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New York Infection Control Guidelines

Nancy Evans, BS

Marian McDonald, RN, MSN, CIC

Also available: Infection Control Guidelines
for nurses, EMTs/paramedics, and OTs/PTs in other states

This course is approved by the New York State Department of Health and State Education Departments (provider ID #IC138). It meets the requirement for infection control and barrier precautions.

Wild Iris Medical Education is an approved provider by the New York State Department of Education, Professional Education Program. Results are automatically reported to the NYS Department of Education.

Preventing the spread of infection and communicable disease has been a key component of healthcare since the work of Semmelweiss in the 1840s. Fast-forward to the 1980s and HIV/AIDS, and infection control gained an importance that continues today and has expanded to include prevention of the transmission of hepatitis B and C viruses.

In 1999 the patient safety movement began with the publication of To Err Is Human by the Institute of Medicine. This brought much-needed attention to the problem of medical errors and healthcare-associated infections (HAIs, formerly called "nosocomial infections"). The CDC estimates that 88,000 Americans per year may die of HAIs.

Since September 11, 2001, the threat of bioterrorism has heightened awareness of infection control. In 2003 the epidemic of severe adult respiratory syndrome (SARS) focused global attention on the need for infection control.

INFECTION CONTROL TRAINING

Since 1994 healthcare workers (HCW) licensed, registered, or certified in New York State (Box 1) have been required to receive training on infection control and barrier precautions every four years unless otherwise exempted. This requirement was established in 1992 by Chapter 786 of the Laws of 1992.

Physicians, physician assistants (PAs), and specialist assistants (SAs) must submit documentation of course completion to the Department of Health (DOH). However, individuals holding privileges, or affiliated with, or employed by, DOH-regulated healthcare facilities, including home healthcare agencies, need not submit documentation of course completion to the department. The following paragraphs are taken directly from the regulations of New York State.

All DOH-regulated healthcare facilities, including home healthcare agencies, must maintain documentation in credentialing or employment files of such infection control training and education of physicians, PAs, and SAs (Subpart 92-1.8, Title 10 [Health] of the Official Compilation of Codes, Rules and Regulations of New York). Exemptions from such training may be granted by the DOH to physicians, PAs, and SAs when the professional demonstrates to the department's satisfaction that:

• No need exists to complete the course work or training due to the nature of his/her practice, or
• He or she has completed equivalent course work of training.
• Health professionals in settings where they do not provide direct patient care do not have responsibility for supervising staff who provide direct patient care or reprocess used patient care equipment, or do not perform services to which these standards would be expected to apply, or when the professional does not practice in New York State.

A physician, PA, or SA who has been granted an exemption must notify the department in writing of any change in the nature of his or her practice within 30 days of the occurrence of such change. The physician, PA, or SA must then obtain necessary course work or training within 90 days of the change in practice (Subpart 92-1.9, Title 10 [Health] of the Official Compilation of Codes, Rules and Regulations of New York).

Equivalent training or course work is that training or coursework that covers concepts of disease transmission, scientifically accepted principles and practices for infection control, and engineering and work practice control as detailed in the syllabus. Equivalent course work or training must emphasize the bidirectional aspect of disease transmission—that is, patient to healthcare worker and vice versa (Subpart 92-1.10, Title 10 [Health] of the Official Compilation of Codes, Rules and Regulations of New York).

The goals of infection control training are to:

• Assure that health professionals understand how bloodborne and other pathogens can be transmitted in the work environment: patient to healthcare worker, healthcare worker to patient, and patient to patient.
• Apply current scientifically accepted infection control principles as appropriate for the specific work environment.
• Minimize opportunity for transmission of pathogens to patients and healthcare workers.
• Familiarize professionals with the law requiring this training and the professional misconduct charges that may result from failure to comply with the law.

Element I

The responsibility to adhere to scientifically accepted principles and practices of infection control and to monitor the performance of those for whom the professional is responsible.

Nearly 2 million hospital patients each year get an infection while being treated for another illness or injury and, as mentioned earlier, nearly 88,000 of them die as a direct or indirect cause of their infection. Healthcare-associated infections not only inflict suffering and death but also cost the United States almost $5 billion each year due to the extra days or weeks of hospitalization needed to treat the infection (CDC, 2000).

Patients in nursing homes and in home care are also at risk for developing HAIs, particularly if they have invasive medical devices such as urinary catheters or central venous catheters. Nearly 1.5 million infections occur annually in nursing homes (Ernst & Ernst, 1999).

Acute infections account for 27% of transfers of nursing home residents to hospitals (Longo et al., 2002) and complications of infections and their treatment can lead to functional decline among nursing home residents. Infection control programs have helped reduce the human and economic toll associated with infections. According to the CDC, HAIs in hospitals that report their findings to the CDC declined 30% between 1990 and 2000 (CDC, 2000).

In New York the New York State Education Department Rules of the Board of Regents, Section 29.2(a) (13), states that unprofessional conduct should include failing to use scientifically accepted infection prevention techniques appropriate to each profession for the cleaning and sterilization or disinfection of instruments, devices, materials, and work surfaces, utilization of protective garb, use of covers for contamination-prone equipment, and the handling of sharp instruments. Such techniques shall include but not be limited to the following:

1. Wearing of appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, nonintact skin, blood-soiled items or bodily fluid–soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and decontamination procedures;
2. Discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient and washing hands prior to performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids;
3. Wearing of appropriate masks, gowns or aprons, and protective eyewear or chin-length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur;
4. Sterilizing equipment and devices that enter the patient's vascular system or other normally sterile areas of the body;
5. Sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient's body, or using high-level disinfection for equipment and devices that cannot be sterilized prior to use for a patient;
6. Using appropriate agents, including but not limited to detergents for cleaning all equipment and devices prior to sterilization or disinfection;
7. Cleaning, by use of appropriate agents, including but not limited to detergents, equipment and devices that do not touch the patient or that only touch the intact skin of the patient;
8. Maintaining equipment and devices used for sterilization according to the manufacturer's instructions;
9. Adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques;
10. Placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers until appropriately cleaned and sterilized;
11. Maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation;
12. Refraining from all direct patient care and handling of patient care equipment when the healthcare professional has exudative lesions or weeping dermatitis and the condition has not been medically evaluated and determined to be safe, or capable of being safely protected against, in providing direct patient care or in handling patient care equipment;
13. Placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking; and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide.

Failing to use these techniques not only jeopardizes the health and safety of patients and other healthcare colleagues but also constitutes unprofessional conduct in the professions of medicine, acupuncture, physical therapy, physician assistant, specialist assistant, chiropractic, dentistry, dental hygiene, pharmacy, podiatry, optometry, ophthalmic dispensing, psychology, social work, massage, occupational therapy, speech pathology, audiology, nursing (registered professional nurse, licensed practical nurse).

Any licensed healthcare professional who fails to use appropriate infection control techniques to protect patients or fails to ensure that healthcare workers under his or her supervision do so may be subject to charges of professional misconduct. Substantiation of professional misconduct charges can result in disciplinary action, revocation of professional license, and/or professional liability.

Any patient or employee complaint regarding lax infection control practices in a private medical or dental office will prompt an investigation by the departments of health and/or education. Substantiated lapses in infection control in a private practice setting may result in charges of professional misconduct against any licensed professional in the practice who was directly involved, was aware of the violation, or had responsibility for ensuring that the office staff were adequately trained and following patient protection measures.

New York State law mandates that all hospitals:

• Train their staff in infection control techniques
• Provide appropriate protective equipment and safety devices
• Enforce use of universal barrier precautions in situations involving potential exposure to blood or other body fluids.

