New York State Mandated Infection Control and
Barrier Precautions
New York State Mandated Infection Control Coursework
This program is designed as a distance learning self-study program, which will meet the
New York State requirements for infection control education every four years. The New York
Professional Nurses Union has been approved by the New York State Education Department to
provide the course for our membership. Your certificate of completion of the Infection Control
requirements will be provided to you upon successful completion of the course. Should you
have any questions along the way, please email NYPNU - nypnu@nypnu.org - for help. We will
get back to you as soon as possible.
Course Objectives
At the completion of the Infection Control coursework, you will be able to:
1. Recognize and explain the benefit to patients and healthcare workers of adhering to
scientifically accepted principles and practices of infection control.
2. Recognize and explain the professional's responsibility to adhere to and monitor scientifically
accepted infection control practices and the consequences of failing to comply.
3. Describe how pathogenic organisms may be spread in healthcare settings.
4. Identify factors that influence the outcome of an exposure.
5. List strategies for preventing transmission of pathogenic organisms.
6. Describe how infection control concepts are applied in professional practice.
7. Define "engineering controls" and "work practice controls" identify how they can be used to
prevent exposure.
8. Identify a hierarchy of exposure prevention strategies.
9. Describe specific practices and settings that increase the opportunity for exposure to
healthcare workers and patients.
10. Describe circumstances requiring use of barriers and personal protective equipment to
prevent patient or healthcare worker contact with potentially infectious material.
11. Identify specific barriers or personal protective equipment for patient and healthcare worker
protection from exposure of potentially infectious material.
12. Recognize the importance of the correct application of reprocessing methods for assuring the
safety and integrity of patient care equipment.
13. Identify the individual's professional responsibility for maintaining a safe patient care
environment.
14. Recognize the role of occupational health strategies in protecting healthcare workers and
patients.
15. Explain non-specific disease findings that should prompt evaluation of healthcare workers.
16. Identify occupational health strategies for preventing HIV, HBV, and tuberculosis (TB) in
healthcare workers.
17. Identify resources for evaluation of health-care workers infected with HIV and/or HBV.
How to Take This Course
Here's what you need to know to take this course:
Take a look at the steps below; this will help you to progress through the course, the postexamination, and receive your certificate of completion.
1. READ THE OVERVIEW
Each chapter has learning objectives you are expected to complete through the coursework.
These provide an overview for the course as a whole. You should focus on the learning goals
listed.
2. STUDY THE CHAPTERS IN ORDER
The material contained in this course is sequential, so you should work your way from start
to finish. This will help you understand following sections.
3. TAKE THE POST-EXAMINATION
After studying the course, click on the Infection Control Post-Examination link on the
NYPNU website to take the exam. All questions must be answered before the test can be
graded, but there is no time limit on this test. You may refer back to this course at any time
during the test.
4. TEST RESULTS WILL BE SUBMITTED TO NYPNU
A score of 75 percent or more is required to pass the test. If your score is less than 75
percent, you'll be able to try again. You will have an opportunity at the end of the exam to
indicate how you want NYPNU, upon passing, to provide the certificate to you.
Course Introduction
New York State Department of Health and State Education Department
Background
In August 1992, Chapter 786 of the Laws of 1992 established a requirement that certain
health care professionals licensed in New York State receive training on infection control and
barrier precautions by July 1994, and every four years thereafter, unless otherwise exempted.
This statute affects every dental hygienist, dentist, licensed practical nurse, optometrist,
physician, physician assistant, podiatrist, registered professional nurse, and specialist assistant
practicing in New York State. The rationale for this requirement has its origins in several events
over the past two years.
One of the most important of these was the Department of Health's establishment of a
policy on health-care workers infected with human immunodeficiency virus (HIV) or hepatitis B
virus (HBV). Another important event was the adoption by the Board of Regents, effective
March 1992, of an amendment to Regents Rules expanding the definition of unprofessional
conduct to include failure to follow appropriate infection prevention techniques in health care
practice. The Department of Health has adopted similar regulations.
The question of how to protect patients from contracting HIV through receipt of health
care has been the subject of debate in the scientific community as well as in public and private
sectors. The Department of Health has been intensely involved in this issue at both the state and
national levels. As a result of these deliberations, consensus has been reached in New York State
that the strategy that offers the greatest opportunity for protecting the public in settings
where they receive health care is one of assuring that infection control measures are
routinely in place and routinely observed. Such practices must provide protection from cross
contamination from patient to patient, as well as patient and health-care worker exposure to
pathogens through the direct provision of care. While blood borne pathogens are the chief
concern driving policy and legislation at this time, other pathogens transmitted by contact spread
(e.g., staphylococci, gram-negative organisms) also may pose a risk. Broad attention to the
principles of infection control will diminish the opportunity for these exposures as well.
