Element III: Engineering, Administrative & Work Practices

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Element III Engineering, Administrative Work
Practices Controls

• The Problem
• Understanding the systematic implementation of
  workplace health safety controls.
• Controlling the problem
• Using engineering and work practice controls to
  reduce the opportunity for patient and healthcare
  worker exposure to potentially infectious
  material in all healthcare settings.

2
Learning Objectives

• Define healthcare-associated disease
  transmission, engineering controls, safe
  injection, and work practice controls
• Describe specific high-risk practices and
  procedures than increase opportunity for
  healthcare worker and patient exposure to
  potentially infectious material
• Describe specific measures to prevent
  transmission of bloodborne pathogens from patient
  to patient, healthcare worker to patient, and
  patient to healthcare worker via contaminated
  injection equipment
• Identify work practice controls designed to
  eliminate the transmission of bloodborne
  pathogens during use of sharp instruments
• Identify where engineering or work practice
  controls can be utilized to prevent patient
  exposure to bloodborne pathogens.

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Engineering ControlsRemoving or isolating the
hazardExamples

• Employee Protection
• self-sheathing or retractable needles
• negative pressure isolation
• puncture-proof sharps containers

• Patient/Consumer Protection
• single dose packaging of medication

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Personal Protective Equipment

• Personal protective equipment (PPE) places
  barriers between patient or employee and the
  hazard

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High risk practices and procedures Peructaneous
exposures

• Exposures through handling, disassembly,
  disposal, and reprocessing of needles and other
  sharp objects
• manipulating needles and sharps by hand
• Delaying or improperly disposing of contaminated
  needles or sharp objects
• recapping using a two-handed technique

• Performing procedures where there is poor
  visualization, such as
• Blind suturing
• non-dominant hand opposing or next to a sharp
• Performing procedures where bone spicules or
  metal fragments are produced

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High risk practices and procedures Mucous
membrane or non-intact skin exposures

• Direct contact with blood or body fluid
• contaminated hand in contact with eyes, nose or
  mouth
• open skin lesions on hand/dermatitis
• cleaning a blood spill
• handling contaminated instruments
• Sprays or splashes of blood or body fluid
• irrigation/suctioning
• surgical procedures

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High risk practices and procedures Parenteral
exposures

• Injection with infectious material may occur
  during
• Administration of parenteral medication,
• Sharing blood monitoring devices,
• Infusion of contaminated blood products or fluids

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Safe Injection Practices Consequences

• Unsafe injection practices have resulted in one
  or more of the following
• Transmission of bloodborne viruses, including HBV
  and HCV to patients
• Notification of thousands of patients of possible
  exposure to bloodborne pathogens and
  recommendation that they be tested for HBV, HCV,
  and HIV
• Referral of providers to licensing boards for
  disciplinary action and
• Malpractice suits filed by patients.

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Safe Injection Practices Contamination

• Pathogens including HCV, HBV, and HIV can be
  present in sufficient quantities to produce
  infection in the absence of visible blood.
• Bacteria and other microbes can be present
  without clouding or other visible evidence of
  contamination.
• The absence of visible blood or signs of
  contamination in a used syringe, IV tubing,
  multi-dose medication vial, or blood glucose
  monitoring device does NOT mean the item is free
  from potentially infection agents.
• All used injection supplies and materials are
  potentially contaminated and should be discarded.

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Safe Injection PracticesPrevention

• Maintain aseptic technique throughout all aspects
  of injection preparation.
• Never administer medications from the same
  syringe to more than one patient, even if the
  needle is changed.
• Never use the same syringe or needle to
  administer IV medications to more than one
  patient, even if the medication is into the IV
  tubing, regardless of the distance from the IV
  insertion site.

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Safe Injection PracticesPrevention

• Never enter a vial with a syringe or needle that
  has been used for a patient if the same
  medication might be used for another patient.
• Dedicate vials of medication to a single patient,
  whenever possible.
• Never use peripheral capillary blood monitoring
  devices packaged as single-patient use on more
  than one patient.

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Evaluation and Surveillance of Exposure Incidents

• Identification of who is at risk for exposure,
• Identification of what devices cause exposure,
• Identification of areas/settings where exposures
  occur, and
• Circumstances by which exposures occur.
• Post exposure management.