All licensed healthcare facilities are responsible for monitoring and enforcing proper use of infection control practices and Standard Precautions by healthcare personnel functioning under their jurisdiction. Failure to comply with this requirement will result in a DOH citation, potential fines, and other disciplinary action against the institution.

Any licensed healthcare professional who fails to use appropriate infection control techniques to protect patients or fails to ensure that healthcare workers under his or her supervision do so may be subject to charges of professional misconduct and disciplinary action.

Any patient or employee complaint regarding lax infection control practices in a private medical or dental office will prompt an investigation by the departments of health and education. Substantiated lapses in infection control in a private practice setting may result in charges of professional misconduct against any licensed professional in the practice who was directly involved, was aware of the violation, or who has responsibility for ensuring that office staff are adequately trained and follow patient protection measures.

Element II

Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control.

THE CHAIN OF INFECTION

The spread of infection is best described as a chain with six links:

1. A pathogen or causative (infectious) agent
2. The reservoir
3. A portal of exit from the reservoir
4. A mode of transmission
5. A portal of entry into a host
6. A susceptible host

If you can break any link of the chain of infection, you can prevent the occurrence of new infection. Infection control measures are designed to break the links and thereby prevent new infection. The chain of infection is the foundation of infection prevention, so we will look at each link and at actions we take to break it.

The Chain of Infection.

Causative Agents

Bacteria, viruses, fungi and protozoa ("germs") are very common in the environment, and most of them are beneficial to people. Creating an environment with no organisms is not a realistic goal outside of highly specialized laboratories.

Bacteria are single-celled organisms, some of which can cause disease. We all live with numerous bacteria—referred to as our "normal flora" or "resident bacteria,"—which usually do not cause disease unless their balance is disturbed. Most bacteria require an "infectious dose" to cause disease, that is, it usually takes thousands to cause disease, not just one or two. Bacteria vary in infectivity (how easy they are to catch) and virulence (the level of danger from the infection they cause).

Viruses are intracellular parasites, that is, they can only reproduce inside a living cell. Viruses such as HIV/AIDS and hepatitis B and C have the ability to enter and survive in the body for years before symptoms of disease occur. Other viruses, such as the influenza viruses, quickly announce their presence through characteristic symptoms.

Fungi are prevalent throughout the world but only a few cause disease in humans, and most of them commonly affect the skin, nails, and subcutaneous tissue. Candida is a fungus that causes "yeast infections." These infections can be life-threatening in critically ill patients. Fungi such as Pneumocystis carinii can be life-threatening to the person with HIV/AIDS.

Prions are a form of infectious protein believed to be the cause of Creutzfeldt-Jakob disease (CJD).

Protozoa are single- or multi-celled microorganisms that are larger than bacteria. Examples of disease-causing protozoa include amoebas and giardia, which cause diarrhea, and plasmodium species, the cause of malaria. They may be transmitted via direct or indirect contact or an arthropod vector (an infected carrier).

Parasites are larger organisms that can infect or infest people. Infestation with arthropods, such as lice and scabies, occurs by direct contact with the arthropod or its eggs. Helminths include roundworms, tapeworms, and flukes. They infect humans principally through ingestion of fertilized eggs or when the larvae penetrate the skin or mucous membranes.

We eliminate the causative organism by several methods, including:

• Sterilizing surgical instruments and anything that touches sterile spaces of the body
• Using good food safety methods
• Providing safe drinking water
• Vaccinating people so they do not become reservoirs of illness
• Treating people who are ill

Reservoirs

Like other organisms, germs require water to grow and reproduce, so reservoirs are commonly wet. In general, if an area is wet it is probably a reservoir unless something specific has been done to prevent bacterial growth. The bacteria may not be pathogens. For some organisms, the reservoir contains our own normal flora; that is, we get our own germs in the wrong place.

In some cases the environment can serve as the reservoir. For example, water supplies may become contaminated by Legionella spp. Inadequate air exchange can allow pathogens such as Mycobacterium tuberculosis and varicella-zoster virus to contaminate air supplies. Appropriate environmental infection-control measures and engineering controls can prevent these environmental reservoirs.

Common reservoirs in healthcare facilities include:

• Ill people.
• Well people. Our normal flora (the germs we live with) include bacteria which can be pathogens if they get into the wrong part of the body. For example, our mouths contain many different kinds of bacteria.
• Soil has rich microbial life, which may include pathogens.
• Raw meat may harbor pathogens.
• Water from fish tanks or flower vases may contain pathogens, especially for compromised patients.

Actions we take to eliminate reservoirs include:

• Treating people who are ill
• Vaccinating people
• Handling and disposing of body fluids responsibly
• Handling food safely
• Monitoring soil and contaminated water in sensitive areas of the hospital and washing hands carefully after contact with either

TABLE 1

HUMAN RESERVOIRS AND TRANSMISSION OF INFECTIOUS AGENTS

Reservoir	Transmission vehicle	Infectious agent
Blood	Blood, needle stick, other contaminated equipment	Hepatitis B and C; HIV/AIDS, S. aureus, S. epidermidis
Tissue	Drainage from a wound or incision	S. aureus, E. coli, Proteus spp
Respiratory tract	Droplets from sneezing or coughing	Influenza viruses, Strep spp., S. aureus
Gastrointestinal tract	Vomitus, feces, bile, saliva	Hepatitis A, Shigella spp, Salmonella spp
Urinary tract	Urine	E. coli, enterococci
Reproductive tract and genitalia	Urine and semen	N. gonorrhoeae, T. pallidum, Herpes simplex virus type 2, Hepatitis B

Portal of Exit

The portal of exit is the way the causative agent gets out of the reservoir, and it is the link of the chain that we can do the least about. Any break in the skin, including natural anatomical openings and draining lesions, may be the portal of exit from a person. Any bodily fluid may carry microorganisms out of the body. Some potent germs live on the patient's skin, and thus can easily exit their reservoir.

Actions we take to reduce risk from portals of exit include:

• Covering coughs and sneezes with a tissue
• Handling body fluids with gloves, then doing hand hygiene
• Keeping draining wounds covered with a dressing
• Not working when you have exudative (wet) lesions or weeping dermatitis

Modes of Transmission

This is the weakest link in the chain of infection! Most of the efforts to prevent the spread of infection are aimed at eliminating the mode of transmission. Transmission can occur by a number of mechanisms.

Direct contact is person-to-person transmission of pathogens through touching, biting, kissing, or sexual intercourse.

Indirect contact is the spread of pathogens by an inanimate go-between, an intermediary between the portal of exit from the reservoir and the portal of entry to the host. Inanimate objects such as patient-care equipment, cooking or eating utensils, handkerchiefs and tissues, soiled laundry, and door knobs are common vehicles that can transmit infection.

Droplet transmission can spread diseases such as influenza, pertussis (whooping cough), and some forms of bacterial meningitis. Droplets are produced when the infected person coughs, sneezes, or speaks, and they travel only about three feet before drying out or falling to the ground.

Airborne transmission can occur when respiratory droplets evaporate, leaving behind droplet nuclei that are so small they remain suspended in the air. Very few diseases are transmitted by the true airborne route since most organisms cannot survive drying. Diseases transmitted by the airborne route include tuberculosis, chickenpox, measles, possibly SARS, and smallpox.

Modes of transmission that are not common in hospitals include common-source vehicles such as blood, serum, plasma, water, food, and milk. For example, food can be contaminated by E. coli if food handlers do not practice appropriate handwashing techniques after using the bathroom. If the food is eaten by a susceptible host, such as a young child or a person with HIV/AIDS, the resulting infection can be life-threatening.

