Universal Precautions

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Universal Precautions

• Greece Central School District
• Sports Medicine
• Robert DuPrau

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Essential Questions

• Be able to Define Universal Precautions?
• When should they be used?
• What is a Bloodborne Pathogen?
• What 3 cause most concern?
• How can they be transmitted?
• What body fluids are of highest concern?
• What 4 methods of prevention help protect us from
  infection?
• Examples of each?
• How Universal Precautions plays a role in Sports
  Medicine?

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Universal Precautions

• Universal Precautions are OSHA's required method
  of control to protect employees from exposure to
  all human blood and other potentially infectious
  material.
• The term, "Universal Precautions," refers to a
  concept of bloodborne disease control, which
  requires that all human blood and certain human
  body fluids be treated as if known to be
  infectious for HIV, HBV, and other bloodborne
  pathogens.

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When should Universal Precautions be used?

• Universal Precautions should be applied whenever
  in doubt as to the specific body fluid and/or if
  there is any possibility that the fluid is
  contaminated with blood.

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What are Bloodborne Pathogens?

• Disease-causing microorganisms that may be
  present in human blood or OPIM (other potentially
  infectious material)
• Viruses
• Bacteria
• Parasites

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The Most Common and Most Threatening Bloodborne
Pathogens.

• HIV - Human Immunodeficiency Virus
• HBV - Hepatitis B
• HCV - Hepatitis C
• Blood is the single most prevalent source of HIV,
  HBV, and other blood borne pathogens in the
  occupational setting

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HIV Defined

• HIV is Human Immunodeficiency Virus
• HIV can cause acquired immune deficiency syndrome
  (AIDS)
• Risk of HIV infection from a puncture injury
  exposure to HIV infected blood is very low -- 0.3

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Signs and Symptoms of HIV

• Signs and symptoms include
• Weight loss
• Night sweats or fever
• Gland swelling or pain
• Muscle and/or joint pain
• Cannot rely on signs and symptoms to confirm if
  one is infected

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Course of Infection With HIV

• Incubation period from HIV infection to AIDS can
  be 8 to 10 years
• Varies Greatly among individuals

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HIV Prevention

• There is no vaccine for HIV infection
• Follow Universal Precautions!!!!

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HIV POST-EXPOSURE PROPHYLAXIS FOLLOW-UP

• No cure for HIV infection
• Testing schedule for HIV antibodies
• at time of exposure
• at 3 months
• at 6 months
• HIV antibodies usually become detectable within 3
  months of infection

• Treatment requires health care provider
• OSHA requires treatment that meets most recent
  CDC guidelines
• Treatment may include antiviral medications and a
  protease inhibitor

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Additional Information

• For additional information on HIV and AIDS care,
  contact the CDC National AIDS Hotline
• 1 [phone]

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HCV Defined

• HCV is Hepatitis C Virus
• It affects the liver
• It is most common chronic bloodborne infection in
  US
• Needlestick injury is only occupational risk
  factor associated with HCV
• Risk of HCV infection after exposure to HCV
  infected blood is 1.8
• 70 to 75 of those with acute HCV infection have
  no symptoms

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Signs and Symptoms of HCV

• Jaundice - yellow color to skin and whites of
  eyes
• Fatigue
• Headache
• Abdominal Pain
• Loss of appetite
• Nausea and vomiting

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Course of HCV Infection

• Incubation period averages 7 weeks
• Chronic liver disease may occur in 70 of those
  infected with HCV

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HCV Prevention

• No vaccine exists to prevent HCV infection
• Follow Universal Precautions!!!!

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HCV POST-EXPOSURE PROPHYLAXIS FOLLOW-UP

• No cure for HCV
• No post-exposure pro-phylaxis recommended
• Tests for HCV anti-bodies liver function
  recommended at time of exposure
• Tests should be repeated 4-6 months post exposure

• Treatment of HCV requires a health care provider
• OSHA requires treat-ment that meets most recent
  CDC guidelines
• HCV infection treatment may include liver
  transplant

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HBV Defined

• HBV is Hepatitis B Virus
• It affects the liver
• Prevalence of HBV infection among healthcare
  workers is 10 times greater than HCV infection

