Module 9

1
Module 9

• Safety and Supportive Care in the Work Setting

2
Module Objectives

• Describe how Universal Precautions can prevent
  healthcare workers (HCWs) from exposure to
  bloodborne pathogens.
• Outline strategies for preventing HIV
  transmission in the healthcare setting.
• Identify key steps in the decontamination,
  cleaning, disinfection and sterilization of
  equipment and materials.

3
Module Objectives (continued)

• Discuss risk reduction in obstetric settings.
• Describe the management of occupational exposure
  to HIV.
• Outline the National PEP regimen.
• Identify personal strategies to manage burnout.

4
Unit 1

• Universal Precautions

5
Unit 1 Objective

• Describe how Universal Precautions can prevent
  healthcare workers (HCWs) from exposure to
  bloodborne pathogens.

6
Basic Concepts of HIV Infection Prevention

• HIV and other bloodborne diseases may be
  transmitted in healthcare settings
• From client to HCW
• From HCW to client
• From client to client
• Primarily spread through blood
• HIV transmission to HCWs almost always associated
  with needlestick injuries

7
Basic Concepts of HIV Infection Prevention

• In practice, transmission occurs during
• Intravenous injections
• Blood donations
• Dialysis
• Transfusions

8
Basic Concepts of HIV Infection Prevention
(continued)

• Client-to-client transmission prevented by
  disinfecting or sterilizing equipment/devices
  used to puncture skin
• Transmission of infectious agents in healthcare
  setting prevented by
• Wash hands with soap and water
• Adhere to Universal Precautions and safe
  environmental practices
• Provide ongoing education for employees about
  infection prevention

9
Universal Precautions

• Definition
• Universal Precautions are simple set of effective
  practices designed to protect HCWs and clients
  from infection with a range of pathogens,
  including bloodborne viruses such as HIV. These
  practices are used when caring for ALL clients
  regardless of diagnosis.

10
Creating Safe Work Environment

• Not feasible or cost-effective to test all
  clients for all pathogens before providing care
• Level of precautions employed should be based on
  nature of procedure involved, not on clients
  actual or assumed HIV status

11
Managing the Work Environment

• To reduce occupational risks
• Assess risks in work setting
• Explore strategies for meeting resource needs
• Develop standards and protocols that address
  safety
• Attain and maintain appropriate staffing levels
• Ensure staff have appropriate workloads
• Orient new staff to infection prevention
  procedures
• Provide ongoing staff education and supervision
• Reduce staff stress, isolation, and burnout
• Acknowledge and address the needs of
  HIV-infected HCWs

12
Universal Precautions

• Ensure that Universal Precautions are
  implemented, monitored, and evaluated.
• Provide protective clothing and equipment,
  including gloves, plastic aprons, gowns, goggles,
  and other protective devices.
• Provide and use appropriate disinfectants to
  clean up spills involving blood or other body
  fluids.
• Increase availability and accessibility of
  puncture-resistant sharps containers

13
Ongoing Education for Employees

• Orient staff to infection prevention policies
• Ensure workers routinely exposed to blood and
  body fluids receive preliminary and ongoing
  training
• Require that supervisors observe and assess
  safety practices and remedy deficiencies

14
Unit 2

• Handling and Decontamination of Equipment and
  Materials

15
Unit 2 Objectives

• Outline strategies for preventing HIV
  transmission in the healthcare setting.
• Identify key steps in the decontamination,
  cleaning disinfection and sterilization of
  equipment and materials.
• Discuss risk reduction in obstetric settings.

16
Hand Washing

• Hand washing with plain soap and water is one of
  the most effective methods for preventing
  transmission of bloodborne pathogens and limiting
  the spread of infection.
• Soap and water hand washing, using friction under
  running water for a minimum of 15 seconds.
• Alcohol-based hand rubs for routine
  decontamination or hand antisepsis for hands not
  visibly soiled.

17
Hand Hygiene Recommendations
18
Personal Protective Equipment

• Personal protective equipment safeguards clients
  and staff.
• Gloves
• Aprons or gowns
• Eyewear
• Footwear
• When resources for purchasing protective
  equipment are limited, purchasing gloves should
  receive priority.