Vector-borne transmission is by an animate intermediary—an animal, insect or parasite that transports the pathogen from reservoir to host. Transmission takes place when the vector injects salivary fluid by biting the host, or deposits feces or eggs in a break in the skin. Mosquitoes are vectors for malaria and West Nile virus. Rodents can be vectors for hantavirus.

Examples of the mode of transmission include:

• Hands that are not washed between patient contacts
• Equipment that touches two or more patients without being cleaned. These are sometimes referred to as fomites.
• Gloves that touch two or more patients. (This will result in disciplinary action in most facilities!)
• Doorknobs, pens, and telephones. These are not reservoirs because they are not wet enough for the germs to reproduce.

Actions we take to eliminate the mode of transmission include:

• Hand hygiene
• Wearing gloves to minimize contamination of hands and discarding them after each patient
• Cleaning, disinfection, or sterilization of equipment used by more than one patient
• Cleaning of the environment, especially high-touch surfaces

Portal of Entry

The portal of entry can be thought of as the hole in the skin that allows the germ to get into the body and cause disease. Pathogens cannot cause disease if they cannot get into the body.

Examples of portals of entry include:

• Mouth, nose, and eyes
• Other anatomical openings
• Skin breaks (cuts, rashes)
• Surgical wounds
• Intravenous sites
• Anatomical openings with tubes in place (more susceptible than those without)
• Needle puncture injuries

Actions we take to protect portals of entry (our own and our patients) include:

• Dressings on surgical wounds
• IV site dressings and care
• Elimination of tubes as soon as possible
• Masks, goggles and face shields
• Keeping unwashed hands and objects away from the mouth (Don't lick your fingers to turn pages!)
• Actions and devices to prevent needlesticks
• Food and water safety

Susceptible Host

Susceptibility can be reduced in several ways. For some diseases we have effective vaccines. Some diseases produce lasting immunity after illness. We have better resistance to disease when we are well-rested, well-fed, and relatively stress-free. People who have healthy immune systems are often able to resist infection even when bacteria do invade.

Host factors that influence the outcome of an exposure include the presence or absence of natural barriers, the functional state of the immune system, and the presence or absence of an invasive device.

Natural barriers to infection include:

• Intact skin and mucous membranes
• Cilia (small, hairlike projections that line the respiratory system) that filter inhaled air and trap microorganisms
• Lung macrophages—large white blood cells that ingest microorganisms, other cells and foreign particles—in a process called phagocytosis
• Antibodies (humoral immunity) resulting from immunization or previous disease
• Acidic environment in the stomach, urine, and vaginal secretions
• Normal flora provide competition to pathogens. An upset to the balance of normal flora can allow pathogens to cause infection, such as when a yeast infection follows a course of antibiotics.
• The immune system is a complex network of cells, tissues, and organs that interact to defend the body against infections. Defense mechanisms can be nonspecific or specific and include humoral immunity (antibodies that circulate in the blood), cell-mediated immunity (white blood cells), and the inflammatory response, which brings an increase in these infection-fighting defenses to the site of infection.

A person with normal immune system function is described as immunocompetent. Someone whose immune system is impaired by illness or age-related factors is said to be immunocompromised. For example, a person with HIV/AIDS is immunocompromised.

The very young and the very old are also at risk for compromised immune function. Infections are a major cause of death among newborns. Although babies receive certain temporary immunities from their mothers through the placenta and in breast milk, their immune systems are still developing, making them vulnerable to infection. Nutritional status is a key factor in immune function.

People with chronic disease may also be immunocompromised. People with diabetes mellitus or peripheral vascular disease are at high risk for infection because of impaired circulation.

Certain medications can impair immunity. For example, cancer drugs and anti-inflammatory medications such as corticosteroids can interfere with normal immune function.

Any surgical procedure carries the risk of infection because it penetrates the skin. Diagnostic or therapeutic procedures that involve an invasive device such as a urinary catheter or a chest tube also increase the risk of infection. Caring for patients with these devices demands strict attention to infection control standards and continuous monitoring for any sign of infection.

Any foreign body, even a joint prosthesis, can act as a focus for infection and increases the risk of infection.

Examples of susceptible hosts include:

• People who are already ill
• People with invasive devices or tubes in place
• Malnourished people
• The very old and very young
• People who are tired or under high stress
• People with skin breaks such as surgical wounds or IV sites
• People undergoing steroid therapy or treatment for cancer
• People with HIV infection
• People who are well and healthy. None of us are immune to all disease!

Actions we take to minimize risk to susceptible hosts include:

• Vaccinating people against illnesses to which they may be exposed
• Preventing new exposure to infection in people who are already ill, are receiving immunocompromising treatment, or are infected with HIV
• Maintaining good nutrition
• Maintaining good skin condition
• Covering skin breaks
• Encouraging rest and balance in our lives

The nature of healthcare settings makes them vulnerable to the spread of infections because they bring together many ill people who are both reservoirs and susceptible hosts. Staff are also both reservoirs and susceptible hosts, so we cannot eliminate those two major links of the chain of infection. That is why we make such efforts to eliminate the mode of transmission, and that is why hand hygiene is still the single most important procedure to prevent the spread of infection!

The reservoir and the susceptible host may reside in the same person, if the individual's normal flora get into the "wrong" part of the body and cause disease. Examples of this situation include:

• Fecal flora in the urinary tract, causing a urinary tract infection (UTI)
• Oral flora in the lungs, causing aspiration pneumonia
• Skin flora in an IV site, causing a site infection or even a bloodstream infection

So we take care to avoid providing the mode of transmission between different body sites of the same patient, changing gloves and washing hands when we must go from a contaminated area to a cleaner one.

Preventing the spread of infectious organisms includes:

• Early identification of the infectious organism
• Prompt appropriate isolation of the patient
• Initiation of appropriate treatment

Isolation precautions have disadvantages to the hospital, patients, personnel, and visitors, including the cost of specialized equipment and environmental controls, inconvenience to healthcare workers, and forced solitude for patients. However, these disadvantages must be weighed against the hospital's mission to prevent the spread of serious infection in the hospital.

STANDARD PRECAUTIONS

This section is based on the CDC Recommendations for Isolation Precautions in Hospitals, which is available at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html.

The Centers for Disease Control (CDC) describe four types of precautions, based on the mode of transmission of the organism known or suspected to be present. CDC Guidelines are not regulations, but they are evidence-based recommendations. These guidelines were developed for hospitalized inpatients, and the principles can be applied in outpatient settings. Refer to your facility's policies for specific procedures.

Standard Precautions are to be used with all patients, regardless of diagnosis. Standard Precautions, formerly known as Universal Precautions, were initially designed to minimize risk to staff from unknown carriers of bloodborne pathogens, such as hepatitis B, hepatitis C, or HIV (Box 4). In addition to protecting staff, Standard Precautions also protect patients from organisms shed in the body fluids of other patients. Standard Precautions are required by good science and by federal law, the OSHA Bloodborne Pathogens Standard.

TRANSMISSION-BASED PRECAUTIONS

In addition to Standard Precautions, which are used with all patients, some patients require additional precautions, known as Transmission-Based Precautions. There are three types of transmission-based precautions: contact, droplet, and airborne.

Contact Precautions

Contact Precautions are designed to minimize transmission of organisms that are easily spread by contact with hands or objects (Box 5). (Think of these germs as being sticky.)

Droplet Precautions

Droplet Precautions are designed to prevent transmission of diseases easily spread by large-particle droplets produced when the patient coughs, sneezes, or talks, or during the performance of procedures (Box 6).

