TITLE:



TITLE: AIRBORNE AEROSOL-TRANSMISSIBLE DISEASE (INCLUDING TUBERCULOSIS) EXPOSURE CONTROL PLAN

PURPOSE:

This exposure control plan has been established in order to minimize, and to prevent, when possible, employee infection with or employee exposure to Airborne aerosol-transmissible diseases (ATD)* including Mycobacterium tuberculosis, the causative microorganism for tuberculosis. All employees who are exposed to sputum and other potentially infectious materials as a part of their job duties are included in this program.

* Airborne Aerosol-Transmissible Diseases/Pathogens include:

Aerosolizable spore-containing powder or other substance that is capable of causing serious human disease, e.g. Anthrax/Bacillus anthracis

Avian influenza/Avian influenza A viruses (strains capable of causing serious disease in humans)

Varicella disease (chickenpox, shingles)/Varicella zoster and Herpes zoster viruses, disseminated disease in any patient. Localized disease in immunocompromised patient until disseminated infection ruled out

Measles (rubeola)/Measles virus

Monkeypox/Monkeypox virus

Novel or unknown pathogens

Severe acute respiratory syndrome (SARS)/SARS-associated coronavirus (SARS-CoV)

Smallpox (variola)/Varioloa virus

Tuberculosis

Any other disease for which the CDC or CDPH recommends airborne infection isolation

POLICY:

The Board of Directors and the Chief Executive Officer have delegated the Integrated Quality Management Committee the administrative authority, responsibility and accountability of implementing our organization’s established policies and procedures governing the infection control, including the components of the program that address airborne-transmissible diseases. The Infection Control Coordinator is the qualified individual responsible to the IQM Committee for overall administration of the ATD Exposure Control Plan (ATDECP) Mendocino Coast District Hospital maintains, reviews and updates the ATD Exposure Control Plan (ATDECP) at least annually, and whenever necessary to reflect new or modified tasks, procedures and engineering controls that affect occupational exposure. The ATDECP is also updated to reflect new or revised employee positions with occupational exposure.

The procedures in this Exposure Control Plan minimize the occupational exposure to ATD. The procedures for isolating and managing care are used until the individual with suspected or confirmed infectious ATD is determined to be non-infectious or until the diagnosis for ATD is ruled out or the patient is discharged from the facility.

REVIEW OF THE PLAN:

The Hospital has established a process for periodic review of the ATDECP. The review includes the assessment of risks of tuberculosis in the organization and in the community. See Policy 170.1035, "ATD Infection Control Plan: Risk Assessment and Periodic Reassessment".

This plan will be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

Review will be by the Infection Control Advisory Committee, the Integrated Quality Management Committee, the Employee Health and Infection Control Coordinators, and other members of the hospital staff, as required.

Employee Exposure Determination:

All Hospital staff, physicians, volunteers, contract employees and Hospital contractors working on the Hospital site are covered under this plan.

Healthcare workers (HCWs) in these classifications have or may have exposure to ATD when they are performing the following tasks and procedures:

• When entering Room 101 or 102 while a patient is in Airborne Precautions.

• When the patient is potentially infectious for ATD and is undergoing a high risk procedure that is likely to produce bursts of aerosolized, infectious particles or to result in copious coughing or sputum production regardless of whether appropriate ventilation is in place. Procedures defined as high-risk are:

o endotracheal suctioning.

o Sputum induction

o Bronchoscopy

o Administration of aerosolized pentamidine or other medications

o Pulmonary function testing

• Laboratory employees assisting with Autopsy or performing laboratory procedures likely to aerosolize airborne-transmissible pathogens.

• Patient care employees assisting or performing surgical procedures that may aerosolize airborne-transmissible pathogens

• In other settings where administrative and engineering controls are not likely to protect them from inhaling infectious airborne droplet nuclei.

On an annual basis all staff covered under this plan are tested for previous exposure to TB using the PPD skin test. See Policies 130.3060 "Tuberculosis Surveillance Program" and 170.1038, "TB Infection Control Program: Tuberculin Skin Testing".

EMPLOYEE NOTIFICATION OF ATD HAZARD:

Education and training regarding the prevention and hazards associated with ATD exposure will be provided to all HCWs upon new-hire orientation and on an annual basis per routinely scheduled re-orientation and annual re-orientation quiz.