19
Gloves

• Use separate pair of gloves for each client
• Protection with gloves recommended when
• Reasonable chance of hand contact with blood,
  other body fluids, mucous membranes
• HCW has skin lesions on their hand.
• Sterile gloves are required for surgical
  procedures.
• Gloves not required for routine care activities
  in which contact is limited to clients intact
  skin.

20
Tips for Effective Glove Use

• Wear correct size gloves
• Use water-soluble hand lotions and moisturizers
• Avoid oil-based hand lotions or creams
• Do not wear rings
• Keep fingernails short
• Store gloves where they are protected from
  extreme temperatures

21
Personal Protective Equipment

• Aprons or gowns
• Aprons provide protective waterproof barrier.
• Gown should be worn to protect skin and prevent
  soiling of clothing
• Eyewear
• Eyewear protects eyes from accidental splashes
• Footwear
• Gum boots or leather shoes provide protection to
  the feet from injury by sharps or heavy items
  that accidentally fall
• Avoid wearing sandals, thongs, or shoes made of
  soft materials

22
Strategies for Resource-Constrained Settings

• Universal Precaution measures are difficult to
  practise when supplies are low and protective
  equipment not available
• Use resources cost-effectively by prioritising
  the purchase and use of supplies
• Reduce occupational exposure to HIV by reducing
  contact with blood

23
Equipment Materials

• Handling and disposal of sharps
• Most HIV transmission to HCWs is the result of
  skin puncture with contaminated needles or sharps
  
• Injuries more likely when sharps are recapped,
  cleaned, or inappropriately discarded.

24
Equipment Materials

• Recommendations for use of sterile injection
  equipment
• Use new, quality-controlled disposable syringes
  needles
• Avoid recapping of needles
• If recapping necessary, use single-handed scoop
  technique.
• Collect used syringes and needles at point of use
  in puncture/leak-proof sharps container
• Destroy or burn used needles and syringes so
  people cannot access them
• Wear gloves
• Handle all laboratory specimens with care
• Use holders for all blades

25
Careful Handling of Sharps

• Always point sharp end away from yourself and
  others.
• Pass scalpels and other sharps with the sharp end
  pointing away from other person.
• Whenever possible, place sharp on flat surface (a
  tray) to pass to other person.
• Pick up sharps one at a time and never pass
  handfuls of sharp instruments or needles.

26
Single-handed Recap Method
Step 1 Scoop up the cap Step 2 Push cap
firmly down
27
Sharps Containers

• Using sharps disposal containers helps prevent
  injuries from disposable sharps
• Sharps containers should be fitted with a cover,
  and should be puncture-proof, leak-proof, and
  tamper-proof
• If safety boxes unavailable, many available
  objects can substitute as sharps containers
• Tin with a lid
• Thick plastic bottle
• Heavy plastic box
• Heavy cardboard box

28
Safe Use of Sharps Containers

• All sharps containers should be clearly marked
  SHARPS
• Place sharps containers away from high-traffic
  areas and as close as possible to where the
  sharps will be used.
• Attach containers to walls or other surfaces if
  possible.
• Never reuse sharps containers for other purposes.
• Seal and close containers when ¾ full.

29
Decontamination, Cleaning, High Level
Disinfection, Sterilization

• Method used to decontaminate equipment or
  supplies should be based on
• Risk of infection associated
• Decontamination process the object can tolerate
• Routine procedures
• Use heavy gloves
• Dismantle all equipment before cleaning
• Wear additional protective clothing such as
  aprons, gowns, goggles, and masks when at risk
  for being splashed with body fluid

30
Decontamination of Equipment Materials

• Definition
• Decontamination is a process that makes inanimate
  objects safer to be handled by staff before
  cleaning
• Soak contaminated items for 10 minutes in 0.5
  chlorine solution
• Larger surfaces should be decontaminated by
  wiping with disinfectant (e.g., 0.5 chlorine
  solution or 12 phenol).
• Decontamination should be done at point of use
  immediately after the procedure.