Airborne Precautions

Airborne Precautions are designed to prevent transmission of diseases spread by the true airborne route (Box 7). These organisms are released from the patient in respiratory droplets, which evaporate shortly after release. Most organisms die when they dry out, but the organisms of these few diseases—tuberculosis, chickenpox, measles, SARS, and smallpox—can survive drying out. The droplet nuclei (small-particle residue of evaporated droplets) remain suspended in the air and can be dispersed widely by air currents within a room or even over a long distance.

Respiratory Hygiene is a relatively new concept introduced in 2003, which recommends use of Droplet Precautions by healthcare workers when providing care to any patient with symptoms of respiratory infection, such as coughing. In addition, signs are posted asking patients to cover their nose and mouth with a tissue when coughing or sneezing or to wear a surgical mask. (This covers their portal of exit.) Patients are also asked to do hand hygiene after contact with their own secretions. Complete details on Respiratory Hygiene may be found at http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm.

Hand Hygiene

Hand hygiene is still the single most important procedure for preventing the spread of infection! This is because healthcare facilities bring many reservoirs (the patients and staff) into close contact with many susceptible hosts (the patients and staff). We cannot eliminate the reservoirs and susceptible hosts, so we must eliminate the mode of transmission. We must not carry germs from reservoir to susceptible host!

Hand hygiene includes both using alcohol-based hand hygiene products and washing with soap and water (Box 8). Alcohol-based hand hygiene products are preferred over soap and water when hands are not visibly soiled. Alcohol-based products are better in three ways:

• They kill the germs better.
• They leave skin in better condition.
• They are quicker and easier to use, so people use them more.

Use hand hygiene products only on dry hands. Use enough of the product so that hands are dry again in 15 seconds, and rub hands together until they are completely dry.

If hands are visibly soiled, wash with soap and water, using friction, for at least 10 to 15 seconds. (Sing "Happy Birthday" twice.) Note that special hand hygiene guidelines are required for surgical staff. Refer to your hospital policy or to the CDC Hand Hygiene Guideline at the CDC website.

The CDC Hand Hygiene Guideline specifies "Do not wear artificial fingernails or extenders when having direct contact with patients at high risk." Check with your facility for their policy. Nails should be unpolished and less than one-quarter inch long. Chipped nail polish, long nails, artificial fingernails, or nail extenders may tear gloves and can harbor pathogens, even after careful handwashing or the use of surgical scrubs.

Element III

Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker contact with potentially infectious material for bloodborne pathogens.

The OSHA Bloodborne Pathogens Standard requires the use, in order, of:

• Engineering controls
• Work practice controls
• Personal protective equipment

These precautions are built into the isolation precautions guidelines of the CDC.

Engineering controls include equipment, devices or instruments that remove or isolate (contain) a hazard. For example, the puncture-resistant containers required by Standard Precautions for the disposal and transport of needles and other sharps are an engineering control. Splatter shields on medical equipment associated with risk-prone procedures such as locking centrifuge lids isolate or contain the hazard. Hand hygiene is also an engineering control, since it removes the microorganisms from the workplace.

Work practice controls are modifications in technique that reduce or eliminate the likelihood of exposure by altering the manner in which a task is performed. These are the workplace procedures that tell you how to do the job safely. Be sure you know where to find the procedure manuals for your workplace.

Personal protective equipment is mutually beneficial for the healthcare professional and the patient. Following guidelines carefully is not only effective but also an expression of good professional practice, whereas neglecting to follow guidelines could lead to a charge of professional misconduct.

ENGINEERING CONTROLS

Every area of the healthcare facility and every type of patient care holds the potential for exposure to pathogens but some settings and practices hold greater risk than others. High-risk settings include:

• Intensive-care units (surgical, medical, coronary, pediatric)
• Operating rooms
• Delivery rooms
• Newborn nurseries
• Isolation units

Engineering controls used to prevent transmission of airborne infections include:

• Isolation rooms with appropriate air exchanges (negative pressure or direct exhaust)
• HEPA filtration
• Ultraviolet irradiation

Safety sharps devices and containers are another type of engineering control, since they isolate or contain the hazard-used sharps. The Occupational Safety and Health Administration (OSHA) requires the use of safety sharps when feasible. Healthcare workers may be exposed percutaneously (through the skin) by sharps or needle sticks to HIV, hepatitis B and C, and other bloodborne pathogens.

When using a safety sharp device, be sure to activate the safety feature before discarding. The stick you prevent may be your own! (This directive was adopted by the NYS Department of Labor's Public Employee Safety and Health program (PESH) and thus applies to all public employees in New York.)

Giving injections, disposing syringes with needles, or reprocessing needles and other sharps all hold potential risk for exposure to pathogens. An estimated 384,000 percutaneous injuries occur annually in U.S. hospitals; about 236,000 of these result from needle sticks involving hollow-bore needles (CDC (2000). These figures represent only part of the picture because they do not include nonhospital settings, which employ more than half of all healthcare workers.

A single needlestick contaminated with blood containing HIV gives a risk of infection of 3 to 4 per 1,000. A single needlestick contaminated with blood containing HBV gives a risk of infection of 60 to 300 per 1,000. It is important to note, however, that an employee can become infected as the result of a single exposure incident. Infection does not require multiple exposures. (OSHA, 1991)

Poor visualization during certain procedures also poses a hazard to both patient and healthcare worker. These procedures include blind suturing, a nondominant hand opposing or next to a sharp, and removal of bone or metal fragments.

In 2000 both New York State and federal laws were enacted to protect healthcare workers against needle sticks; these laws require that healthcare facilities evaluate and provide safe needles. OSHA has revised their guidelines on bloodborne pathogens to require that employers:

• Use engineering controls or work practices that "eliminate or minimize exposures" (OSHA 2001, CPL2-2.44D)
• Provide details about selecting, evaluating, and purchasing safe devices and instituting work practice controls
• Involve employees in the selection process
• Provide effective safe needles and sharps
• Provide training covering personal protective equipment, how to use safe-needle devices, and limitations of such devices

Always use safety devices when available. Always activate the safety feature. Never try to work around or disable it.

WORK PRACTICE CONTROLS

Work practice controls to eliminate or reduce the likelihood of exposure to potentially infectious material include general practices such as the following:

• Prompt cleanup of blood and body fluid spills with appropriate disinfectant
• Proper disposal/handling of blood and body fluid, including contaminated patient-care items
• Safe handling of used linen and waste

Work practice controls also include specific practices to avoid exposure and injury by modifying procedures and use of equipment. Percutaneous exposures can be prevented by:

• Avoiding unnecessary use of needles and other sharps
• Using care in the handling and disposal of needles and other sharps
• Not recapping unless absolutely medically necessary and then using one-hand technique or safety device to recap
• Passing sharp instruments by use of designated "safe zones"
• Disassembling sharp equipment by using forceps or other devices
• Closing and replacing sharps containers when they are full (rather than overfilling) according to the manufacturer's instructions
• Using forceps, suture holders, or other instruments for suturing
• Not holding patient tissue with fingers when suturing or cutting
• Having the patient wear a surgical mask
• Instructing the patient to cover the mouth with tissue when coughing or sneezing
• Early identification and isolation of suspect cases
• Transportation of potentially infectious patients

Work practices used when patients potentially or actually infected with virulent or epidemiologically important microorganisms are transported include:

• Appropriate barriers (eg, masks, impervious dressings) should be worn or used by the patient to reduce transmission of infection to other patients, personnel, and visitors, and to avoid contamination of the environment.
• Personnel in the area to which the patient is to be taken should be notified of the impending arrival of the patient and precautions to be used to reduce the risk of transmission.
• Patients are informed of ways in which they can assist in preventing the transmission of their infection to others.