The HCW will receive periodic ATD education appropriate for their work responsibilities and duties. It includes:

• Tuberculosis

• Other airborne aerosol-transmissible diseases*

• Epidemiology of ATD in the facility

• Concepts of pathogenesis and occupational risks for ATD.

• Work practices that reduce likelihood of transmitting M. tuberculosis.

The Infection Control Coordinator maintains contact with all outside contractors who provide temporary or contract employees who may incur occupational exposure. This allows the contractor to institute precautions to protect his or her employees. Theses contractors are informed of the ATD hazard and the facility's procedures for protecting themselves from exposure.

Warning signs indicating "Airborne Precautions" (Refer Infection Control Policy - Isolation Precaution Guidelines) are used to inform workers of a ATD exposure hazard. These signs are posted on the outside of the patient's door and outside any area where procedures or services are being performed on an individual with suspected/confirmed infectious ATD. The patient's door must remain closed at all times and entry into 101 or 102 should occur through the ante room door.

Warning labels are placed on AFB isolation room exhaust ducts and areas where occupational exposure to ATD is expected.

All systems carrying air that may be contain aerosolized M. Tuberculosis or other ATDs are labeled at all points where ducts are accessed prior to HEPA filter, at fans and at the discharge outlets of non-HEPA filtered direct discharge systems. The label says: "Contaminated Air–Respiratory Protection Required".

The entrances to the Clinical Laboratory indicate it is a Bio-hazardous work area. Specimens known or suspected to contain M. tuberculosis organisms are not cultured or analyzed for M. tuberculosis on-site. Some specimens are analyzed in the Laboratory for novel influenza. Laboratory procedures that involve analysis for ATDs are performed in a biological safety cabinet.

VACCINATION PROGRAM

The Hospital provides vaccination at no charge to employees for the following ATDs:

o mumps measles and rubella (MMR),

o varicella-zoster,

o tetanus, diphtheria and Pertussis (TDAP) and

o seasonal influenza

Employees may decline vaccination.

EXPOSURE INCIDENT REPORTING

All employees must report exposure incidents immediately to the Employee Health department. The Employee Health Coordinator is responsible for investigating, evaluating, and documenting the circumstances surrounding the exposure incident for instituting changes to prevent similar occurrences.

The following procedures are used to investigate/evaluate exposure incidents:

• Report of Work-Related Injury – Filled out by employee, reviewed by Department Manager and Employee Health Coordinator.

• Report of investigation and findings to the Hospital Safety Committee.

• Report and review of findings by the Integrated Quality Management Committee.

• Follow-up screening with the PPD skin test and/or Chest X-ray.

PROMPT IDENTIFICATION OF INDIVIDUALS WITH SUSPECTED OR CONFIRMED ATD

The Hospital has established the criteria for identification of suspect infectious tuberculosis See Policy 170.1036, "ATD Infection Control Plan: Identification of Suspect Infectious Tuberculosis Cases". Other cases of suspect airborne transmissible diseases are identified on the basis of disease-specific clinical data and laboratory testing. The Infection Control Coordinator consults with the Communicable Disease Officer in the Mendocino County Public Health Department, Infectious Disease Physician consultant for the Hospital, staff physicians and patient-care staff to identify other individuals with suspected or confirmed ATD besides tuberculosis.

On an annual basis, the Hospital provides tuberculin skin testing, symptom surveillance and chest X-ray (if applicable) to all employees to identify any case of new or re-activated case of tuberculosis or other ATD.

source control procedures for people entering the facility

The Hospital provided hand-washing stations, surgical masks, tissue dispensers and signage at all entrances to encourage good cough-etiquette and hand-washing by visitors to the facility.

PERSONAL PROTECTIVE EQUIPMENT

The Hospital provides the N95 respirator to all employees, physicians, providers and volunteers where there is potential for exposure to ATDs or when the healthcare worker is engaged in performing or assisting with a procedure designated in this policy as high-hazard. The Hospital provides education, training and fit testing to all healthcare workers that are required to use the particulate respirator when performing or assisting with a high hazard procedure.

