CHERRY STREET HEALTH SERVICES - midwest-site



CHERRY STREET HEALTH SERVICES

POLICY AND PROCEDURE

SUBJECT: INFECTION CONTROL PLAN

POLICY:

Cherry Street Health Services (CSHS) is committed to providing a safe and efficient working environment for all employees. All employees have a right to know about health hazards associated with their work. Education and inservice training will enable employees to make knowledgeable decisions about any personal risks of employment. The Safety and Infection Control Manual will include policies, procedures, and responsibilities designed to make employees aware of hazards in the work place and to train employees in appropriate and safe working conditions.

CSHS has assigned the responsibility, authority and accountability for safety to all management and supervisory personnel. Accident prevention is the primary objective of a “hazard-free” work place. To accomplish this, CSHS folllows these federal and state regulations:

1) OSHA’s Occupational Exposure to Hazardous Chemicals in Laboratories

2) 2) OSHA’s Occupational Exposure to Blood Borne Pathogens.

These regulations, along with prudent infection control measures, will be the primary components of the Safety and Infection Control Manual.

A hazard-free work place is everyone’s responsibility. All employees must continuously work together to promote a safe work place. Management and supervisory personnel will consistently enforce all policies and procedures. Each employee will have the responsibility of performing their own work in a safe and efficient manner and to report unsafe acts or conditions to their supervisor.

I. OBJECTIVES

A. Safe work methods will be developed and maintained. All employees will be appropriately trained in these methods.

B. Chemical management requirements will be covered by the Safety and Infection Control Manual.

1. Implementation of procedures and work practices that protect employees from health hazards associated with chemicals used by this organization.

2. Maintain employee exposures below permissible exposure limits for OSHA regulated substances.

C. Exposure Control Plan requirements will be covered by the Safety and Infection Control Manual.

1. Exposure determination will be listed by job title descriptions for all job classifications that are determined to be a Risk Category I, Category II or Category III. *Refer to Form IC - 1A for the organizations personnel risk categories.

2. Methods of compliance will be through the practice of universal precautions, Personal Protective Equipment (PPE) and engineering controls, handwashing practices, sharps precautions, hazardous waste disposal and decontamination procedures.

D. All employees needing medical attention will use the employee health services available through Spectrum Health. All medical examinations and consultations will be performed without cost to the employee, without loss of pay, and in a reasonable time. This service must not be misconstrued as an employee’s personal physician. This service is for exposure incidents due to a hazardous chemical, blood borne pathogen, or other workplace occurrence.

III. GLOSSARY

A. Chemical

1. Carcinogen: a substance capable of causing cancer.

2. Combustable: able to catch on fire and burn.

3. D.O.T: Department of Transportation.

4. EPA: Environmental Protection Agency.

5. Flammable: capable of being easily ignited and of burning with extreme rapidity.

6. Laboratory scale: work with chemicals that can easily and safely be manipuIated by one person, excluding the commercial production of chemicals for sale.

7. Laboratory use: a work place where relatively small quantities of hazardous chemicals are used on a non-production basis.

8. MSDS: Material Safaty Data sheets.

9. OSHA: Occupational Safety and Health Administration - The regulatory branch of the Department of Labor concerned with employee safety and health.

10. PEL: Permissisle Exposure Limit. This is the legally allowed concentration in work place that is considered a safe level of exposure for an 8 hour shift, 40 hours per week.

B. Blood Borne Pathogens

1. Blood: human blood, human blood components, and products made from human blood.

2. Blood borne pathogens: pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).

3. Contaminated: the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

4. Decontaminated: the use of physical or chemical means to remove, inactivate, or destroy blood borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

5. Engineering controls: controls (i.e. sharps disposal containers, self-sheathing needles) that isolate or remove the blood borne pathogen hazards from the workplace.

6. Exposure Incident: a specific eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

7. Occupational Exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material that may result from the performance of an employee’s duties.

8. Other Potentially Infectious Materials

a. The following human body fluids: semen, vaginal excretions, 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 impossible to differentiate between body fluids.

b. Any unfixed or unpreserved tissue or organ (other than intact skin) from a human (living or dead).

9. Parenteral: piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.

10. Personal Protection Equipment (PPE): specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be PPE.

11. Source Individual: any human body or organ part living or dead, whose blood or other potentially infectious fluid or organ may be a source of occupational exposure to the employee.

12. Universal Precautions: an approach to infection control. According to the concept of univeral precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HVB, or other blood borne pathogens.

13. Work Practice Controls: controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

IV. RESPONSIBILITIES

A. Safety Committee: The objective of this committee is to maintain a “hazard-free” workplace for the organization. The committee will be chaired by the Operations Director . The committee will meet monthly to review any incidents and annually review all policies and procedures developed. The Safety Committee has the following responsibilities:

1. Work with administration and other key personnel to develop and implement appropriate policies and practices.

2. Certify the performance of protective equipment.

3. Identify, monitor procurement, use and disposal of hazardous chemicals and blood borne pathogens in the work place.

4. Know current regulations that impact the work place.

5. Always search for new methods to improve policies and procedures developed.

6. Review infection control and safety surveys.

B. Operations Director/Executive Director

1. Responsible for providing a “hazard-free” environment for all patients and personnel.

2. Aware of potential hazards in the organization and appropriate precautionary measures are implemented.

3. Communication with practice physicians and other key personnel on any changes in policies and procedures.

C. Facility Managers

1. Responsible for providing a “hazard-free” environment for all patients and personnel.

2. Communication with Operations/Executive Director, etc.

3. Provide formal safety inspections monthly and a semi annual risk assessment inspection of all clinical sites. Reports to be submitted to the safety committee.

4. Know current regulations.

D. Clinical Coordinators/ Supervisor(s)

1. Works closely with Facility Managers in the administration of Safety

and Infection Control program. Specifically identifies needs of the department or site.