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Signs and Symptoms of HBV

• Jaundice - yellow color to skin and whites of
  eyes
• Fatigue
• Headache
• Abdominal Pain
• Loss of appetite
• Nausea and vomiting

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Course of HBV Infection

• Incubation period averages 12 weeks
• Most cases of HBV resolve without complications
• Chronic liver disease may occur in 6 - 7 of
  those infected with HBV

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HBV Prevention

• A vaccine does exist to prevent HBV infection
• Employers are required to offer HBV vaccination
  HBV vaccination to employees covered under BBP
  standard
• Follow Universal Precautions

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HBV POST-EXPOSURE PROPHYLAXIS FOLLOW-UP

• No cure for HBV infection
• Post-exposure prophy-laxis should begin within 24
  hours no later than 7 days after exposure
• Exposed person should receive HBV vaccine

• Treatment requires health care provider
• OSHA requires treatment meet CDCs most recent
  guidelines
• HBV infection treatment may require liver
  transplant

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HBV Immunization

• Employees with routine occupational exposure to
  blood/OPIM have right to HepB vaccination at no
  personal expense
• Employee refusal established by signing HepB
  vaccination declination form
• Vaccine is Recombivax HB or Energix-B
• Must be made available within 10 working days of
  initial assignment to job

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HBV Vaccination Schedule

• Vaccine given in 3 doses over 6 months
• 1st on initial assignment
• 2nd one month later
• 3rd five months after 2nd dose
• CDC recommends HepB antibody testing 1 to 2
  months following 3rd dose
• Employer cannot require employee to use health
  insurance to cover test cost
• Pre-screening is not required
• HBV is declining because of vaccine use!

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Modes of Transmission

• Puncture wounds or cuts
• Contact (touch, splash, or spray) with blood or
  OPIM on
• mucous membrane
• non-intact skin
• cuts, abrasions, burns
• acne, rashes
• papercuts, hangnails
• contaminated sharps

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Body Fluids

• The body fluids of all persons should be
  considered to contain potentially infectious
  agents.

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Dangerous Body Fluids

• Blood
• Semen
• Vaginal secretions
• Cerebrospinal, synovial or pleural fluid
• Body fluids containing visible blood
• Any unidentifiable body fluid
• Saliva from dental procedures

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Safe Body Fluids

• Sweat
• Urine
• Vomitus
• Feces
• Tears

What do we mean by saying these fluids are safe?
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Infectious Diseases are those that can be spread
from person to person.

• Infections may be spread in the following five
  ways
• Through the intestinal and urinary tracts through
  contact with feces/stool, vomitus or urine.
• Through the respiratory tract (in secretions from
  the mouth, nose and lungs).
• Through direct contact or touching of skin
  lesions or mucous membranes.
• Through contact with blood or certain body
  secretions.
• Through contact with vaginal fluids/semen.

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Body Substance Isolation (BSI)

• Treats ALL body fluids and substances as
  infectious
• BSI is similar in nature to universal
  precautions, but goes further in isolating
  substances not currently known to carry HIV.

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Body Fluids Include

• Blood
• Semen
• Drainage from scrapes and cuts
  
• Feces

• Vomitus
• Urine
• Respiratory Secretions
• Saliva

Universal precautions should be used when there
is exposure to any body fluid.
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How can we protect ourselves from Infection?
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Prevention

• Engineering Controls
• Work Practice Controls
• Personal Protective Equipment
• Universal Precautions

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Protective Behaviors

• Use common sense
• Survey the surroundings
• Remove nonessential bystanders
• Seek professional assistance and/or advice
• Wash hands with soap and warm water frequently

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EXAMPLES OFENGINEERING CONTROLS

• Hand and eye washing facilities
• Sharps container use
• Biohazard labeling
• Self-sheathing needles
• Needleless IV systems

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Needles, Scalpels, and other Sharp Instruments

• Proper handling and disposal of needles.
• Taking precautions to prevent injury from
  scalpels, needles, and other sharp instruments.