For many years, regulated health care settings, such as hospitals, nursing homes, and
diagnostic and treatment centers have been required to have in place infection control programs
designed to protect patients, employees, and visitors. Established policies and procedures address
a number of concerns including hand washing, prevention of infection associated with surgery,
IV delivery, the use of urinary catheters and other invasive procedures, housekeeping,
disinfection and sterilization of equipment, waste disposal, and other areas that may be a source
of infection. Isolation and employee health policies also limit the potential for exposure to
communicable diseases and provide a mechanism for follow-up when inadvertent exposures
occur. Through surveillance of infection in these settings, and quality assurance and risk
management programs, compliance with infection control standards are monitored and problems
identified early. Attention to the infection control program has had an important impact on
reducing nosocomial and occupationally acquired infections.
Goal of Infection Control Training as Mandated by Chapter 786
The goal of the recently established infection control training requirement is to assure
that licensed, registered, or certified health professionals understand how blood borne pathogens
may be transmitted in the work environment and recognize their professional responsibility for
assuring that they, and those for whom they are responsible, apply scientifically accepted
infection control principles, as appropriate to their work setting, to minimize the opportunity for
transmission to patients and employees. In addition, the training should establish that failure to
adhere to such standards can be considered evidence of professional misconduct and could lead
to disciplinary action.
MINIMUM CORE ELEMENTS OF REQUIRED COURSE WORK OR TRAINING IN
INFECTION CONTROL
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.
Element II: Modes and mechanisms of transmission of pathogenic organisms in the health-care
setting and strategies for prevention and control.
Element III: Use of engineering and work practice controls to reduce the opportunity for patient
and health-care worker exposure to potentially infectious material.
Element IV: Selection and use of barriers and/or personal protective equipment for preventing
patient and health-care worker contact with potentially infectious material.
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.
Element VI: Prevention and control of infectious and communicable diseases in health-care
workers.
ELEMENT I - PROFESSIONAL RESPONSIBILITY
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
DEFINITIONS
Unprofessional Conduct - The failure to use scientifically accepted infection prevention
techniques for the cleaning, disinfection and/or sterilization of instruments, devices, materials,
and work surfaces; utilization of protective garb; use of covers for contamination prone
equipment, and the handling of sharp instruments.
HCW - Health Care Worker
Introduction
Mandatory Infection Control Training for Health Care Personnel
The New York State Education Department and Department of Health are actively promoting
infection control training to prevent blood borne disease exposure to both health care workers
and their patients. Recent regulations require hospitals to train their staff, provide appropriate
equipment, and enforce the use of universal barrier precautions in situations involving potential
exposure to blood and body fluids. In addition, the state requires licensed health care
professionals, including registered nurses, to complete infection control training and barrier
precautions course every four years. (A waiver of this training requirement may be granted by
the Department of Health to health professionals who demonstrate that such training is not
needed due to the nature of their work, or that they have met criteria for equivalency.)
Enforcement of Infection Control Standards
Hospitals and other licensed health care facilities are responsible for monitoring and enforcing
infection control practices by HCW under their jurisdiction. Failure to do so can result in
citations, fines, and other disciplinary action. Likewise, any licensed health care professional
who fails to use proper infection control techniques to protect patients can be subject to
disciplinary action and charges of professional misconduct. HCWs must also ensure that those
under his or her supervision use appropriate infection control techniques as well.
Complaints by patients or employees of lax infection control practices will result in Department
of Health or Education investigations. If the charges are substantiated, it may result in charges of
misconduct for any licensed worker who was directly involved, who knew about the violation, or
who is responsible for supervising an inadequately trained staff.
I. SOURCE OF REGULATIONS, STANDARDS, AND SCOPE OF AUTHORITY FOR
INFECTION CONTROL STANDARDS FOR PROFESSIONAL CONDUCT
A. Federal Regulations
1. The Occupational Safety and Health Administration (OSHA) issued mandatory
regulations requiring employees to provide a safe and healthful workplace. Recent
regulations: Blood borne Pathogen Standards and tuberculosis enforcement policy
and procedures.