2. Is a member of Safety Committee. Participates in the development and implementation of new policies and procedures as needs change.

E. Employees

1. Employees are asked to utilize safety procedures implemented for protection for everyone.

2. All employees have the responsibility to be aware of hazards, and follow policies and procedures designed to protect them.

3. Report all incidents or accidents so that steps may be taken to prevent a reoccurrence.

All employees must be aware that protective clothing and equipment alone offer minimal protection. It is extremely important to follow all policies and procedures contained in this manual.

V. MANAGEMENT OF HBV, HIV, AND MICROORGANISMS

A. Universal Precautions: Universal precautions require health care workers (HCW) to assume that all body fluids are potentially infected with HBV, HIV, or other blood borne pathogens, and to use personal protective equipment, work practice controls, prudent infection control measures and common sense to prevent parenteral, mucous membrane, and non-intact skin exposure to blood and all body fluids.

The following is a list of other potentially infectious materials: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visisly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.

B. Modes of Transmission

1. Microorganisms: are transmitted by several routes, and the same microorganisms may be transmitted by more than one route. For instance, Varicella-Zoster virus (Chicken Pox) can spread by either the airborne route or by direct contact. There are four main routes of transmission: contact, vehicle, airborne, and vectorborne.

2. Contact transmission: This mode of transmission is the most important and frequent cause of nosocomial infections and can be further classified by three subgroups: direct contact, indirect contact and droplet contact.

a. Direct contact: This involves direct physical transfer between a susceptible host and an infected or colonized person (e.g., initial examinations, suturing, dressing wounds, venipunctures, or other procedures that require direct personal contact.

b. Indirect contact: This involves personal contact of the susceptible host with a contaminated intermediate object, usually an inanimate object.

c. Droplet contact: This involves infectious agents that may come in contact with conjunctivae, nose, or mouth of a susceptible person as a result of coughing, sneezing, or talking with an infected person who has clinical disease or is a carrier of the organism. This is considered “contact” transmission, rather than airborne, since droplets usually travel no more than about 3 (three) feet.

3. Vehicle Transmission: the vehicle route applies to diseases transmitted through the use of contaminated items.

a. Food, such as in Salmonella.

b. Water, such as in Legionellosis.

c. Drugs, such as in bacteremia resulting from infusion of a contaminated infusion product.

d. Blood, such as in Hepatitis B, or Hepatitis C

4. Airborne Transmission: This occurs by dissemination of either droplet nuclei (residues of evaporated droplets that may remain suspended in the air for long periods of time) or dust particles in the air containing the infectious agent. Organisms carried in this manner can be widely dispersed by air currents before being inhaled by or deposited on the susceptible host.

5. Vectorborne Transmission: This mode is of greater concern in tropical countries, for example, with mosquito transmitted Malaria. It is of little significance in the United States.

6. HBV and HIV can be transmitted by direct contact, indirect contact, fecal-oral transmission, and airborne transmission.

a. Direct contact

1) The transfer of blood borne pathogens or other infectious agents may occur through accidental needlesticks, broken glass, scalpel cuts, etc.

2) Transfer of blood borne pathogens or other infectious agents has occurred through pre-existing minute scratches, abrasions, burns, weeping or exudative skin lesions, etc.

3) Contamination of mucosal surfaces with blood borne pathogens, or other infectious agents as may occur with mouth pipetting, splashes, spattering, or conjunctival contact.

b. Indirect Contact

1) HBV can be transmitted indirectly from common surfaces such as examination tables, patient beds, patient personal items, laboratory counter tops, test tubes, lab instruments, and other surfaces contaminated with infectious blood, blood products, or body fluids. Transfer to the skin or mucous membranes is typically by hand contact.

2) Nail biting, application of cosmetics, eating and other hand-to-nose, hand-to-mouth, and hand-to eye actions may contribute to indirect transmission.

c. Fecal-Oral transmission: The fecal-oral route does not appear to be an efficient mode of transmission of either HBV or HIV. Therefore, routine precautions used in handling of feces are adequate to prevent transmission of HBV or HIV. Fecal-oral transmission may pose a hazard for Hepatitis A Virus infection.

d. Airborne Transmission

l) Airborne transmission of HBV and HIV through inhaled aerosol has been hypothesized; thus far, none have been documented.

2) Splashing, splattering, centrifuge accidents, and removal of rubber stoppers from tubes can produce large or small droplets that may be transferred into the mouth, eyes or onto breaks in the skin surface. This is not an example of airborne transmission by aerosol, but rather transmission by direct droplet contact.

C. Preventing HBV, HIV and Microorganism transmission in the clinical setting: if at all possible, employees need to attempt to identify patients suspected of having diseases that are spread by airborne transmission. This will include childhood diseases, influenza, and TB. Diseases other than those that are not classified as airborne should not pose a threat to patients in the waiting room.

1. Practice universal precautions.

2. Handwashing techniques and guidelines will be followed by all employees.

3. The organization facilities will be maintained in a clean and sanitary condition. All employees will follow housekeeping guidelines.

4. Grossly contaminated equipment, work surfaces, examination rooms, spills, leakage, etc., will be immediately decontaminated.

5. All employees will use appropriate PPE as detertermined by the Safety Committee for that particular task.

6. All infectious waste shall be segregated and packaged as recommended.

7. To prevent needlestick injuries, needles should never be recapped, separated from syringes, or manipulated by hand in any way. (Exception: allergy injections - double needle technique recommended; also if the needle is contaminated when preparing injections and tubex administration kits i.e. dental anesthesia and IM Penicillin administraton in medical)

8. Devices, such as sharps or glass pipettes should be placed in puncture-resistant and leakproof containers and will be labeled with the Biohazard symbol.

