens and ensure proper medical management following an exposure.
Avoiding contaminated sharps injuries to healthcare workers is a responsibility of every employer. The OSHA Bloodborne Pathogens Standard (29CFR1910.1030) and subsequent updates to it are legal requirements for any work setting in which there is a possibility of on-the-job exposure to blood, bloody body fluids or fluids containing other potentially infectious materials (OPIM). These include cerebrospinal, pericardial, pleural, peritoneal, synovial and amniotic fluids; semen; vaginal secretions; and fluids that cannot be differentiated. OPIM does NOT include tears, sweat, saliva (except in dental settings), urine or stool, as these do not contain bloodborne pathogens unless they are visibly bloody. However, they may contain other pathogens, so protection for ALL body fluids is a must.
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Sharps injuries
Sally is an RN in an ambulatory surgery center (ASC), where she has worked for more than 10 years. While starting an IV, as she's removing the stylet, the patient jerks and Sally sticks herself with the bloody needle.
Q: What could have helped prevent this exposure?
A. Use of a safety engineered needle with a finger-activated sheath.
B. Use of a retractable needle.
C. Use someone strong to hold the patient still until the procedure was done.
D. Letters A and B.
While some sharps injuries are unavoidable, employers must do everything possible to prevent exposures. This includes implementing the use of sharps with engineered sharps injury protections, which are non-needle sharps or needle devices used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident. "I don't like it" is not a justification for not using safety sharps devices. Some sharps, such as spinal needles, haven't been available in a safety format; however, these are just beginning to show up with safety features.
The OSHA hierarchy of protection of workers specifies engineering controls first. If a device or process can be engineered to be safer, that device or process must be used, regardless of cost. This includes safety sharps devices, like blunt needles for internal sewing; retractable needles or those with safety shields built in; Mylarwrapped capillary tubes; plastic blood specimen tubes instead of glass; needleless IV systems; and safety scalpels. Safety device evaluation must include front-line workers. Devices cannot simply be imposed by management based on cost or other factors.
If a hazard cannot be mitigated through engineering, then workers must be taught work practice controls. These are practices that keep workers safe. A very good example of what not to do is to recap needles. Recapping will lead to a sharps injury. It is not a matter of IF someone will be stuck, but WHEN they will be stuck!
Personal protective equipment (PPE) must be employed when engineering and work practice controls don't mitigate a hazard. PPE must protect the worker from the hazard identified. An example of appropriate PPE use is donning a moisture-resistant or impervious gown or apron for a large wound irrigation or suturing in order to keep blood and bloody body fluids off clothing. Another example includes wearing impermeable gowns for surgery. Gloves must always be worn to prevent contact with blood and body fluids while starting IVs, drawing blood, and dressing bloody wounds. Gowns that allowed fluids to penetrate to the clothing underneath would not be acceptable protection. Gloves that easily tear are not acceptable. Masks and eye shields must be worn if spraying or splashing the face is anticipated. Moisture-resistant or waterproof booties may be worn in the operating room (OR) to protect feet from irrigation fluids mixed with blood or OPIM.
Most PPE, such as gloves and masks, is single-use disposable and should not be reused. Washable gowns are fine, but must be single patient use only. Goggles and face shields may be either disposable or reusable. If reusable, there must be a written policy for cleaning and disinfection between uses and wearers.
It's Friday afternoon and you're working at full speed to clear the last of the patients out of the OR so they can begin recovery and go home. Surgical tech Tom comes out of the OR at the end of a case and tells you he's been stuck by a contaminated scalpel blade. The surgeon passed it back and nicked Tom's hand. He stepped away from the table so he wouldn't bleed into the surgical site, and then washed it with antiseptic soap. Tom now has a dry, sterile bandage on his small, deep puncture wound.
Q: What needs to happen to protect Tom from bloodborne pathogens?
A. Nothing. The surgeon assessed the patient for risk of bloodborne pathogens and there was no risk.
B. The source patient must have the following labs drawn: hepatitis B surface antigen, hepatitis C antibody and HIV antibody.
C. Tom must be drawn for hepatitis B surface antibody, hepatitis C and HIV and provided the results of the source patient testing that is also furnished to a provider knowledgeable in bloodborne pathogens exposures who will follow up with Tom for management of this exposure.