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Personal Protective Equipment

• Specialized clothing or equipment worn by an
  employee for protection against infectious
  materials (OSHA)
• Gloves extending above wrist protect hands
• Gowns/aprons protect skin and/or clothing
• Masks and Respirators/Resuscitation Devices
  protect mouth/nose
• Respirators/Resuscitation Devices protect
  respiratory tract from airborne infectious agents
• Goggles protect eyes
• Face shields protect face, mouth, nose, and eyes

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Regulations and Recommendations for PPE

• OSHA issues workplace health and safety
  regulations. Regarding PPE, employers must
• Provide appropriate PPE for employees
• Ensure that PPE is disposed or reusable PPE is
  cleaned, laundered, repaired and stored after use
• OSHA also specifies circumstances for which PPE
  is indicated
• CDC recommends when, what and how to use PPE

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Gowns or Aprons

• Purpose of use
• Material
• Natural or man-made
• Reusable or disposable
• Resistance to fluid penetration
• Clean or sterile

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Face Protection

• Masks protect nose and mouth
• Should fully cover nose and mouth and prevent
  fluid penetration
• Goggles protect eyes
• Should fit snuggly over and around eyes
• Personal glasses not a substitute for goggles
• Antifog feature improves clarity
• Face shields protect face, nose, mouth, and
  eyes
• Should cover forehead, extend below chin and wrap
  around side of face

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Respiratory Protection

• Purpose protect from inhalation of infectious
  aerosols (e.g., Mycobacterium tuberculosis)
• PPE types for respiratory protection
• Particulate respirators
• Half- or full-face elastomeric respirators
• Powered air purifying respirators (PAPR)

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When should I where gloves?

• Anytime you may come in contact with blood or
  other body fluids such as urine, saliva, vomit,
  or the mucous membranes of the mouth or nose.
• When touching skin that may have sores, open
  wounds, cuts, or scratches.
• When handling any object that may have been
  soiled with blood or body fluids.
• When you have a cut or scratch on your hands.

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Dos and Donts of Glove Use

• Work from clean to dirty
• Limit opportunities for touch contamination -
  protect yourself, others, and the environment
• Dont touch your face or adjust PPE with
  contaminated gloves
• Dont touch environmental surfaces except as
  necessary during patient care

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Dos and Donts of Glove Use

• Change gloves
• During use if torn and when heavily soiled (even
  during use on the same patient)
• After use on each patient
• Discard in appropriate receptacle
• Never wash or reuse disposable gloves

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If I wear gloves, do I still have to wash my
hands?

• YES!
• Wash hands before putting on gloves.
• Wash hands immediately after removing gloves.
• Gloves should be changed every time you are in
  contact with a new person

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Hand Washing

• Hand washing is the single most important
  practice in preventing transmission of infectious
  organisms

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When should I wash my hands?

• Whenever your hands look dirty
• Before preparing food
• After preparing food
• Before eating food

• After using the bathroom
• After touching pets
• After playing outside
• After blowing your nose
• Between each person or activity

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What happens when I do not wash my hands?

• Bacteria and viruses are picked up and stay on
  your hands.
• You can pass them to other people when you touch
  them with your hands.
• Also, bacteria and viruses can get into your body
  when you touch your eyes, mouth, or nose with
  your hands.

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No sink, no soap.What to do?

• If possible, carry a waterless antibacterial
  hand sanitizer with you.
• Apply an amount about the size of a quarter to
  the palm of one hand.
• Rub your hands together using a washing motion
  (including your nails and between your fingers)
  until the cleanser has dried completely.

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Whats so bad about a little germ?

• Some bacteria and viruses can make you sick for
  example, the common cold is spread by a virus.
• Or they can cause much worse illnesses, such as
  diarrhea or vomiting.
• Some bacteria and viruses are especially
  dangerous for people with weak immune systems,
  like the elderly and those with immune
  deficiencies or cancer.