9. Mouth pipetting/suctioning of any substance is prohibited.

*Refer to Form IC for the organization’s housekeeping schedule.

VI. RISK CATEGORY CLASSIFICATION SYSTEM

Job positions at the organization were reviewed for their probability of performing work tasks that may cause exposures to blood, body fluids, or tissues. Consideration has been given to tasks that may be performed by positions in the facility that would not be a-part of the normal position requirements. Categories apply to physicians, all employees’ students, contractors, or others who may be called upon to perform tasks within the facility.

A. Category I: This category includes positions which are required to perform procedures or other job related tasks that involve an inherent potential for mucous membrane or skin contact with blood, body fluids, tissues or a potential for spills or splashes of them. The use of appropriate protective measures is required for each Category I position.Personnel who are considered in this category may be:

1. Any individual who administers any type of direct patient care.

2. Any individual who handles items that may come in contact with blood or body fluids.

3. Any individual who handles blood, body fluids or tissue.

4. Employees who fall into Category I are as follows:

• Physicians

• Registered Nurses

• Nursing Assistants/Medical Assistants

• Soiled Linen Handlers ( housekeeping)

• Dentists

• Hygienist

• Dental Assistants

• Opthamology tech’s

• Optometrist

• Registered Dietician

• WIC clerks

• Licensed Practical Nurse’s

• Lab or X-Ray personnel

• Bio-hazard Waste Handlers

B. Category II: This category includes those staff whose normal work routine involves no exposure to blood, body fluids, tissues, but exposure may be required as a condition of employment. Appropriate protective measures should be readily available to every employee engaged in Category II tasks. Employees who fall into Category II are as follows:

• Medical Office Assistant/Receptionist

• Office Clerks

• Social Workers

• Facility Mangers / Supervisors

• General Maintenance Workers

C. Category III: The normal work routine involves no exposure to blood, body fluid, or tissues. Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or to be potentially exposed in some other way. Category III employees are as follows:

• Accounting/Finance,

• Clerical, and

• Data Procsssing Personnel

• MIS staff

• Translators

• Administrators

D. Documented Evidence of Employee Categories: All individuals performing procedures or tasks within the organization shall have documented evidence that they are aware of which category their duties shall-place them in.

1. This documentation shall include a clear understanding of the proper use of personal protective clothing and equipment.

2. For Category I or Category II employees, the location of this clothing and equipment is identfied and is continually maintained for their use.

VII. STANDARD OPERATING PROCEDURES

A. The organization has identified the following substances and procedures as hazardous:

1. Cleaning Germicides, disenfectants and cleaners

2.. Instrumentation Reagents

3. Prepackaged Reagent kits (Pregnancy, Strep A, and Mono),

4. Use of Sharps,

5. Medical Procedures,

6. Hazardous Waste

7. X-ray chemicals (Cleaning & mixing chemicals of X-Ray processor).

B. The hazards listed present eye, skin and respiratory hazards. The procedures listed can present specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials. All employees will use the following protocol when working with these hazards.

C. Bleach: Target organs: eye, skin, and lungs.

1. PPE required and usage

a. Protective eyewear/mask combinatlon or full face shield, gloves and laboratory coat.

b. PPE will be worn during preparation and usage.

c. MSDS: Material Safety Data Sheets located at each clinical site.

2. Preparation and Storage

a. Refer to decontamination procedure located and engineering practices

b. Undiluted bleach is stored at room temperature in the supply closet. Store in cool, dry place.

c. Do not reuse empty bleach containers.

D. Germicides: Byrex, Dispatch, Sklar Kleen, Sporox, Cavicide, Omini Cleaner, Isopropyl Alcohol, Hydrogen Peroxide, Povidone solution, Phisodex, Lysol disinfectant spray, and Citrace Spray. Target organs: eyes, skin and lungs.

1. PPE required and usage

a. Protective eye wear/mask combination or full face shield, gloves and laboratory coat.

b. PPE will be worn during preparation and usage.

c. MSDS: Material Safety Data sheets are located at each facility. This facility stores the MSDS sheets posted at each center for location

2. Preparation and storage

a. Follow manufacturer’s directions for usage. Store in original container.

b. Store at room temperature in supply closet.

MSDS sheet locations are listed on staff bulliten boards and lab areas located in each facility.

G. Prepackaged Reagent Test Kits: Target Organs--Eyes and skin

1. The chemicals used in these test kits are in such small quantities that they pose very minimal risk for employees.

2. PPE Required and Usage

a. Protective eyewear/mask combination or full face shield, gloves, and laboratory coat.

b. Laboratory coats and gloves are required if upon receipt a test kit is damaged or is leaking. Otherwise, all PPE is required during testing procedure.

c. MSDS: Material Safety Data sheets are located at each facility.

3. Preparation and Storage: Refer to laboratory procedure manual for directions for each test kit.

H. Sharps Protocol: Target Organs--Eyes and Skin

1. PPE Required and Usage

a. Protective eyewear or full face shield gloves and laboratory coat.

b. PPE will be worn at all times during phlebotomy procedures.

2. Preparation and Disposal

3. Refer to laboratory procedure manual for instructions on phlebotomy procedures.

4. All contaminated sharps will be disposed at the closest possible puncture resistent sharps container from its place of generation.

5. Biohazardous sharps containers will be disposed of when they are three-quarters (75%) full.

I. Medical Procedures: Target Organs: Eyes, Skin, and Mucous Membranes

1. PPE Required and Usage

2. Laboratory coats and gloves will be worn during the following procedures: ear, nose, and throat exams, as well as oral temperature monitoring.

3. Protective eyewear/mask combination or full face shield, gloves, and laboratory coat will be worn during the following procedures: mole and lesion removal, suturing, pelvic and rectal exams, and any emergency/trauma situation.