D. Letters B and C.
Q: Tom's employee health record should be examined for what specific piece of information?
A. His hepatitis B vaccine status — Did he have it and did he develop antibodies?
B. His immunizations/immunity to mumps, measles and rubella.
C. His pertussis status.
D. None of the above.
OSHA requires each work settings in which exposure could occur to have a written exposure control plan to prevent exposure and ensure proper evaluation and follow-up of exposed workers. Many ambulatory settings have written agreements with nearby emergency departments, occupational medicine or infectious disease clinics to do this for them. This keeps the employee's personal health information out of their clinic or ASC and ensures proper follow-up. Labs must be drawn on the source patient and the employee. The source is tested for hepatitis B surface ANTIGEN, hepatitis C and/or HIV in their blood. The exposed worker is tested for ANTIBODIES to hepatitis B from the vaccination or from having the disease, and for hepatitis C and HIV to demonstrate that the employee did not have these diseases at the time of the injury.
The blood samples should be transported to a clinical laboratory as soon as possible to expedite results. Depending on the results, Tom may need immediate treatment to reduce his risk of acquiring hepatitis B or HIV from the puncture. Sadly, at this point, there is no treatment for exposure to hepatitis C other than serial testing to see if infection occurs. It's good to know ahead of time exactly which tubes to draw, where the specimens will be sent, how quickly results will be available, and to whom they will call the results. This should all be included in the written exposure control plan.
The test results conclude that the patient is HIV positive. The rapid test will have to be confirmed with a Western Blot, but the rapid test is quite reliable. The tests for hepatitis B and hepatitis C will take a bit longer. The surgeon speaks with the patient and learns that she is aware she is HIV positive and is being seen by an infectious disease physician. She didn't mention it to the surgeon prior to her surgery because she was embarrassed.
Q: So, what needs to be done for Tom?
A. Call an infectious disease physician on Monday and see when an appointment is available.
B. Send him to your Occupational Medicine referral office that has the expertise to manage this high-risk exposure.
C. Start him on antiretroviral medication.
D. Wait until the results of the other two tests are available before doing anything.
E. Letters B and C.
A provider with knowledge and experience in managing HIV exposures should be available 24/7. This is especially important if your facility is open after "normal" business hours, evenings, nights or weekends. It is essential for an HIV-exposed employee to start on antiretroviral medications as quickly as possible, within several hours. Waiting until Monday or sending Tom to a provider who isn't well-versed in this level of exposure management could result in Tom becoming infected with HIV. Some employees have medical conditions that might contraindicate certain antiretrovirals; this needs to be taken into account. Because the sourcepatient knows that she is HIV-positive and is being treated, a viral load might be available to guide treatment. HIV medications are not benign; many exposed healthcare workers are not able to take them for the full four weeks due to severe side effects.
If Tom had received the hepatitis B vaccine and developed antibodies, he would have been protected against hepatitis B. If not, hepatitis B immune globulin and hepatitis B vaccine should be administered in two different sites. The follow-up test for antibodies to hepatitis B should also be done several weeks after the third injection. The immunization record and result should be kept in Tom's employee health file. These may be maintained on-site or at a contracted provider's office. They should not be accessible to clinic ownership, only to those involved in Tom's care.
The onset of the AIDS epidemic in the early 1980s forever changed healthcare workers' (HCWs) perception of needlestick and other contaminated sharps injuries. Prior to that time, it's estimated that fewer than 1 in 10 such injuries was reported. That has improved to some degree, but the frequency of reporting is often dependent on what the employee knows — or doesn't know — about the risks, the type of injury and the history of the patient.
In response to the risks posed to HCWs, OSHA published the first Bloodborne Pathogens Standard in December of 1991 (29CFR1910.1030.) Prior to this standard, OSHA was not very involved in hospitals and healthcare. OSHA's standards are federal law and apply to everyone in the U.S.
Some states have their own agencies that enforce OSHA standards. The state programs must be as stringent but can be more stringent than the federal OSHA standards. Check with your state's Department of Occupational Safety and Health to find out which type of program you have.
OSHA, or a State Department of Labor and Industries in states that have their own OSHA programs, can inspect and levy fines for not following the Bloodborne Pathogens Standard. More importantly, following the standard protects our most valuable asset — our staff.
Learn more at www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051.
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