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Engineering Controls

• Use Safer devices whenever possible to prevent
  sharps injuries.
• Use puncture resistant-containers for the
  disposal and transport of needles and other sharp
  objects.
• Use splatter shields on medical equpipment with
  risk prone procedures (e.g., locking centrifuge
  lids).

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Engineering controls for bloodborne pathogens

• Needleless systems
• Retractable or Self-sheathing needles
• Puncture-resistant sharps containers
• Blunt suture needles
• Centrifuge covers
• Mechanical pipettes
• Needle holders

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Engineering ControlsPuncture Resistant
Containers

• Refer to published guidelines for the selection,
  evaluation and use (e.g., placement) of sharps
  disposal containers
• National Institute for Occupational Safety and
  Health (NIOSH)
• http//www.cdc.gov/niosh/topics/bbp/prevent
• NYSDOH recommendations Household Sharps-Dispose
  of them safely
• http//www.health.state.ny.us/publications/0909.p
  df

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Work practice controls for Bloodborne Pathogens

• Hand hygiene
• Procedures for cleaning blood and body fluid
  spills.
• Initial removal of bulk material followed by
  disinfection with an appropriate disinfectant.
• Proper handling/disposal of blood and body
  fluids, including contaminated patient items.
• Proper selection, putting on, taking off and
  disposal of PPE.
• Protection of work surfaces in direct proximity
  to patient procedure treatment areas.

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Work practice controls for Bloodborne Pathogens

• Avoid unnecessary use of needles and other sharp
  objects
• Use care when handling needles other sharp
  objects
• Avoid recapping unless absolutely medically
  necessary
• When recapping, use only a one-handed technique
  or safety device
• Pass sharp instruments by use of designated safe
  zones
• Disassemble sharp equipment by use of forceps or
  other devices

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Reducing Hospital InfectionsCDC Guidelines

• Hand Hygiene Environmental Control

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Importance of Hand Hygiene

• Single most important practice to prevent
  institution-based infections
• Infections are often caused by aerobic
  gram-negative micro-organisms
• Resident on hands (10-20 deep in skin)
• Killed or inhibited by soaps, detergents,
  antimicrobials
• May enter surgical wounds and infect

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Importance of Hand Hygiene

• Transient microorganisms often pathogens
• acquired from colonized or infected patients
• high-risk and/or isolation units containing
• virulent or drug resistant organisms
• wounds or invasive procedures
• lowered immune function
• Most transient contaminants removed by
• vigorous washing for at least 15 seconds
• rinsing thoroughly under a stream of water

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Handwashing Products

• Antiseptics and germicides used on skin
  categorized by Food Drug Administration (FDA)
• no independent testing
• not regulated or registered
• Types
• Alcohol-based hand sanitizers
• Antimicrobial soaps
• Surgical scrubs

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Handwashing Products

• Use plain soap or antimicrobial soap when hands
  are visibly dirty or contaminated
• If bar soap is used, should be on drainage rack
• Liquid soap must have dispenser emptied, cleaned
  and filled with fresh product (do not add liquid
  to partially filled dispenser)
• Alcohol based hand rub
• When hands are not visibly dirty
• Alternate washing hands with antimicrobial soap

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Handwashing Facilities

• Potable (drinkable) water
• Located conveniently
• Located in or just outside every patient room
• Located in or adjacent to rooms for
• Diagnostic procedures
• Invasive procedures (cardiac catheterization,
  bronchoscopy, sigmoidoscopy, etc,)
• Isolation
• Antimicrobial foams, gels or wipes between
  handwashings

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Professional and Gender Differences in Observed
Handwashing Between Patients - Australian
Study-2002

• In CCU
• Males washed one-third less than females after
  contact with patient or invasive instrument
• Among nurses in general
• Both genders had high rates of handwashing
• Doctors
• Women washed 88 of time, men 54
• Physical therapists
• Both men and women washed after every patient
  contact

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Needlestick Prevention

• Mandated by OSHA
• Evaluation and use of safest available technology
• Documenting use of frontline employees in
  choosing safer devices
• Maintaining a sharps injury log
• Education and training on sharps and their safety
  features
• ALWAYS activating and not bypassing safety
  features

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Hypodermic syringes with Retractable Technology
safety feature
Retracted protected position