31
How to Prepare 0.5 Chlorine Solution
Brand of Bleach, chlorine To obtain a 0.5 chlorine solution
Household bleach, 5 chorine 1 part household bleach to 9 parts water
Jik, 3.5 chlorine 1 part Jik bleach to 6 parts water
Powder bleach, 35 chlorine 14.2 grams of dry powder to 1 litre of water
32
Definition

• Cleaning is a process that physically removes all
  visible dust, soil, blood or other body fluids
  from inanimate objects as well as removing
  sufficient numbers of microorganisms to reduce
  risks for those who touch the skin or handle the
  object
• Consists of washing with soap or detergent and
  water, rinsing with clean water and drying
• If tap water contaminated, use water that has
  been boiled for 10 minutes and filtered to remove
  particulate matter
• OR use chlorinated water

33
Cleaning of Equipment

• Any instrument or equipment that comes into
  contact with intact skin should be cleaned before
  use
• Any instrument or equipment should be thoroughly
  cleaned rinsed before further processing
• Use personal protective equipment during cleaning
• Can be performed in department, unit, and ward or
  in a central sterilization department/area.

34
Definition

• High-level disinfection (HLD) is a process that
  eliminates nearly all microorganisms, except some
  bacterial endospores, from inanimate objects by
  boiling, steaming, or using chemical
  disinfectants.

35
High-Level Disinfection (HLD)

• Any instrument or equipment that comes into
  contact with non-sterile tissue should be
  high-level disinfected or sterilized before it is
  used.
• Decontaminate, clean instruments and equipment
  prior to HLD.
• HLD is not a sterilization process.
• HLD by
• Boiling or steaming instruments and other items
  for 20 minutes.
• Soaking the instruments and other items for 20
  minutes in 24 glutaraldehyde solution, 8
  formaldehyde solution, or 0.1 chlorine solution
  and rinse with sterile or HLD water

36
Definition

• Sterilization is a process that eliminates all
  microorganisms (bacteria, viruses, fungi and
  parasites) including bacterial endospores from
  inanimate objects by high-pressure steam
  (autoclave), dry heat (oven), chemical sterilants
  or radiation.

37
Sterilization

• All instruments and equipment should be
  decontaminated, cleaned, and dried prior to
  sterilization.
• Any instrument or equipment used to enter sterile
  tissue or the vascular system of a client, should
  be sterilized before it is used.
• Microwaves ovens, pressure cookers, dishwashers,
  ultraviolet cabinets, ultrasonic cleaners, and
  similar devices do not sterilize and should not
  be used for this purpose.

38
Sterilization (continued)

• If using steam sterilization
• Observe recommended temperature, pressure and
  holding time. For most autoclaves (unless
  otherwise recommended by the manufacturer)
• Temperature should be 121?C (250?F)
• Pressure should be 106 kPa (15 lbs/in2)
• Time should be 20 minutes for unwrapped items, 30
  minutes for wrapped items

39
Sterilization (continued)

• If using dry heat sterilization
• Unless otherwise recommended by the manufacturer,
  recommended temperature and times are as follows
  
• Sterilize at 170?C (340?F) for 1 hour (total
  cycle timeplacing instruments in oven, heating
  to 170?C, timing for 1 hour, and then coolingis
  from 22.5 hours), OR
• Sterilize at 160?C (320?F) for 2 hours (total
  cycle time is from 33.5 hours).
• All packed and wrapped instruments and equipment
  should be stored in a manner that ensures
  sterility is maintained.

40
Sterilization (continued)

• If using chemical sterilization
• Some high-level disinfectants will kill
  endospores after prolonged (1024 hour) exposure.
  