ENVIRONMENTAL CONTROLS

Environmental control measures also help prevent the transmission of infection. These measures include:

• Environmental cleaning (housekeeping)
• Waste management
• Linens (textiles) and laundry management

Housekeeping

Appropriate housekeeping and sanitation practices are essential to reduce the spread of infection, particularly in high-risk areas such as nurseries, operating rooms, and intensive-care units. The CDC guidelines include the following recommendations:

• Keep housekeeping surfaces (eg, floors, walls, tabletops) visibly clean on a regular basis and clean up spills promptly.
• Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in patient-care areas.
• Follow proper procedures for effective uses of mops, cloths and solutions.

Waste Management

There are two categories of hospital waste: regulated medical waste and unregulated waste. According to the CDC (2000), most hospital waste is no more infective than ordinary residential waste, nor is there evidence that current hospital waste management practices have caused disease in the community.

Regulated medical waste ("red bag" waste) requires special precautions in handling and disposal. Regulated medical waste includes:

• Microbiology laboratory waste
• Pathology and anatomy waste
• Bulk blood or blood products
• Sharps items such as used needles or scalpel blades (CDC, 2003)

These items require special handling, transport, and storage procedures. The CDC (2003) recommends the following guidelines:

• Personnel responsible for waste management must receive appropriate training in handling and disposal methods in accordance with hospital policy.
• Waste generated in isolation areas should be handled using the same methods used for waste from other patient care areas.
• Disposable syringes with needles, including sterile sharps that are being discarded, scalpel blades, and other sharp items, should be disposed of in puncture-resistant containers located as close as practical to the point of use.
• Do not bend, recap, or break used syringe needles before discarding them into a container.
• Sanitary sewers may be used for safe disposal of blood, suctioned fluids, ground tissues, excretions, and secretions, provided that local sewage discharge requirements are met and that the state has declared this to be an acceptable method of disposal.
• Store regulated medical wastes awaiting treatment in a properly ventilated area inaccessible to vertebrate pests. Use waste containers that prevent development of noxious odors.
• If treatment options are not available at the site where the waste is generated, transport regulated medical waste in closed, impervious containers to the on-site treatment location or to another facility for treatment as appropriate.
• Regulated medical waste must be treated by a method (steam sterilization, incineration, interment, or an alternate treatment technology) approved by the appropriate authority (eg, the state, Veterans Administration, Indian Health Service) before disposal in a sanitary land fill. (CDC, 2003)

Linens and Laundry

According to CDC (2003), except for soiled textiles from patients in isolation, the risk of actual disease transmission from soiled laundry is negligible. Thus commonsense hygienic practices for handling, processing and storage of textiles are recommended. These practices include:

• Minimal handling and agitation of soiled laundry to prevent gross microbial contamination of the air, surfaces, and healthcare workers.
• No sorting or rinsing of textiles in the location of use.
• Bagging or placing soiled textiles in containers at the location where it was used.
• Labeling or color-coding bags or containers for contaminated waste.
• If laundry chutes are used:
• Ensure that laundry bags are closed before tossing the filled bag into the chute.
• Do not place loose items in the laundry chute.
• Textiles heavily contaminated with blood or other body fluids should be bagged and transported in a manner that will prevent leakage.
• Do not use dry cleaning for routine laundering in healthcare facilities.
• Clean textiles should be handled, transported, and stored by methods that will ensure their cleanliness.

Note: Employers are responsible for laundering workers' person protective garments or uniforms that are contaminated with blood or other infectious materials (OSHA, 1991).

Training healthcare workers who are responsible for housekeeping and management of linen and waste in appropriate infection control for their particular duties is essential for safe patient care.

Element IV

Selection and use of barriers and/or personal protective equipment for preventing patient and healthcare worker contact with potentially infectious material.

Personal protective equipment (PPE) is specialized clothing or equipment worn by a healthcare worker for protection against a hazard. OSHA guidelines state that PPE will be considered "appropriate" only "if it does not permit blood or other potentially infectious materials to pass through or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used." (OSHA, 1991).

Use of PPE is built into the descriptions of all four kinds of isolation precautions (Standard, Contact, Droplet, and Airborne) described by the CDC. Use appropriate barriers and/or PPE whenever you may have contact with the blood or body fluids of any patient and to prevent exposure to the droplets of patients with respiratory symptoms.

A barrier is a material object that separates a person from a hazard. The type of PPE selected should be based on the procedure and reasonably anticipated events such as:

• Blood or body fluid splash
• Contact with minimal bleeding/drainage/body substance
• Contact with large volume bleeding/drainage/body substance that is likely to soak through the contact area
• Respiratory droplet pathogens
• Airborne pathogens

Some barriers are used to protect the patient, including:

• Sterile barriers for invasive procedures
• Masks for the prevention of droplet contamination

Personal protective equipment includes:

• Gloves
• Cover garb (gowns, aprons, fluid-resistant laboratory coats)
• Face shields
• Masks
• Eye protection
• Caps and hoods

Gloves are available in several materials including latex, nitrile, or rubber (utility/housekeeping). Many healthcare workers have developed an allergy to latex and should use gloves made of nitrile or other latex-free alternative.

For some procedures, wearing two pair of gloves (double-gloving) helps reduce the risk of contamination with blood and body fluids. One clinical study found that wearing a single pair of surgical gloves resulted in a failure rate (loss of glove integrity) of 51%. Double-gloving reduced the failure rate to 7% (Quebbeman et al., 1992). Double-gloving is recommended for surgical procedures in which the patient is known or suspected to be infected with a transmissible virus and for all procedures expected to last more than two hours. If double-gloving is not done, healthcare workers should frequently check for blood penetration and should change gloves every 1 to 3 hours (Raahve, 1996).

Disposable examination gloves should never be washed or decontaminated after use. This does not apply to heavy vinyl or rubber gloves used for housekeeping tasks. These may be decontaminated and reused, as long as glove integrity remains intact (APIC, 2003). Always use nitrile or other appropriately protective gloves when handling chemotherapy or other chemicals. Both examination (nonsterile, clean) gloves and surgical (sterile) gloves must be available for specific healthcare tasks. Avoid use of petrolatum-based lotions or creams when using latex gloves; these products may affect the integrity of the gloves.

Gloves are the first line of PPE, and can prevent heavy contamination of hands during patient care and transmission of pathogens. However, wearing gloves does not provide complete protection against acquiring viral infections, particularly hepatitis B and herpes simplex viruses.

Wearing gloves does not replace the need for handwashing because gloves may have small, unnoticeable defects or may tear during use, and hands can become contaminated during glove removal. Hands should be washed with soap and water after glove removal if hands are visibly soiled or if the glove has torn. In the absence of visible hand contamination, hand hygiene with alcohol hand rubs is appropriate after glove removal (APIC, 2003). Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks, even with the same patient.

Gowns are available in both sterile (surgical) and nonsterile (clean) versions and in fabrics of varying permeability (impervious, fluid-resistant, permeable). Gowns protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to involve contact with or generate splashes or sprays of blood or body fluids. Choose the type of gown which will provide adequate protection for the task you will be doing.