4. PPE is not required in the following procedures: blood pressure check, pulse, height, weight and charting patient information.

J. Hazardous Waste: The organization utilizes the services of

SteriCycle

Name of Waste Management Vendor

13975 Polo Trail Drive Suite 201

Street Address

Lake Forest Illinois 60045 ( 800) 457-9167

City/State/ZIP

1. Definition of Hazardous Waste: any material which is generated in the health care community in the diagnosis, treatment, immunization, or in the care of human beings.

a. Sharps: Any object that may cause puncture or cuts, including but not limited to: needles, syringes, lancets, broken glass, and scalpel blades.

b. Microbiologicals--specimens, cultures discarded live and attenuated vaccines; culture dishes/devices used to transfer, inoculate, will be discarded in the red sharps containers).

c. Blood and Blood Products: all waste, unabsorbed human blood or blood products, including but not limited to serum, plasma, and other components of blood, and visiby bloody body fluids such as suctioned fluids, excretions, and secretions.

d. Pathological waste: all teeth, tissue from biopsy and removal.

2. Medical Waste Segregation

a. Segregate infectious waste from other waste at point of generation.

b. 20cc or greater bulk of human blood and blood products (synovial fluid, vaginal fluid, cerebrospinal fluid, etc.) and absorbent items that are “super saturated,” or freely dripping or if lightly sqeezed will release contents.

c. Sharps (scalpel blades, syringes, needles, test tubes, slides, disposable speculums, and broken glass) should be placed in rigid, puncture resistent containers.

d. Urine specimens may be discarded into the sewer. Used urine cups should be placed in solid waste.

3. Storage

a. Waste must be properly packaged in a red bio-hazard bag, sealed and placed in the designated cardboard receptacle and stored in the designated area of each building site with a hazard warning clearly marking the area.

b. Sites that generate small quantites of waste and transport waste to larger facilities must prperly package waste in a double biohazard bag, seal and place in a trunk of a car.

4. Spill Procedure: The spill kit is located at each site and is accessible to all staff members. If a spill were to occur, proceed as follows:

a. Minimize patient and staff contact with spill area.

b. Sprinkle chlorasorb around the perimeter of the spill with an even coating. Let area stand until absorbed.

c. The following PPE must be worn: disposible gown, gloves, eye protection if indicated.

c. Use shovel to scoop solids and absorbed powder. Place in bio-hazard bag or decontaminate.

d. Spray Tor Aerosol to clean the area. Allow to stand for 10 minutes then wipe with absorbent towel. Place soiled towel into red plastic bag. Place any broken glass or sharps into puncture resistant container. Put sharps container into bag.

e. Place gloves and disposible gown in biohazard bag.

f. Tie off bag and place in an appropriate waste container.

g. Restock spill kit.

5. Recordkeeping

a. Bio-hazard waste is disposed of by our waste management vendor. The manifest copies are kept on file at each clinic site.

b. All records will be retained for three years.

J. X-Ray chemicals & cleaning of X-Ray processor, developer, and fixer

1. Target organs: Eyes, Skin, and Lungs

2. PPE Required and Usage

a. Protective eyewear/mask combination or full face shield, gloves and laboratory coat.

b. PPE will be worn during preparation and usage, also in cleaning the X-ray processor.

c. MSDS: Material Safety Data sheets are located at each facility.

Preparation and Storage

a. Refer to MSDS decontamination procedure listed in manual .

b. chemicals are stored in the cabinet in the dark room within the x-ray area. The containers are to be disposed in accordance with manufacturer’s specifications.

c. The exhaust fan is to be on at all times during the operation and cleaning of the x-ray processor.

K. Laundry Policy

1. Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. This laundry will be placed in color coded red bags at the location where it is used. Laundry will not be sorted or reused in this area.

2. Laundry at this facility is cleaned by Valley Cleaners. All laundry is placed in color coded red bags indicating potentially infectious material may be present.

VIII. General Safety Procedures

A. Eye Contact: Promptly flush eye with water for a prolonged period (15 minutes) at the eyewash station and seek medical attention.

B. Skin Contact: Promptly flush the affected area with water and remove contaminated clothing. If symptoms persist after washing, seek medical attention.

C. Clean Up Spills Promptly

1. Bleach or Germicides: If spilled, gloves, laboratory coat and full face shield will be worn during clean up. Toweling used can be disposed of in the regular trash receptacle. Rinse thoroughly with water and dry completely.

2. Instrument Reagents and Test Kits: If spilled, gloves, laboratory coat and full face shield will be worn during clean up. Toweling used should be disposed of in a bio-hazard waste receptacle. Rinse thoroughly with water and dry completely. Make sure broken reagent containers thatare made of glass are disposed of in puncture resistant bio-hazard containers.

D. Labels and Signs: Universal bio-hazard symbols will be placed on all refrigerators used to store laboratory reagents, controls, specimens, and storage area for medical waste. While the organization follows universal precautions for handling of all specimens, but we feel these signs are necesssry for our patients’ protection as well.

IX. Engineering and Work Practice Control

A. Eyewash Fountains

1. Inspected every month by practice employees.

B. Handwashing

1. Handwashing will be done before and after contact with each patient, using the restroom, eating, and drinking.

2. It is mandatory that all employees wash their hands with soap and water as soon as possible after removal of gloves or other PPE. All employees that have contact of any body area with potential infectious agent shall wash areas immediately.

3. The following handwashing protocol will be used by all employees:

a. Wet hands under moderate stream of water at a comfortable temperature.

b. Dispense approximately 5 ml of lotion soap into cupped hands.

c. Wash hands and wrists vigorously for 20 seconds.

1) Use a rotary motion and friction to the palms, back of hands, between fingers, and wrists.

2) Hold the hands higher than the elbows.