• Common disinfectants used for chemical
  sterilization include glutaraldehydes and
  formaldehyde.
• Sterilize by soaking at least 10 hours in 24
  glutaraldehyde solution or at least 24 hours in
  8 formaldehyde.
• Both glutaraldehydes and formaldehyde require
  special handling and leave a residue on treated
  instruments therefore, rinse with sterile water
  afterwards

41
Handling of Soiled Linen

• Use gloves
• Collect linen in bags or fold with the soiled
  parts inside for transport (do not rinse or sort
  in the patient care area)
• Soak in 0.5 chlorine solution for ten minutes
• Wash in hot soapy water and air dry
• If the linen is to be used in theatre, it should
  be sterilized.

42
Reducing Risk of Occupational Exposure in the
Obstetric Setting

• Potential for exposure to HIV-contaminated blood
  and body fluids is highest during labour and
  delivery.
• Wash hands
• Cover broken skin or open wounds with watertight
  dressings
• Wear gloves
• Wear a waterproof plastic apron during delivery
• Cover the cord with gloved hand or gauze before
  cutting

43
Reducing Risk of Occupational Exposure in the
Obstetric Setting (continued)

• Wear eye shield during episiotomy and suturing
• Use needle holders when suturing
• Pass all sharp instruments on a tray, rather than
  hand-to-hand
• When episiotomy is necessary, use
  appropriate-sized needle (21 gauge, 4 cm, curved)
  and needle holder
• If blood splashes on skin, immediately wash the
  area with soap and water.
• If splashed in the eye, wash the eye with water
  only.
• If blood splashes on floor, wash with chlorine
  solution
• Dispose of solid waste according to local
  procedures

44
Exercise 9.1

• Promoting a Safe Work Environment Resource List
  Group Discussion

45
Exercise 9.2

• Reducing HIV transmission Risk in MCH Settings
• Case Study

46
Unit 3

• Managing Occupational Exposure to HIV

47
Unit 3 Objectives

• Describe the management of occupational exposure
  to HIV.
• Outline the National PEP regimen.

48
Managing Occupational Exposure to HIV Infection

• Occupational risk of becoming HIV-infected due to
  needle-stick is low (less than 1)
• Risk of exposure from needle-sticks and contact
  with blood and body fluids exists in settings
  where
• Safe needle procedures and Universal Infection
  Prevention Precautions are not followed
• Waste management protocols are inadequate or not
  consistently implemented
• Protective gear is in short supply
• Rates of HIV infection in the client population
  are high

49
Benefits of Making PEP Available for HCWs

• Promotes retention of staff who are concerned
  about the risk of exposure to HIV
• Increases staff willingness to work with
  HIV-infected people
• Reduces the occurrence of occupationally-acquired
  HIV infection in HCWs
• A comprehensive PEP protocol outlines the methods
  for preventing occupational exposure to HIV and
  other bloodborne pathogens.

50
PEP Low risk and High risk

• PEP refers to treatment (using ARV drugs) of
  the HCW who has experienced an occupational
  exposure.
• ARV therapy started immediately after exposure to
  HIV may prevent HIV infection, although not 100
  effective.
• Treatment should be initiated within 1-2 hours of
  exposure, but PEP can be started up to 72 hours
  after exposure.
• HIV exposure is classified as either low risk or
  high risk.

51
Post-Exposure Prophylaxis (PEP) Low risk and
High risk (continued)

• High risk exposures Percutaneous injuries with
  hollow needles and large volume of blood onto a
  mucosal surface from a source person who is known
  or highly likely to be HIV-positive
• Low risk exposures All other exposures,
  including percutaneous injuries with solid
  needles, exposures to fluids other than blood,
  and exposures to non-intact skin.
• Exposure of blood or other fluids to intact skin
  is not a risk

52
After Occupational Exposure

• First aid and other immediate measures
• To reduce contact time with source persons blood
  or body fluid and decontaminate the site of the
  exposure
• Use soap and water to rinse any wound or skin
  site in contact with infected blood or fluid.
• Rinse exposed mucous membranes thoroughly with
  water.
• Irrigate generously any open wound with sterile
  saline or disinfectant solution (2-5 minutes).
• Irrigate eyes with clear water, saline, or
  sterile eye irrigants.
• Report exposure to the clinician on duty as soon
  as possible.