Masks protect both the healthcare worker and the patient from transmission of pathogens. Different types of masks are available for different tasks and purposes, including:

• Single-use disposable mask with eye shield should be used when splash splatter is anticipated, such as in the OR. These must be changed if wet or soiled. These protect the patient and sterile field from the exhaled droplets of the surgical staff as well as protecting the eyes of surgical staff.
• Single-use disposable masks are used for Droplet Precautions. They are also used on patients with respiratory symptoms as part of respiratory hygiene or on patients known or suspected to have TB. Both these types of masks contain the droplets coming out of the person wearing the mask (covering their portal of exit).
• N-95 respirators are required for staff sharing air space with the patient in Airborne Precautions. They must make a tight seal against the face, and must be fit tested. This type of respirator protects the person wearing it from possible pathogens in the air of the room, protecting their portal of entry. Some N-95 respirators have an exhalation valve, and these do not prevent contamination of a sterile field and so should not be worn alone in the OR.

Masks should cover both the mouth and the nose. If the mask has a metal strip, it should be fitted securely over the bridge of the nose to prevent inhalation or exhalation of pathogens and to prevent fogging of eyeglasses. If glasses are worn, the upper edge of the mask should fit under the glasses to prevent fogging.

When wearing a mask with strings, tie the strings securely to prevent strings from coming loose during the procedure. Tie the upper strings at the back of the head and the lower strings at the neck. Do not cross the strings; this will cause a gap around the cheeks (Fortunato, 2000). When untying the mask, untie the lower strings first. This prevents the mask from falling onto the chest and contaminating the gown.

Masks with eye shields or face shields and other eye protection (goggles, safety glasses) are essential to protect the mucous membranes of the eyes, nose, and mouth during procedures that are likely to generate splashes or sprays of blood or body fluids. Although percutaneous injuries (needle sticks) are the most common route for transmission of viruses, splashes or sprays to the mucous membranes are the second most common route.

Eye protection includes masks with eye shields, goggles, and face shields. Eyes should be protected whenever splash or splatter of blood or body fluids may be anticipated. When eye protection is worn, a mask should also be worn (OSHA, 2001).

Some barriers and PPE are worn to protect the patients from the germs of healthcare professionals, especially in the OR. Sterile drapes are used to create a sterile field in which the operative procedure can take place. Surgical masks reduce risk of droplet contamination of the operative field. Caps and hoods are worn to reduce shedding and promote environmental control. The Association of Operating Room Nurses recommends that a cap or hood be worn that fully covers all hair on the head and face when in restricted and semi-restricted areas of the surgical suite (AORN, 2000).

Barriers and PPE are most effective when appropriately selected, properly fitted, worn according to manufacturer's instructions, inspected frequently to verify integrity of the barrier, and changed between patients. The cost of barriers and PPE are far less than the cost of treating preventable infections of patients and personnel.

Element V

Creation and maintenance of a safe environment for patient care through application of infection control principles and practices for cleaning, disinfection, and sterilization.

The potential for contamination exists in every area of the hospital or other healthcare facility. Contaminated patient-care equipment (wet or soiled dressings), invasive devices that were used in diagnosis and treatment (surgical instruments or endoscopes), and environmental surfaces (doorknobs, floors, toilets) can act as vehicles for the transmission of infection to healthcare workers and/or patients.

Endoscopes can transmit pathogens to patients by contaminated internal channels even if the exterior has been disinfected, if the internal channels have not been adequately cleaned or if contact of the disinfecting solution with the internal channel is incomplete or does not last long enough.

Understanding and applying appropriate procedures for cleaning, disinfection, and sterilization are essential to maintaining a safe patient-care environment.

Keep in mind that all disinfectants and sterilizing chemicals have a degree of toxicity necessary to kill the microorganisms. In general, the lowest level of product that will do the job should be used, to minimize exposure to toxic chemicals.

All environmental surfaces should be kept visibly clean and all spills should be cleaned up promptly, using appropriate detergents or disinfectants. High-touch surfaces such as doorknobs, bed rails, light switches, and surfaces in or around patients' rooms should be cleaned more frequently than surfaces touched less frequently.

The CDC (2002) recommends the following principles concerning sterilization or disinfection of patient-care equipment:

1. Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce organic material or bioburden before being exposed to germicide. The instructions from the manufacturers of the germicide and the device should be closely followed. Items that have been wet for several hours may have developed biofilm, complex colonies of bacteria protected by "slime" which protects the bacteria from contact with disinfecting chemicals. (An example of biofilm is the coating on our teeth when we awaken.) Biofilm must be removed by mechanical action (scrubbing) before disinfection or sterilization.
2. In general, reusable medical devices or patient-care equipment that enter normally sterile tissue or the vascular system or through which blood flows should be sterilized before each use. Sterilization means the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. The major sterilizing agents used in hospitals are:
• Moist heat by steam autoclaving (the gold standard, also minimally toxic)
• Ethylene oxide gas (highly toxic; use is decreasing)
• Peracetic acid (used in proprietary machines, often for endoscopes)
• Plasma (new method with little toxicity)
• Dry heat
3. Heat-stable reusable medical devices that enter the bloodstream or enter normally sterile tissue should always be reprocessed using heat-based methods of sterilization (eg, steam autoclave, dry-heat oven) (CDC, 2002).
4. Effectiveness of the sterilization process depends on:
• Selection and use of appropriate sterilization methods
• Monitoring the sterilization process using biologic and process monitors, such as time, pressure, and temperature gauges.

Proper handling and storage after sterilization, including package integrity and shelf-life or event-related sterility criteria, are required to maintain these items in a sterile state. Event-related sterility means that sterilized items do not outdate by an arbitrary date, but are judged to be sterile unless an "event" has compromised sterility.

Compromising events include circumstances that break the integrity of the sterile packaging by creating holes or wetting the package, which could carry bacteria into it. The end user of the package is responsible for inspecting its integrity, verifying that no event has compromised sterility. In use, this means that the sterile package that has come loose, has holes, or shows evidence of wetting, presently or in the past, cannot be used because sterility may have been compromised.

5. Disinfection means the use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (eg, bacterial endospores) on inanimate objects. There are three levels of disinfection:
• High-level disinfection is effected with a chemical germicide cleared for marketing as a sterilant by the Food and Drug Administration.
• Intermediate-level disinfection uses a chemical germicide registered as a "tuberculocide" by the Environmental Protection Agency (EPA).
• Low-level disinfection is done with a chemical germicide registered as a hospital disinfectant by the EPA. (CDC, 2002)

Care must be taken to use the right disinfectant for the purpose, consistent with its legal registration.

6. Laparoscopic or arthroscopic telescopes (optic portions of the endoscopic set) should be subjected to a sterilization procedure before each use. If this is not feasible, they should receive high-level disinfection. Heat-stable accessories to the endoscopic set (eg, trocars, operative instruments) should be sterilized by heat-based methods (eg, steam autoclave, dry-heat oven). Chemicals used for disinfection must be monitored for activity as recommended by the manufacturer, generally using a daily test strip. Results of monitoring should be documented.
7. Reusable devices or items that touch mucous membranes should, at a minimum, receive high-level disinfection between patients. These devices include reusable flexible endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment. Methods for verifying contact with all internal channels and components must be monitored.
8. Devices labeled "for single patient use only" should be discarded properly following use. Reuse of such devices is prohibited unless specific FDA regulations are followed and documented. Check with your facility's risk management department if reuse of devices so labeled is considered.
9. Except on rare and special instances (as mentioned below), items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients. These items include crutches, bed boards, blood pressure cuffs, and a variety of other medical accessories. Consequently, depending on the particular piece of equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed. If noncritical items are grossly soiled with blood or other body fluids, the CDC recommends the following HIV-related precautions:
• Standard chemical germicides at concentrations much lower than commonly used in practice can rapidly inactivate HIV.
• Chemical germicides registered as "sterilants" with the Environmental Protection Agency (EPA) and cleared for marketing for use on medical devices by the Food and Drug Administration (FDA) may be used either for sterilization or high-level disinfection of medical devices, depending on contact time.
• Extraordinary attempts to disinfect walls, floors, or other environmental surfaces are not necessary. However, cleaning and removal of soil should be done routinely. An inexpensive environmental surface germicide effective against HIV is a solution of sodium hypochlorite (1 part household bleach to 99 parts water, or 1/4 cup bleach to 1 gallon of water) prepared daily. However, bleach is corrosive to metals (especially aluminum) and should not be used to decontaminate medical instruments with metallic parts. (CDC, 2002)

EPA-approved hospital disinfectants that are tuberculocidal/virucidal should be used to decontaminate spills of blood or other body fluids that contain blood in the following areas:

• Blood spills should be absorbed with paper towels or other absorbent material, then discarded according to hospital policy and local regulation. Tuberculocidal disinfectant should be applied to the area and sufficient contact time allowed before final cleaning.
• In the laboratory, large spills of cultured or concentrated infectious agents should be flooded with a liquid germicide before cleaning, then decontaminated with fresh germicidal chemical after organic material has been removed. It is not necessary to flood spills of blood or other body fluids with germicide before cleaning.