PROCEDURES TO ISOLATE AND MANAGE CARE

The Hospital has established the plan to isolate and manage the care of suspected or confirmed cases of tuberculosis and other airborne transmissible diseases. See Policies 170.1037, "ATD Infection Control Plan: Initiation and Discontinuation of Airborne Precautions" and Policy 170.1039, "ATD Infection Control Plan: Respiratory Protection Program". The following procedures are used to isolate individuals with suspected or confirmed infectious ATD:

• All individuals with suspected or confirmed infectious ATD are placed in isolation rooms 101 or 102 on the Medical/Surgical unit or in Room 1 in the ER when equipped with portable negative-pressure air handling units, or in the ICU Rooms 1,2,3 or 4 when equipped with portable negative-pressure air handling units.

• To minimize the time an individual with suspected or confirmed infectious ATD remains outside of an isolation room or area, patent treatments and testing procedures are performed within the room whenever possible.

• Patients in Airborne isolation are instructed not to leave their room or go to common areas such as the cafeteria, conference rooms or the nursing stations.

• The number of visitors to the room at one time is kept to a minimum to assure a negative-pressure environment. Is maintained.

• All HCWs providing care & treatment to the patient or working in the patient's room wear the N95 respirator.

• All Laboratory personnel that analyze specimens for ATDs, including novel influenza wear the N95 respirator and perform the procedure in a biological safety cabinet.

TRANSPORT OR RELOCATION OF THE PATIENT

he following procedures to delay transport or relocation within the facility until the individual is considered non-infectious:

• Services are provided in the patient's room whenever feasible such as portable x-ray.

• The patient is fitted with a surgical mask whenever it is necessary the patient is moved or leaves the room.

• The patient are is not allowed to smoke in the facility or on hospital grounds.

• The patient is masked at all times when outside the negative pressure environment. The patient is transported immediately and directly back to the isolation room after a treatment or procedure.

• Treatments & procedures that take place outside the patient's room are performed in a negative-pressure environment. If this is not possible, all HCWs present will wear an N95 respirator until the patient is returned to a negative-pressure room.

• Elective high-hazard procedures and surgery are delayed until the patient is non-infectious.

HIGH-HAZARD PROCEDURES

High-hazard procedures (where ATD may be aerosolized) require precautions to prevent/minimize occupational exposure to infectious ATD. The following high-hazard procedures are performed at this facility:

• Sputum induction

• Breathing treatments

• Bronchoscopy

• Endotracheal suctioning

• Pulmonary function testing

These procedures are performed in negative-pressure rooms and, when appropriate, in conjunction with portable HEPA filtration units. All HCWs in attendance during these procedures will wear the N95 respirator while in the room with the patient.

ENGINEERING CONTROLS MAINTENANCE SCHEDULES AND RECORDS

The maintenance schedule for engineering controls is as follows:

Negative pressure areas are qualitatively demonstrated by using smoke trails on every day of use.

Whenever HEPA filters are changed, the system is inspected and its performance monitored in accordance with current USPHS guidelines. HEPA filters are changed every 2 years in this facility or whenever indicated.

Every six months–HEPA filters in contained air exhaust systems are inspected, maintained and performance monitored in accordance with current USPHS guidelines.

Attachments:

Policies:

170.1031 "Isolation Precaution Guidelines"

170.1035 "ATD Infection Control Plan: Risk Assessment and Periodic Reassessment"

170.1036 "ATD Infection Control Plan: Identification of Suspect Infectious Tuberculosis Cases".

170.1037 "ATD Infection Control Plan: Initiation and Discontinuation of Airborne Precautions"

170.1038 "ATD Infection Control Program: Tuberculin Skin Testing in Immuno-compromised Patients"

1039. "ATD Infection Control Plan: Respiratory Protection Program".

130.0060 “Tuberculosis Surveillance Program (Employee Health Policy & Procedure Manual)

New: 12/2008 Revised: 09/2009

Approval Signatures:

________________________________ ______________________

Infection Control Coordinator Date

________________________________ ______________________

Employee Health Coordinator Date

_______________________________________ ___________

Chairperson, Infection Control Advisory Committee Date

_____________________________________________ ___________

Chairperson, Integrated Quality Management Committee Date

________________________________ ______________________

Medical Chief of Staff Date

________________________________ ______________________

Chief Executive Officer Date

________________________________ ______________________

President, Board of Directors Date

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download