3) Rinse the wrists and hands thoroughly with running water. Hold hands so water flows from wrist, to hands, and off finger tips.

4) Dry the arms and hands thoroughly with a paper towel. Hold the hands higher than the elbows.

d. Hand Control Faucets: Since faucets are considered contaminated, always turn faucet off with paper towel.

Special considerations:

1) Hold hands away from the side of the sink.

2) Avoid splashing your uniform or PPE.

3) Avoid rings and cracked or chipped nail polish, since it makes it difficult to remove organisms.

C. Decontamination: All spills should be wiped up immediately. The following procedure is used for the decontamination of blood spills. For large spills, see spill kit procedure.

1. Wear heavyweight puncture resistant gloves and a gown.

2. Absorb the blood with disposable towels.

3. Sprinkle chorasorb on the spill site of all visible blood. Let it sit until all fluid is absorbed.

3. Place all disposable materials used to decontaminate the spill into a bio-hazard container. Handle the material in the same manner as other infectious waste.

4. If the spill site is bleach reisistant may use dispatch spray. The time of exposure to solution may be brief inactivates HBV in 10 minutes and HIV in 2 minutes. If the spill has been adequately decontaminated before disinfection, the spill may be blotted up with disposable absorbent towels immediately after the spill area has been soaked.

Bleach solutions are less effective in the presence of high concentration of protein.

Therefore, remove as much liquid blood or serum as possible before

contamination. If a surface or medical device is contaminated with dried blood,

remove all of it before disinfection. The dried blood should be wet and softened

with dispatch spray before being scraped off to prevent scattering potentially

infectious material and to facilitate complete removal. If complete removal is not

possible, expose the surface to dispatch spray for a longer time (20-30 minutes

may be necessary).

For large spills of culture or concentrated infectious agents, the spill should first

be flooded with a disinfectant, then dispatch spray is added and then allowed to

stand for 10 minutes before being decontaminated as outlined above.

Counters will be cleaned weekly with dispatch or Byrex spray and wiped between each patient with a cloth. Examination tables will be cleaned weekly with dispatch solution and wiped between each patients. New examination table paper will be provided for each patient. A blue pad will be placed under the table paper during all pelvic examinations to prevent contamination of the exam table.

D. Autoclave

1. Cleaned every month with Omni cleaner according to manufacturer’s specifications.

2. Soak filter in full strength Omni cleaner for 24 hours rinse and replace.

E.. X-Ray Processor

1. Cleaned monthly (see agreement-Kent Radiology)

2. PPE equipment to be used during cleaning and mixing of chemicals.

G. Instrument Tray

See procedure for instrument decontaimination process

H. Policy for minimizing risk of transmission of AIDS during actual CPR:

No tranamission of hepatitis B virus (HBV) infection during mouth-to-mouth resuscitation has been documented. However, because of the theoretical risk of salivary transmission of HIV during mouth-to-mouth resuscitation, special attention should be given to the use of disposable airway equipment or resuscitation bags and the wearing of gloves when in contact with blood or other body fluids. Resuscitation equipment and devices known or suspected to be contaminated with blood or other body fluids will be thoroughly cleaned and disinfected after each use. Clear plastic face masks with one-way valves are available for use during mouth-to-mouth ventilation. These masks provide diversion of the victim‘s exhaled gas away from the rescuer and may be used by health-care providers and public safety personnel properly trained in their use during two-person rescue, in place of mouth-to mouth ventilation. The need for and effectiveness of this adjunct in preventing transmission of an infectious disease during mouth-to-mouth ventilation are unknown. If this type of device is to be used as reassurance to the rescuer that a potential risk might be minimized, the rescuer must be adequately trained in its use, especially with respect to making an adequate seal on the face and maintaining a patient airway. Such a device requires two hands to secure a proper face seal and to maintain an open airway. As an additional precaution, the rescuer should elect to wear gloves because saliva or blood on the victim’s mouth or face may be transformed to the rescuers hands.

X. Personal Protective Equipment (PPE)

A. Purpose: The purpose of PPE is to prevent blood or other potentially infectious materials passing through to or reaching the employees work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use for the duration of time which the protective equipment will be used.

1. PPE will be provided for all employees at no cost to them. The Safety Committee has specified that the following equipment will be utilized by all employees.

2. Protective eyewear/mask combination.

3. Full face shields

4. Gloves: Single use, disposable type. Hypoallergeric gloves will be available to employees that develop allergies to the latex. Utility gloves will be provided for housekeeping procedures and mixing of chemicals.

5. Impervious laboratory coats and aprons

B. Accessibility

1. The organization will provide appropriately sized PPE that is accessible to all employees.

2. Disposal, repair and replacement of PPE will be the responsibility of the practice. Employees are asked to be prudent with their use of safety equipment. All employees must use PPE as needed, but must not be wasteful.

3. All PPE will be removed and properly stored prior to leaving the facility.

a. Laboratory coats, aprons, face shields, and protective eyewear/mask combinations must be disposed of in a designated biohazard container if contaminated.

b. PPE that has not been contaminated but is torn, dirty, or has lost effectiveness to provide protection may be discarded in solid waste container designated for noncontaminated PPE.

c. Contaminated gloves may be disposed in the nearest bio-hazard container.

4. PPE will be used in the following conditions:

a. Gloves will be worn when it can be reasonably anticipated that the employee will have had contact with blood or other infectious materials. Gloves will be disposable, single use type. They will not be washed or decontaminated for reuse.

b. Face and eye protection will be provided by a full face shield or eyewear/mask combination. This type of PPE will be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, or nose, mouth contamination can be reasonably anticipated.

c. Laboratory coats and aprons will be of impervious material. Therefore, employees work clothes, street clothes, and undergarments will be protected.