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Hand Hygiene

• Required for Universal and Expanded Precautions
• Perform
• Immediately after removing PPE
• Between patient contacts
• Wash hands thoroughly with soap and water or use
  alcohol-based hand rub

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Contaminated and Clean Areas of PPE

• Contaminated outside front
• Areas of PPE that have or are likely to have been
  in contact with body sites, materials, or
  environmental surfaces where the infectious
  organism may reside
• Clean inside, outside back, ties on head and
  back
• Areas of PPE that are not likely to have been in
  contact with the infectious organism

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Public Protective Equipment

• Emergency Eye Wash Station
• Access to copious amounts of warm water
• Antibacterial Soap
• Clean towels
• OSHA Approved First-Aid Kit

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Work Practice Controls

• Behaviors using engineering controls safely and
  effectively
• Work Practice Controls include
• using sharps containers
• using an eyewash station
• WASHING HANDS after using PPE
• cleaning work surfaces
• proper laundering

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Prohibited Work Practices

• Do not break, shear, bend or recap needles
• Do not reach into used sharps containers
• Do not pick up contaminated items, such as broken
  glass with bare hands
• Do not use a vacuum cleaner to clean up
  contaminated items
• Do not open or empty sharps containers

• Do not pipette or mouth suction blood on OPIM
• Do not eat, drink, smoke, apply cosmetics, or
  handle contact lenses in areas of potential
  occupational exposure
• Do not store beverages or food in refrigerators,
  freezers, or cabinets where blood or OPIM are
  present

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What type of PPE would you wear?

• A deep cut on the face of a soccer player laying
  unconscious on the field.
• A broken leg of a football player on the field.
• A bloody nose of a basketball player on the
  court.
• Field Hockey player with broken arm, bone
  protruding through skin.

• An unconscious/not breathing baseball player in a
  hot practice.
• A knocked out tooth of a hockey player on the
  ice.
• An eye poked out of a wrestler on the mat.
• Torn ACL/MCL of a Tennis player on the court.

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What type of PPE would you wear?

• A deep cut on the face of a soccer player laying
  unconscious on the field.
• Gloves
• A broken leg of a football player on the field.
• Usually none, unless severe break and bone has
  protruded through skin.
• A bloody nose of a basketball player on the
  court.
• Gloves
• Field Hockey player with broken arm, bone
  protruding through skin.
• Gloves

• An unconscious/not breathing baseball player in a
  hot practice.
• Resuscitation Device
• A knocked out tooth of a hockey player on the
  ice.
• Gloves
• An eye poked out of a wrestler on the mat.
• Gloves
• Torn ACL/MCL of a Tennis player on the court.
• None
• Sprained ankle of Figure Skater on Ice.
• None

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Universal Precautions in Sports Medicine?

• On your own, quickly write a small blurb as to
  how you think Universal Precautions play a major
  role in Sports Medicine. Be specific and Be
  ready to share.

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Universal Precautions in an Athletic Environment

• In 1991 the Occupational Safety and Health
  Administration (OSHA) established standards for
  an employer to follow that govern occupational
  exposure to bloodborne pathogens.
• The guidelines instituted by OSHA were developed
  to protect the health care provider and the
  patient against bloodborne pathogens.

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Preparing the Athlete

• Before an athlete participates in practice or
  competition, all open skin wounds and lesions
  must be covered with a fixed dressing that does
  not allow transmission to or from another
  athlete.
• Example Hydrocolloid dressing
• This type of dressing will also reduce the
  chances of the wound reopening because it keeps
  the would moist and pliable.

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When Bleeding Occurs in Athletics

• Athletes with active bleeding must be removed
  from participation as soon as possible and can
  only return when deemed safe by the medical
  staff.
• Uniforms containing blood must be evaluated for
  infectivity
• A uniform soaked with blood must be removed
  before the athlete may return to competition.
• All personnel managing potential infected wound
  exposure must follow universal precautions.

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Personal Precautions in Athletics

• When working directly with bodily fluids on the
  field or in the training facility, personnel must
  make use of the appropriate protective equipment
  (PPE) in all situations which there is potential
  contact with bloodborne pathogens.
• Should be available in sideline emergency kits.
• Disposable nonlatex gloves must be used when
  handling any potentially infectious material.
• If needed, heavy toweling may be used until
  gloves can be obtained.

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Blood on my skin!!!!