53
Operational Considerations

• Each health facility should keep a bottle of
  AZT3TC (Duovir) in designated unit for
  easy/secure access.
• HCW should immediately report the exposure to
  senior staff
• 3-day supply of AZT3TC given to HCW to begin PEP
  regimen as soon as possible after the exposure.
• HCWs must be counselled about ARV side effects

54
National PEP Protocol

• The source client
• If HIV-positive, then PEP is indicated.
• If HIV-negative discontinue PEP
• If HIV-negative and possibly in the window
  period, seek specialist advice.
• The HCW
• Encouraged to undergo HIV testing and counselling
  immediately or within 72 hours of exposure.
• If HCW is HIV-positive, then PEP is not necessary
• HCW who tests HIV-negative should receive
  follow-up HIV testing at 3 and 6 months. If
  negative at 6 months, counsel as if negative as a
  result of the exposure

55
PEP Regimen
Duovir should be available at every health
facility and at central medical stores. In some
cases, lopinavir/ritonavir can be added to the
Duovir therapy specialist advice is necessary.
56
Guidelines for Providing PEP

• Monitoring and management of PEP toxicity
• If PEP used, HCWs should be monitored for drug
  toxicity by laboratory testing at baseline and 2
  weeks
• May experience adverse symptoms including nausea,
  malaise, headache, and anorexia.
• Pregnant workers or women of childbearing age who
  may be pregnant may receive PEP.
• PMTCT services should support workers while they
  take PEP and help manage side effects.

57
Exercise 9.3

• PEP Case Study
• Small-Group Discussion

58
Unit 4

• Supportive Care for the Carer

59
Unit 4 Objective

• Identify personal strategies to manage burnout.

60
Care for the Carer

• Burnout
• Burnout syndrome stems from extended exposure to
  intense job-related stress and strain.
• Emotional exhaustion feelings of helplessness,
  depression, anger, and impatience
• Depersonalisation detachment from the job and an
  increasingly cynical view of clients and
  co-workers
• Decreased productivity due to real or perceived
  sense that their efforts are not worthwhile and
  do not seem to have an impact

61
Signs and Symptoms of Burnout
62
Risk Factors for Burnout

• Institutional or job-related risk factors for
  burnout
• Work overload, limited or no breaks
• Long working hours
• Poorly structured work assignment (worker not
  able to use skills effectively)
• Inadequate leadership and support
• Lack of training and skill-building specific to
  your job
• Personal risk factors for burnout
• Unrealistic goals and job expectations
• Low self-esteem
• Anxiety
• Caring for clients with a fatal disease

63
Tips for Managing Burnout

• Find or establish a support group of peers
• Search out a mentor
• Read books or listen to tapes
• Take a course to learn about a subject relevant
  to your work
• Take structured breaks during work hours

• Make time for yourself and your family
• Exercise, eat properly, and get enough rest
• Link with social groups, social functions or
  services that can provide support
• Where possible, delegate some work-related
  responsibilities to colleagues

64
Exercise 9.4

• Burnout in the PMTCT Service Large Group
  Discussion

65
Module 9 Key Points

• Creating a safe work environment involves
  practising
• Universal Precautions
• Management of the work environment
• Ongoing education of employees in all aspects of
  infection prevention

66
Module 9 Key Points (continued)

• Universal Precautions apply to all clients,
  regardless of diagnosis. Key components include
• Hand washing
• Use of personal protective equipment
• Decontamination of equipment
• Safe handling and disposal of sharps
• Safe disposal of infectious waste materials
• Safe environmental practices

67
Module 9 Key Points (continued)

• Decontaminated, cleaning, high-level
  disinfection, and/or sterilized of all
  instruments used in invasive procedures reduce
  risk of transmission of infection.
• Post-exposure prophylaxis (PEP) is short-term
  antiretroviral prophylaxis that reduces the risk
  of HIV infection after occupational exposure. The
  regimen (one tablet of Duovir twice a day for 30
  days) should be started within 1-2 hours of
  exposure.
• Burnout is related to intense, prolonged job
  stress but can be managed, even prevented through
  personal strategies, particularly if there is
  organizational support.