XI. Occupational Exposure

A. Chemical Exposure - Definition

1. Whenever signs and symptoms associated with a hazardous chemical develops.

2. Whenever an event takes place in the work area such as a spill, splash, or leak resulting in a hazardous chemical exposure.

B. Action - The organization will provide the following information to the employee and the attending physician:

1. The identity of the hazardous chemical to which the employee may have been exposed.

2. A description of the signs and symptoms of exposure.

3. A copy of the MSDS for the chemical involved.

4. A copy of the regulation.

5. The organization will provide a written opinion that will not reveal specific findings of diagnosis unrelated to the exposure but will include:

a. Any recommendations for further follow up.

b. Results of the medical examination and any associated test results.

c. Any medical conditions that may be revealed in the course of the examination that may place the employee at increased risk as a result of an exposure in the work place.

d. A statement by the physician that the employee has been informed of the consultation/examination result and any medical condition that may require further examination or treatment.

B. Blood Borne Pathogen: Exposure incident is defined as a specific eye, mouth, or other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

1. Hepatitis Exposure Policy Employees who receive a puncture wound from a contaminated sharp or splashes to the mucous membrane from blood or body fluids are to be reported to the Safety Officer to ensure that employees exposed to Hepatitis receive prophylactic treatment if needed.

a. Exposure: Significant exposure to Hepatitis is defined as follows and is an indication for prophylactic treatment:

1) Direct blood exposure (accidental needle stick, blood or an open wound)

2) Oral ingestion

3) Direct mucous membrane contact (accidental splashing of serum, blood or body fluids in the eye or other mucous membrane)

4) Direct oral contamination by a patient‘s excrete (feces, urine, etc.)

b. Send employee to Spectrum Health Occupational medicene downtown.

2) Hepatitis B

a) The employee is to be referred to Spectrum Health Occupational medicene for exposures.

b) Prophylaxis is to be provided, according to current CDC recommendations, by the organization free of charge.

c) CDC Recommendations are: (For those who have no imunity - active or passive)

• A single dose of HBlg is to be given as soon as possible after exposure.

• The first dose of Hepatits B vaccine is to be given in the deltoid muscle as soon as possible, but within 7 days of exposure.

• The second dose of vaccine is to be given in one month and the third and last dose is to be given in 6 months.

d) Hepatitis B surface antibody is to be done before the administration of medications and again 2 months after completion of the series of vaccine.

d) Non-specific: if the exposure is significant, the employee is to be given Hepatitis A prophylaxis.

e) Dosages

• Immune Serum Globulin: 0.03 ml/kg body weight

• HBlg (Human): 0.06 ml/kg body weight

2. HIV Exposure Policy: Employees are sent ot Spectrum Health Occupational Medicene Clinic .

a. To ascertain thorough internal serological testing if the exposed employee has contracted the virus.

b. To counsel employees who have significant exposure to HIV.

c. Procedure

1) Employees who incur a significant exposure to HIV are to have an employee incident/injury report form completed by the immediate supervisor and involved employee and submitted to the Operations Director.

2) Significant exposure is defined as:

a) Direct blood exposure/needle puncture

b) Oral ingestion

c) Direct mucous membrane contact

3) Serological testing for evidence of HIV antibody is to be done as soon as possible after the exposure. If negative, the employee is to be retested in 6 weeks and at 3, 6, and 12 month intervals following exposure through occupational medicene clinic.

4) Counseling about the risk of infection is to be done by Spectrum Health Occupational Medicene Clinic. The recommendations of the Public Health Service include:

a) Refrain from donating blood.

b) Avoid exchange of saliva and/or deep kissing.

c) Use condoms during sexual intercourse.

3. The organization will provide the following information to the employee and the attending physician

a. Documentation of the route(s) of exposure and circumstances under which the exposure incident occurred.

b. Identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by federal, state or local law.

1) The source individual‘s blood shall be tested as soon as possible after consent is obtained in order to determine HBV and HIV infectivity. If source is known to be MBV or HIV positive, testing need not be repeated.

2) Results of source individual’s testing will be made available to exposed employee.

d. Exposed employee’s blood shall be collected as soon as feasible and tested after consent is obtained. If employee consents to baseline blood collection, but does not give consent at the time for HIV serologic testing, the sample shall be preserved for at least 90 days. If within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible. If negative, blood will be collected again in 6 weeks, 3 months, 6 months and 12 months intervals following exposure.

e. HBV status: The organization will provide a record of all vaccinations given including non-responder status, Hepatitis B surface antibody status, or any reason that is medically indicated for not receiving the vaccination.

f. Health care professionals written opinion: Spectrum Health will provide the employee with a copy of the evaluating physician’s opinion of his/her status to incude:

1) HBV status

2) Employee has been informed of any medical conditions resulting from the exposure incident.

3) All other findings or diagnosis shall remain confidential.

g. Medical Records: The organization will maintain an accurate record for each employee with an occupational exposure. The records will include:

1) Social security number

2) HBV status and dates of vaccination

3) Copy of all results, examinations, medical testing, and follow up procedure.

4) Employers copy of written opinion of evaluating physician.

5) The organization ensures the confidentiality of employee medical records and will not disclose or report any information without the employee’s written consent.

6) The organization will maintain these records for at least the duration of employment plus 30 years.

Refer to Appendix D for the following documents:

• EC - 1.3C Occupational Occurrence Report Form

• IC - 1E Hepatitis B Vaccine Consent Form

• IC - 1F Hepatitis B Vaccine Decline Form

• IC - 1G Exposure Consent

• IC - 1H Needle Stick Exposure Protocol

XII. Education and Training

A. New Employee Orientation: All new employees will be appropriately oriented and instructed on the organization’s Environment of Care and Infection Control programs at the time they are hired. This orientation is recorded in the employee’s personnel file. Initial orientation will include the following:

1. Fire safety and emergency evacuation of facilities.

2. Location and summary of the Federal Register 29 CFR Part 1910. Occupational Exposure to Hazardous Chemicals in Laboratories and 29 CFR Part 1910.1030. occupational Exposure to Blood Borne Pathogens. Both standards are final rules.