Exceptional circumstances that require noncritical items to be either dedicated to one patient or patient cohort, or subjected to low-level disinfection between patient uses, are those involving:

• Patients infected with vancomycin-resistant enterococci (VRE) or other drug-resistant microorganisms judged by the infection control program, based on current state, regional, or national recommendations, to be of special or clinical or epidemiologic significance
• Patients infected with highly virulent microorganisms, eg, viruses causing hemorrhagic fever (eg, Ebola or Lassa)
• Patients infected with infected or colonized methicillin-resistant Staphylococcus aureus (MRSA)

When preparing reusable devices for reprocessing (sterilization or disinfection), a few principles must be kept in mind:

• When handling and cleaning contaminated items, wear appropriate gloves.
• Always clean items before reprocessing. First rinse with cold water to remove blood or body fluids, then wash with hot soapy water and rinse again to remove the soap before disinfecting or sterilizing. Cleaning methods may be manual or mechanical and may require a rinse or presoak, depending on the nature and amount of blood or body fluids. Once cleaned, avoid cross-contamination by other articles or surfaces.
• When choosing a reprocessing method, bear in mind whether devices or equipment are critical (sterilize), semi-critical (high-level disinfect), or noncritical (clean or low-level disinfect).

Always follow the device/equipment manufacturer's recommendations for reprocessing to ensure that the method chosen is compatible with the components and materials in terms of heat and pressure tolerance and time required for reprocessing.

Reported cases of use of contaminated patient care equipment have usually resulted from:

• Inadequate cleaning before reprocessing (disinfection or sterilization)
• Inadequate disinfection or sterilization processes (failure to monitor the quality of the process)
• Contamination of disinfectant or rinse solutions
• Improper storage or handling following reprocessing
• Failure to reprocess or dispose of equipment between patients

Once devices/equipment have been disinfected, proper handling and storage are required to maintain these items in ready-to-use condition.

Every healthcare professional should recognize potential sources of cross-contamination in the healthcare environment and apply infection-control procedures to avoid cross-contamination. These sources include:

• Surfaces or equipment that require cleaning between patients
• Practices that contribute to hand contamination and potential for cross-contamination
• Implications of reuse of disposable equipment or devices

The area of professional practice dictates the scope of responsibility for recognizing various levels of disinfection/sterilization methods and agents. Those health professionals who practice in settings where handling, cleaning, and reprocessing equipment and devices are performed elsewhere, such as a central sterile processing facility, should be cognizant of the basic concepts and principles of cleaning, disinfection, and sterilization described above. In addition, these professionals are responsible for application of safe practices for handling devices and equipment in the area of their professional practice.

Those individuals who have primary or supervisory responsibilities for equipment or device reprocessing should also understand the core concepts and principles of cleaning, disinfection, and sterilization as described above. They also are responsible for appropriate application of safe practices for handling devices and equipment. In addition, these individuals require more detailed knowledge of the various considerations for selecting of appropriate methods, which include:

• Antimicrobial efficacy
• Time constraints and requirements for various methods
• Compatibility with equipment/materials
• Toxicity
• Residual effect
• Ease of use
• Stability
• Odor
• Cost
• Ability to monitor process
• FDA regulations for reuse of single devices

Element VI

Prevention and management of infectious or communicable diseases in healthcare workers.

Prevention of infectious diseases in healthcare workers (HCWs) means protecting them from infections they do not already have. Management of infectious diseases in HCWs means protecting others from the diseases the HCW already does have. This protection must work in both directions!

Protecting HCWs from disease is accomplished in many ways, including:

• Use of Standard Precautions with all patients
• Use of additional isolation precautions to protect HCWs as well as patients
• Influenza vaccine is offered annually and staff are encouraged to accept it as a method for protecting patients. Vaccinating staff against influenza is associated with lower patient death rates from influenza (Carman et al., 2000)

If you suspect that you have been exposed on the job to a communicable disease, let your supervisor and your infection control practitioner know without delay. This will allow evaluation of the circumstances to prevent exposure of others, management of the exposure, and appropriate follow-up of your health as needed. For some diseases, post exposure prophylaxis (preventive medication) is available.

Protecting others from infections of health professionals is a responsibility of the facility and the individual HCW. Employees are responsible for reporting to their supervisor or occupational health service any signs or symptoms of a communicable disease. Symptoms that should be reported and evaluated include:

• Fever
• Unusual rash
• Unexplained blisters
• Purulent skin lesions, such as boils (resequenced only)
• Exudative (weeping) dermatitis
• Sore throat with fever
• Gastrointestinal symptoms (vomiting, diarrhea)
• Recent onset of unexplained cough or congestion suggesting an acute respiratory infection
• Jaundice
• Symptoms suggesting active tuberculosis (chronic productive cough with unexplained weight loss, fever, night sweats or hemoptysis [bloody sputum])

Employees who report symptoms of illness should be removed from duty and medically evaluated to determine their ability to work and the duration of work restrictions. Those found to have a legally reportable communicable disease should have their illness reported to the local health unit for follow-up (NYS DOH, 1994).

New York State law also recommends that:

• All healthcare workers whose job responsibilities involve contact with blood or sharp objects likely to be contaminated with blood should be offered and encouraged to receive the hepatitis B vaccine.
• All healthcare personnel should receive information about the risks associated with HIV, HBV, and HCV infection and the merits of knowing their status if they have personal occupational risks so they may benefit from medical management.
• All healthcare workers should be informed that if they have an impaired immune system due to HIV infection or other medical condition, they are at risk of acquiring potentially life-threatening infections, including TB, from patients.
• Information on the availability of voluntary, confidential, anonymous counseling and testing for HIV, HBV, and HCV must be made available to all healthcare workers. Employees must be offered the HBV vaccine and the NYS Department of Health strongly recommends that at-risk healthcare workers receive this vaccine.

The New York State Department of Health (1994) recommends that every health facility and home health agency incorporate the evaluation of personnel for a communicable disease into a broader occupational health program. Policies and procedures should be developed for reporting signs and symptoms of illness and diagnosis of or exposure to a communicable disease. All employees must receive initial and ongoing education regarding these policies and procedures.