2. Centers for Disease Control and Prevention (CDC) issued guidelines and
recommendations concerning infection control standards such as “Universal
Precautions”.
B. Rules of the Board of Regents, Section 29.2(a)(13)
1. Establishes the failure to adhere to accepted infection control techniques as
unprofessional conduct under the law. This regulation specifies several techniques
for infection prevention and requires licensed health care professionals to understand
the methods of cleaning and sterilization, utilization of protective clothing, and
handling of sharp instruments. Please be sure to read the text of the rules.
C. Part 92 of Title 10 Health Regulations
Laws of New York Chapter 786
1. The Department of Health issued these regulations to protect HIV or HVB infected
HCWs from discrimination in employment and in their professional practice and to
secure the public safety. The DOH evaluated the risks and potential for exposure, and
concluded the following. Click here for the text.
2. The New York State Public Employees Safety and Health Act (PESH) is responsible
for the protection of public employees at the workplace.
3. Chapter 786 of the Laws of New York State 1992 includes provisions to protect
citizens from exposure to HIV, HBV, and other pathogens during medical and dental
procedures. This law identified the failure to comply with the implementation of
infection control prevention strategies as grounds for charges of unprofessional
conduct.
Subsequent amendments created:
Infection Control Standards
Course work or training in infection control practices
State Advisory Panel on HIV/HBV infected healthcare workers
D. Other Professional Organizations/Accrediting Agencies Providing Guidelines for
Preventing Transmission of Infections of Healthcare Organizations
1.
2.
3.
4.
JCAHO - Joint Commission on Accreditation of Healthcare Organizations
AHA - American Hospital Association
APIC - Association for Professionals in Infection Control and Epidemiologist, Inc.
SHEA - Society for Hospital Epidemiologist of America
LAWS OF NEW YORK, 1992
CHAPTER 786
An Act to amend the Public Health Law and the Education Law, relating to preventing
transmission of human immunodeficiency virus (HIV) and hepatitis B (HBV) in health care
settings.
Became a law August 7, 1992, with the approval of the Governor. Passed on message of
necessity pursuant to Article III, section 14 of the Constitution by a majority vote, three fifths
being present.
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND
ASSEMBLY, DO ENACT AS FOLLOWS:
1. The Public Health Law is amended by adding a new section 230-a to read as follows:
& 230-A. INFECTION CONTROL STANDARDS
The department shall consult with the Education Department to ensure that regulatory standards
for scientifically acceptable barrier precautions and infection prevention techniques promulgated
pursuant to this section are consistent, as far as appropriate with such standards adopted by the
Education Department applicable to persons licensed under the Education Law other than
Articles one hundred thirty-one and one hundred thirty-one B of such law.
2. Article 2 of the Public Health Law is amended by adding a new title II-D to read as follows:
TITLE II-D
HIV/HBV PREVENTION TRAINING
Section 238. COURSE WORK OR TRAINING IN INFECTION CONTROL
PRACTICES.
Education must be completed as previously stated except that the department shall
provide an exemption from this requirement to anyone who requests such an exemption and who
(1) clearly demonstrates to the department’s satisfaction that there would be no need for him or
her to complete such course work or training because of the nature of his or her practice or (II)
that he or she has completed course work or training deemed by the department to be equivalent
to the standards for course work or training approved by the department pursuant to this section.
The department shall consult with organizations representative of professions, institutions and
those with expertise in infection control and HIV and HBV with respect to the regulatory
standards promulgated pursuant to this section.
3. The Public Health Law is amended by adding a new Article 27-DD to read as follows:
ARTICLE 27-DD
STATE ADVISORY PANEL ON HIV/HBV INFECTED HEALTH CARE WORKERS
SECTION
2760. ADVISORY PANEL ESTABLISHED
2761. FUNCTION, POWERS AND DUTIES IDENTIFIED
NEW YORK STATE EDUCATION DEPARTMENT
RULES OF THE BOARD OF REGENTS
SECTION 29.2 (a)(13)
UNPROFESSIONAL CONDUCT IN THE AREA OF INFECTION CONTROL
29.2 General provisions for health professionals. a) Unprofessional conduct should also include,
in the professions of:
medicine, acupuncture, physical therapy, physician’s assistant, specialist’s 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):
(13) 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:
(i) wearing of appropriate protective gloves at all times when touching blood, saliva, other body
fluids or secretions, mucous membranes, non-intact skin, blood-soiled items or bodily fluid
soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and
decontamination procedures;
(ii) discarding of gloves used following treatment of a patient and changing to new gloves if torn
or damaged during treatment of a patient; washing hands and donning new gloves prior to
performing services for another patient; and washing hands and other skin surfaces immediately
if contaminated with blood or other body fluids;
(iii) 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.