3. Explanation of how Safety and Infection Control manual meets the requirements of the Chemical Hygiene Plan and the Exposure Control Plan.

4. Explanation of risk categories, and determination of which category new employees’ responsibilities place them.

a. Actions taken if unplanned category tasks are encountered.

b. Work practices and protective equipment available to employee.

c. Location and proper use of protective clothing and equipment; and the proper removal, handling, and decontamination of equipment.

d. Limitations of protective clothing and equipment.

5. Identification and location of hazards. Explanation of use, storage, and Material Safety Data Sheets.

6. Appropriate reporting procedures in the event of spills or personal exposure to fluids or tissues and medical monitors associated with exposures.

7. Epidemiology, symptoms, and modes of transmission of blood borne diseases.

8. Explanation of exposure incident reporting, method of reporting, and post exposure medical follow up evaluation.

B. Inservice/Continuing Education

1. All employees are required to review the Environment of Care and Infection Control Plan annually. Attendance at inservice meetings is mandatory and recorded.

2. Any additions, deletions, revisions, or new policies made to the Safety and Infection Control manual must be communicated to all employees through inservice education.

3. All employees will participate annually in continuing education and inservice training.

4. Training records will be maintained for three years.

OCCUPATIONAL OCCURRENCE REPORT FORM

|SECTION I |

| |

|Employee: SS#: DOB: |

| |

|Date of Occurrence: Time: am/PM Location: |

| |

|Reported to Supervisor: |

|Signature Print Name of Supervisor |

|SECTION II | | | | |

| | | | | | |

| |Type Occurrence: | | Blood Borne Pathogen | | Chemical Exposure |

| | | |Exposure | | |

| | | | Eye, mouth, nose, mucous | | Acid |

| | | |membrane | | |

| | | | Non-intact skin (sore, | | Base |

| | | |wounds, etc.) | | |

| | | | Needle Stick/Sharps | | Carcinogen |

| | | | Other | | Other |

| | | | | | |

| |

| |

|Details of Occurrence: |

| |

| |

| |

| |

| |

| |

|Instructions to Prevent Further Occurrences: |

| |

| |

| |

| |

| |

| |

| |

|Employee/Date Safety Officer/Date |

|SECTION III For Blood Borne Pathogen Exposure |

| |

|Source Individual |

|SECTION IV For Blood Borne Pathogen Exposure |

| |

|Does the source individual have a positive test for infectious disease? |

(Page 2)

|SECTION V |

| |

|HBV Status: Series Initiated Second Shot Third Shot |

| |

|Seroconversion: Hepatitis B - Surface Antibody |

|(result) (date) |

|SECTION VI Medical Examination & Consultation |

| |

|Physician Information: |

| |

|Name: Phone: |

| |

|Address: |

| |

|Date of Employee Examination: |

| |

|Recommendations, treatment comments: |

| |

| |

| |

| |

| |

|Follow-up necessary? |

| |

|SECTION VII Employee Consent for Baseline Testing for HBV and/or HIV |

| |

|I (employee name) understand and agree with the information contained in this occupational occurrence report form. On , I have given |

|consent to baseline blood collection and testing for the following tests: . I understand the collection and testing will be done confidentially.|

|All laboratory results will only be released to the physician performing the medical exam and consultation unless I give written consent for them to be |

|released elsewhere. |

| |

|I (employee name) consent to baseline blood collection. I decline testing of the following at this time: . I understand that I may elect |

|to have above tests performed within 90 days of my baseline collection. |

| |

|Comments: |

| |

| |

| |

| |

| |

|Employee/Date Witness/Date |

CLASSIFICATION SYSTEM FOR EVALUATING POTENTIAL EXPOSURE

TO BLOOD AND BLOOD-BORNE PATHOGENS

A. CATEGORY I: Tasks that involve exposure to blood, body fluids or tissues.

1. Includes positions which are required to perform procedures or other job-related tasks that involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues or a potential for spills or splashes of them. The use of appropriate protective measures is required for each Category I position.

2. Gloves, mask, safety glasses, protective clothes covers (head cover, plastic apron or cover gown, shoe covers) are to be worn appropriately according to the type of procedure or tasks. Probable or suspected exposure must be considered by the individual when judging the extent of personal protective clothing and equipment that should be worn.

3 Personnel who are considered in this category may be:

• Any individual who administers any type of direct patient care.

• Any individual who handles items that may have come in contact with blood or body fluids.

• Any individual who handles blood, body fluids or tissues.

B. CATEGORY II: Tasks that involve no exposure to blood, body fluids or tissues, but employment may require performing unplanned Category I tasks.

1. The normal work routine of these positions involves no exposure to blood, body fluids or tissues but exposure or potential exposure may be required as a condition of employment. Appropriate protective measures are readily available to every employee engaged in Category II tasks.

2. Personal protective clothing and equipment shall be available to this individual that is appropriate for the tasks they may be asked to perform.

C. CATEGORY III: Tasks that involve no exposure to blood or body fluids, or tissues. Category I tasks are not a condition of employment.

The normal work routine of these positions involves no exposure to blood, body fluid, or tissues. Persons who perform these duties are not called upon as part of their employment to be potentially exposed in some other way. Tasks that involve handling of implements or utensils, use of public or shared bathroom facilities or telephones and personal contacts such as handshaking are Category III tasks.

D. DOCUMENTED EVIDENCE OF EMPLOYEE CATEGORY: All individuals performing procedures or tasks within the facility shall have documented evidence that they are aware of which category their duties shall place them. This documentation shall include a clear understanding of the proper use of personal protective clothing and equipment and where this clothing and equipment is maintained for their use, if they are in Category I or Category II. All employees shall receive training in Universal Precautions and barrier protection techniques.