Other occupational health strategies for preventing transmission of bloodborne pathogens and other communicable diseases include:

• Pre-employment evaluation to screen for:
• Tuberculosis
• Rubella (German measles) immunity
• Measles immunity
• Annual assessment of staff (including surveillance for TB)
• Influenza immunization
• Removal from work or modification or limitation of work practices

TABLE 2

IMMUNIZING AGENTS RECOMMENDED FOR HCWs

Generic name	Indications
Hepatitis B recombinant vaccine	Healthcare personnel at risk of exposure to blood and body fluids
Influenza vaccine (inactivated whole or split virus)	Healthcare personnel with contact with high-risk patients or working in chronic care facilities; personnel with high-risk medical conditions and/or ≥ 65 yr
Measles live virus vaccine	Healthcare personnel born in or after 1957 without documentation of (a) receipt of two doses of live vaccine on or after their 1st birthday, (b) physician-diagnosed measles, or (c) laboratory evidence of immunity; vaccine should be considered for all personnel, including those born before 1957, who have no proof of immunity
Mumps live virus vaccine	Healthcare personnel believed to be susceptible can be vaccinated; adults born before 1957 can be considered immune
Rubella live virus vaccine	Healthcare personnel, both male and female, who lack documentation of receipt of live vaccine on or after their 1st birthday, or of laboratory evidence of immunity; adults born before 1957 can be considered immune, except women of childbearing age
Varicella zoster live virus vaccine	Healthcare personnel without reliable history of varicella or laboratory evidence of varicella immunity
Source: CDC, 1998.

TABLE 3

IMMUNIZING AGENTS FOR SPECIAL CIRCUMSTANCES

Generic name	Indications
BCG vaccine (for tuberculosis)	Healthcare personnel in communities where (a) MDR-TB is prevalent, (b) strong likelihood of infection exists, and (c) full implementation of TB infection control precautions has been inadequate in controlling the spread of infection (Note: BCG should be used after consultation with local and/or state health department)
Hepatitis A vaccine	Not routinely indicated for U.S. healthcare personnel; persons who work with HAV-infected primates or with HAV in a laboratory setting should be vaccinated
Meningococcal polysaccharide (quadrivalent A, C, W135, and Y) vaccine	Not routinely indicated for healthcare workers in the United States
Polio vaccine	Healthcare personnel in close contact with persons who may be excreting wild virus and laboratory personnel handling specimens that may contain wild poliovirus
Rabies vaccine	Personnel who work with rabies virus or infected animals in diagnostic or research activities
Tetanus and diphtheria (Td)	All adults; tetanus prophylaxis in wound management
Typhoid vaccines: IM, SC, and oral	Personnel in laboratories who frequently work with Salmonella typhi
Vaccinia vaccine (smallpox)	Personnel who directly handle cultures of or animals contaminated with recombinant vaccinia viruses or orthopox viruses (monkeypox, cowpox, vaccinia, etc.) that infect human beings
Source: CDC, 1998.

BLOODBORNE PATHOGENS TRAINING

Bloodborne pathogens training must include:

• Information on hazards associated with blood or other potentially infective material (OPIM)
• OPIM includes semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids
• Protective measures to minimize risk of occupational exposure
• Information on appropriate actions to take if exposure occurs

New York State law requires retraining employees every four years, or when changes in procedures or tasks affecting occupational exposure occur.

All employees whose jobs involve participation in tasks or activities with exposure to blood/OPIM shall be offered the first of the hepatitis B vaccination series within 10 working days of employment and/or new assignment. The vaccination is free, safe, and highly recommended.

Serologic testing after vaccination (to ensure that the vaccination was effective) is recommended for all persons with potential occupational exposures. The brief summary that follows is not meant to replace or supplant required bloodborne pathogens training.

Although HBV and HIV are specifically identified in the standard, "bloodborne pathogens" include any pathogen present in human blood/OPIM that can infect and cause disease in people exposed to the pathogen. Bloodborne pathogens may also include HCV, malaria, West Nile virus, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I–associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

The risk of developing HIV infection from a needle stick with infected blood is about 1:300 without prompt antiretroviral treatment. As of December 2002 (latest statistics available), the CDC reported 57 documented and 139 possible cases of HIV seroconversion among healthcare personnel in the United States. Most were exposed to blood through percutaneous injuries, and eight of the workers were infected despite receiving postexposure prophylaxis (PEP) (Do et al., 2003). Twenty-six later developed AIDS.

To prevent transmission of bloodborne pathogens to healthcare workers, the CDC recommends that postexposure prophylaxis (PEP) begin within 1 to 2 hours after the exposure (CDC, 1999). Specific guidelines are summarized in Box 11.

The CDC recommends that healthcare facilities monitor the effects of PEP and track safety and acceptability of different PEP regimens that include new antiretroviral agents. Communication prior to treatment about possible side effects and follow-up during treatment with PEP increase compliance
(Table 4).

TABLE 4

POSTEXPOSURE PROPHYLAXIS FOR HCW

Disease	Indication
Diphtheria	For healthcare personnel exposed to diphtheria or identified as carriers
Hepatitis A	May be indicated for healthcare personnel exposed to feces of infected persons during outbreaks
Hepatitis B	HBV-susceptible healthcare personnel with percutaneous or mucous-membrane exposure to blood known to be HBsAg seropositive
Meningococcal disease	Personnel with direct contact with respiratory secretions from infected persons without the use of proper precautions (eg, mouth-to-mouth resuscitation, endotracheal intubation, endotracheal tube management, or close examination of oropharynx)
Pertussis	Personnel with direct contact with respiratory secretions or large aerosol droplets from respiratory tract of infected persons.
Rabies	Personnel who have been bitten by human being or animal with rabies or have had scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or other potentially infective material (eg, brain tissue)
Varicella zoster virus	Personnel known or likely to be susceptible to varicella and who have close and prolonged exposure to an infectious healthcare worker or patient, particularly those at high risk for complications, such as pregnant or immunocompromised persons
Source: CDC, 1998.

The following standards are based on recommendations by the CDC.

Healthcare workers who have or may have HBV or HIV should be evaluated for the ability to work safely. This evaluation should be based on the premise that HIV or HBV alone is not sufficient justification to limit the worker's professional duties. Case-by-case evaluation should be done to determine whether an individual healthcare worker poses a risk to patients that warrants job modification, limitation, or restriction. If a patient is exposed to the blood of a healthcare worker, that patient must be informed of the exposure and appropriate follow-up offered.

Periodic re-evaluation of a healthcare worker infected with HIV may be appropriate if the disease progression alters physical or mental functioning. Other factors that may affect the ability of healthcare workers to provide quality healthcare include:

• Lack of compliance with established infection control guidelines
• Appropriateness of techniques as related to performance of procedures
• Any health condition that would pose a significant risk to others

Healthcare facilities are required to establish a mechanism for evaluating healthcare workers with HIV or HBV infection. However, this does not include involuntary screening of employees for HIV or HBV. New York State law prohibits HIV testing of any citizen without written informed consent.

Institutional evaluation of individual workers known to be infected with HIV or HBV shall be based on DOH criteria and shall involve consultation with experts who can provide a balanced perspective. Such experts can include:

• An infectious disease physician and/or hospital epidemiologist with an understanding of HIV/HBV
• A representative from the infected healthcare worker's practice area
• The personal physician of the infected worker

All matters related to evaluation must be handled confidentially.

Any modification of work practice must seek to impose the least-restrictive alternative in accordance with federal disability laws. Workers who believe that their employment has been unfairly restricted or terminated may ask for a second opinion from a DOH review panel and/or file a complaint with the NYS Human Rights Commission.

All HIV-infected healthcare workers are entitled to protection under the NYS HIV Confidentiality Law, as are other citizens. Such workers are not required to disclose their status to patients or employers. For more information about Authorization for Release of Confidential HIV Related Information go to http://www.health.state.ny.us/nysdoh/hivaids/hivpartner/pdfs/authoriz.pdf.

Posted August 8, 2006

Expires November 3, 2008

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