• Hands and skin surfaces that come into contact
  with any blood or other body fluids should be
  washed immediately with soap and water or other
  antigermicidal agents.
• First aid kits must contain protection for hands,
  face, eyes, and resuscitation mouthpieces.
• Aprons/gowns to protect clothing
• Towelettes to quickly clean skin surfaces

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Summary

• Universal Precautions recommend that you treat
  all bodily fluids as if they are infected with a
  blood-borne disease.
• Universal Precautions should be applied whenever
  in doubt as to the specific body fluid and/or if
  there is any possibility that the fluid is
  contaminated with blood.
• Disease-causing microorganisms that may be
  present in human blood or OPIM (other potentially
  infectious material)

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Summary

• Human Immunodeficiency Virus, Hepatitis B, and
  Hepatitis C are 3 major Blood-borne pathogens.
• Potentially dangerous fluids include
• Blood
• Semen
• Vaginal secretions
• Cerebrospinal, synovial or pleural fluid
• Body fluids containing visible blood
• Any unidentifiable body fluid
• Saliva from dental procedures
• Engineering Controls, Work Practice Controls,
  Personal Protective Equipment and following
  Universal Precautions are methods of prevention
  against blood-borne pathogens.

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2005-2006 Sports Medicine NCAA Handbook

• Care of the Athlete
• All personnel involved in sports who care for
  injured or bleeding student-athletes should be
  properly trained in first aid, and
  standard/Universal precautions.
• Assemble and maintain equipment and/or supplies
  for treating injured/bleeding athletes. Items
  may include
• Personal Protective Equipment (PPE) minimal
  protection includes gloves goggles, mask, fluid
  resistant gown if chance of splash or splatter
  antiseptics antimicrobial wipes bandages or
  dressings medical equipment needed for
  treatment appropriately labeled sharps
  container for disposal of needles, syringes,
  scalpels and waste receptacles appropriate for
  soiled equipment, uniforms, towels and other
  waste.
• Pre-event preparation includes proper care for
  wounds, abrasions, or cuts that may serve as a
  source of bleeding or as a port of entry for
  blood-borne pathogens or other potentially
  infectious organisms. These wounds should be
  covered with an occlusive dressing that will
  withstand the demands of competition. Likewise,
  care providers with healing wounds or dermatitis
  should have these areas adequately covered to
  prevent transmission to or from a participant.
  Student-athletes may be advised to wear more
  protective equipment on high-risk areas, such as
  elbows and hands.

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2005-2006 Sports Medicine NCAA Handbook

• Care of the Athlete, cont
• The necessary equipment and/or supplies important
  for compliance with universal precautions should
  be available to caregivers. These supplies
  include
• appropriate gloves, disinfectant bleach,
  antiseptics, designated receptacles for soiled
  equipment and uniforms, bandages and/or dressings
  and a container for appropriate disposal of
  needles, syringes or scalpels.
• When a student-athlete is bleeding, the bleeding
  must be stopped and the open wound covered with a
  dressing sturdy enough to withstand the demands
  of activity before the student-athlete may
  continue participation in practice or
  competition. Participants with active bleeding
  should be removed from the event as soon as is
  practical. Return to play is determined by
  appropriate medical staff personnel and/or sport
  officials. Any participant whose uniform is
  saturated with blood must change their uniform
  before return to participation.
• During an event, early recognition of
  uncontrolled bleeding is the responsibility of
  officials, athletes, coaches and medical
  personnel. In particular, student-athletes should
  be aware of their responsibility to report a
  bleeding wound to the proper medical personnel.

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2005-2006 Sports Medicine NCAA Handbook

• Care of the Athlete, cont
• Personnel managing an acute blood exposure must
  follow the guidelines for universal precaution.
  Gloves and other PPE if necessary should be worn
  for direct contact with blood or other body
  fluids. Gloves should be changed after treating
  each individual participant. After removing
  gloves, hands should be washed.
• If blood or body fluids are transferred from an
  injured or bleeding student-athlete to the intact
  skin of another athlete, the event must be
  stopped, the skin cleaned with antimicrobials
  wipes to remove gross contaminate, and the
  athlete instructed to wash with soap and water as
  soon as possible.
• Any needles, syringes, or scalpels should be
  carefully disposed of in an appropriately labeled
  sharps container. Medical equipment, bandages,
  dressings, and other waste should be disposed of
  according to facility protocol. During events,
  uniforms or other contaminated linens should be
  disposed of in a designated container to prevent
  contamination of other items or personnel. At
  the end of competition, the linen should be
  laundered and dried according to facility
  protocol hot-water at temperatures of 71C
  (160F) for 25 minutes cycles may be used.