OSHA CATEGORY CLASSIFICATION

Employee Name Department Job Title/Positlon

CATEGORY I

I understand that the duties that are required of me in my job position places me in Category I. I have a thorough knowledge of the proper use of personal protective clothing and equipment and where the clothing and equipment is maintained throughout the facility. I have received education and training in Universal Precautions, barrier protection techniques and modes of transmission of blood-borne pathogens.

SIGNATURE DATE

CATEGORY II

I __________________________________ understand that the duties that are required of me in my position places me in Category II but I may be required to perform unplanned Category I duties. If I have to perform unplanned Category I duties I have a thorough knowledge of the proper use of personal protective clothing and equipment and where the clothing and equipment is maintained throughout the facility. I have received education/training in Universal Precautions, barrier protection techniques and modes of transmission of blood-borne pathogens.

SIGNATURE DATE

CATEGORY III

I understand that the duties that are required of me in my position places me in Category III and I will not have to perform duties that will require the use of personal protective clothing or equipment. I have received education/training in Universal Precautions and modes of transmission of blood-borne pathogens.

SIGNATURE DATE

CLASSIFICATION VERIFICATION

I have reviewed the job tasks of this position with and verify this classification to be correct.

CLINICAL MANAGER DATE

REQUIREMENTS FOR CONTRACTED HOUSEKEEPING SERVICES

1. Provide Hepatitis B Vaccine for their employees or have documented declination form signed.

2. Wear utility gloves when cleaning. Use gown and mask if danger of splash or spills.

3. Vacuum carpet at each cleaning session.

4. Mop floors with a 1:100 solution of household bleach.

5. Clean bathrooms with a 1:100 solution of household bleach.

6. Clean examination tables at each cleaning session with a 1:100 solution of household bleach.

7. Clean counters at each cleaning session with a 1:100 solution of household bleach.

8. Clean doorknobs at each cleaning session with a 1:100 solution of household bleach.

9. Clean the portable lights and the lights that are mounted on the wall at each cleaning session with a 1:100 solution of household bleach.

10. Do not handle or empty the infectious waste containers. This will be done by clinic staff.

11. Notify the infectious waste coordinator if you see any contaminated object (used needles, instruments, etc) that has not been disposed of properly.

12. Make a special attempt at replacing items on the examination room counters, as closely as possible where you found them.

13. Notify clinic personnel of any items needed for cleaning.

14. Wipe outside of regular trash cans at each cleaning session with a 1:100 solution of household bleach.

15. Clean inside of trash cans monthly with a 1:100 solution of household bleach.

16. Wipe down chairs in halls and exam rooms. Also waiting rooms with 1:100 solution of household bleach weekly.

17. Janitorial services to be rendered daily.

18. Shampoo carpet annually.

EXPOSURE CONSENT FORM

I understand that my blood sample was involved in a laboratory accident. At this time I give my consent to to perform Human Immunodeficiency Virus (HIV) and Hepatitis B Surface Antigen testing in order to determine prophylactic treatment of our healthcare worker(s).

I underetand that if my HIV results are positive that the testing laboratory may be required by law to report all positive HIV s to the Department of Public Health or other state agency. All test results will be handled in a confidential manner.

Patients Signature Date

Witness Date

Form IC - 1H

NEEDLE STICK/EXPOSURE PROTOCOL

I. Supervisor / Facility Managers refers employee to Spectrum Health Occupational Health. The employee will complete an Occurrence Report and forward it to their immediate supervisor. The employee will be referred to occupational medicene .

II. Substantiate exposure:

A. Contaminated needle or injury from sharps

B. Blood or certain body fluids to non-intact skin (chapped abraded, or afflicted with dermatitis).

C. Blood or certain body fluids to mucous membranes, mouth nose, or eyes.

III. Evaluate contaminating source:

. Source known/HIV and HBV

1. Test source for HIV and HBV: Test for HBV only if employee is unvaccinated or a non-responder. If positive, give employee HBV vaccine one immediately and initiate Hepatitis B vaccine series.

2. Treat employee for HIV and HBV.

3. If source is HIV positive, high risk, or refuses tests, test employee at the time of exposure for HIV and retest at 6 weeks, 3 months, 6 months and 12 months.

NOTE: Employee and source individual must consent to testing. Employee must consent to prophylactic treatment if indicated.

Results to be forwarded to Occupational medicene at Spectrum Health. Results are placed in confidential health record with follow up plan suggested by occupational medicene. Employees will be asked to follow up with Occupational medicene at Spectrum Health as deterined by occupational medicene clinic.

Protocol for Disposing of Infectious Waste

I. Infectious waste is defined as “any material which is generated in the health care community in the diagnosis, treatment, immunization, or care of human beings.”

II. Disposing of Infectious Waste

A. Any used or discarded article that may cause punctures or cuts, including but not limited to: needles, syringes, lancets, tubes of blood, broken glass, and scalpel blades are to be discarded in sharps containers.

B. All waste, unabsorbed human blood, blood products, or absorbed blood when the absorbent is supersaturated, including but not limited to: serum, plasma, and other components of blood and visibly bloody body fluids are to be disposed of in either the sharps containers or the red infectious waste bags.

C. Specimens, cultures, and stacks of etiological agents, including but not limited to: waste which has been exposed to human pathogens in the production of biologicals; and culture dishes/devices used to transfer, inoculate, and mix cultures will be placed in the infectious waste containers.

III. Gloves are to be worn while handling infectious waste items.

IV. Infectious waste containers will be picked up by

NAME Stericycle Inc

ADDRESS 2695 Elmridge NW

Walker Michigan 49544

Phone: 616 454-9405

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