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Universal Precautions and Sports Medicine

• Knowing and following Universal Precautions is
  essential to the safety of both the health care
  provider as well as the athlete.
• Within sports, there are many opportunities for
  injury, and therefore, many opportunities for
  transmission of infection.

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Sources

• Sports Medicine Essentials Core Concepts in
  Athletic Training and Fitness Instruction.
  Thomson-Delmar 2001, 11-1 - 11-17.
• Arnheims Principles of Athletic Training A
  Competency-Based Approach. McGraw-Hill 2006,
  387-398.

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Websites for further knowledge

• Occupational Safety and Health Administration
  (OSHA)
• http//www.osha.gov
• Department of Health and Human Services
• http//www.os.dhhs.gov
• HIV/AIDS Prevention
• http//cdc.gov/nchstp/hiv_aids/dhap.htm
• Centers for Disease Control and Prevention
• http//www.cdc.gov
• National Institutes of Health
• http//www.nih.gov

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Critical Thinking Exercise

• The athletic trainer is responsible for taking
  every precaution to prevent infection by
  bloodborne pathogens.
• How are bloodborne pathogen infections prevented
  from spreading from one athlete to another?

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Critical Thinking Exercise

• A wrestler has been diagnosed with hepatitis B
  virus.
• What are the symptoms and signs of HBV infection?

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Critical Thinking Exercise

• A wrestler comes into the training room very
  concerned that his wrestling partner got a bloody
  nose and that he came in contact with a few drops
  of that athletes blood.
• What should the athletic trainer tell the athlete
  about the transmission of HIV from this type of
  contact?

75
Critical Thinking Exercise

• A female athlete has had unprotected sex with a
  male whom she has dated only once previously.
  She knows that she should be tested for HIV but
  is so worried and embarrassed that she has
  avoided going to a medical facility to have a
  test. Finally she goes to her athletic trainer
  and confides her concerns.
• What should the athletic trainer tell her about
  being tested for HIV?

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Critical Thinking Exercise

• During a basketball game, one of the players
  sustains a nose bleed. Blood is visible on the
  court and on the players jersey and skin.
• What actions need to take place before the game
  can resume?

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Scenario 1

• Youre the athletic trainer for Olympia High
  School. During a basketball game, the point
  guard reached to make a steal and hits his face
  in the opponents shoulder. This knocks out his
  two front teeth and starts bleeding immediately
  all over the court. The teeth are on the floor,
  while blood is on the floor, the opponents jersey
  and the point guards jersey.
• What universal precautions should be taken to
  prevent the possible exchange of bloodborne
  pathogens from athlete to athlete or athlete to
  Trainer and what actions need to take place
  before the game can resume?

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Scenario 2

• Youre the cheerleading coach at a big
  competition. The trainer is unable to be there,
  making you the unofficial trainer at the site.
  In the middle of the final routine, the girl at
  the top of the pyramid falls and breaks her leg.
  The bone has broken the skin and is bleeding on
  the mats. Along with the broken leg, the girl
  has hit her head and been knocked unconscious on
  the fall.
• What universal precautions should be taken to
  prevent the possible exchange of bloodborne
  pathogens from athlete to coach and what actions
  need to take place before the routine can resume?

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Scenario 3

• You are the athletic trainer/coach for a figure
  skating team. During a competition, one of your
  skaters attempts a somersault in her routine and
  falls to the ice. Her head has struck the ice,
  knocking her out and bleeding all over the ice.
• What universal precautions should be taken to
  prevent the possible exchange of bloodborne
  pathogens from athlete to trainer and what
  actions need to take place before the competition
  can resume?

80
Scenario 4

• Youre the athletic trainer for GOHS. While
  working a Varsity baseball game you see one of
  the most vicious collisions at home plate ever.
  The baserunner hit the catcher at full speed,
  dropping his shoulder right under the mask of the
  catcher and striking the his jaw. This causes an
  immediate concussion along with bleeding within
  the mouth (possible tongue bite).
• What universal precautions should be taken to
  prevent the possible exchange of bloodborne
  pathogens from athlete to trainer and what
  actions need to take place before the game can
  resume?