(iv) sterilization equipment and devices that enter the patient’s vascular system or other normally
sterile areas of the body;
(v) 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.
(vi) using appropriate agents including but not limited to detergents for cleaning all equipment
and devices prior to sterilization or disinfection.
(vii) cleaning, by the use of appropriate agents including but not limited to detergents, equipment
and devices which do not touch the patient or that only touch the intact skin of the patient;
(viii) maintaining equipment and devices used for sterilization according to the manufacturer’s
instructions.
(ix) adequately monitoring the performance of all personnel, licensed or unlicensed, for whom
the licensee is responsible regarding infection control techniques;
(x) 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.
(xi) maintaining appropriate ventilation devices to minimize the need for emergency mouth-tomouth resuscitation;
(xii) refraining from all direct patient care and handling of patient care equipment when the
health care 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; and
(xiii) 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.
NEW YORK STATE DEPARTMENT OF HEALTH
MEDICAL CONDUCT IN THE AREAS OF ACCEPTABLE BARRIER PRECAUTIONS
AND INFECTION CONTROL PRACTICES
Statutory authority: Public Health Law, section 230-a)
Part 92 of Subchapter N of Chapter II of Title 10 (Health) of the Official Compilation of
Codes, Rules and Regulations of the State of New York
PHYSICIANS, REGISTERED PHYSICIAN ASSISTANTS AND SPECIALIST
ASSISTANTS REQUIRED USE OF INFECTION CONTROL PRACTICES.
Section 92.2 For physicians, registered physicians assistants, and specialist assistants, the
definition of unprofessional conduct shall include the failure to use scientifically accepted
infection control practices to prevent transmission of disease pathogens from patient to patient,
physician to patient, registered physician (assistant) or specialist assistant to patient, employee to
patient, and patient to employee, as appropriate to physicians, registered physician assistants and
specialist assistants. Such practices include:
(a) adherence to scientifically accepted standards for: hand washing; aseptic technique; use of
gloves and other barriers for preventing bi-directional contact with blood and body fluids;
thorough cleaning following sterilization or disinfection of medical devices; disposal of nonreusable materials and equipment; and cleaning between patients of objects that are visibly
contaminated or subject to touch contamination with blood or body fluids;
(b) use of scientifically accepted injury prevention techniques or engineering controls to reduce
the opportunity for patient and employee exposure; and
(c) performance monitoring of all personnel, licensed or unlicensed, for whom the licensee is
responsible regarding infection control techniques.
II. IMPLICATIONS OF PROFESSIONAL CONDUCT STANDARDS
A. Health care professionals have a responsibility to adhere to infection control standards
mandated both by law and agency policies and procedures.
B. Professionals have a responsibility for monitoring other HCWs under their supervision and
making sure that these standards are properly carried out.
C. Consequences of failing to follow accepted standards of infection control:
1. Increased risk of disease and adverse health outcomes for patients and health care
workers
2. Charges of unprofessional conduct
a. Mechanisms for reporting unprofessional conduct
Reports are made by patients or other employees to the Dept of Health,
Dept of Education, and/or the licensing board. Individuals and
organizations are required to report and failure to do so may result in
charges against that individual.
b. Complaint investigation
c. Possible outcomes of the investigation:
1. Disciplinary action against the HCW
2. Revocation of professional license
3. Professional liability, malpractice claims and law suits.
III.
METHODS OF COMPLIANCE
To comply with the professional conduct regulations:
A. Participate in required, approved infection control training every four years.
B. Adhere to accepted principles and practices of infection control as outlined in this course.
a. Supervise others properly
b. Report failures to adhere to infection control standards by your institution
ELEMENT II - TRANSMISSION AND PREVENTION
MODES AND MECHANISMS OF TRANSMISSION OF PATHOGENIC ORGANISMS
IN THE HEALTH CARE SETTING AND STRATEGIES FOR PREVENTION AND
CONTROL
DEFINITIONS
Infection: Replication of organisms in tissues of a host, with a development of an overt clinical
manifestation - disease.
Pathogen or Infectious Agent: A biological agent capable of causing disease.
Portal of exit/entry: Path by which a pathogen leaves the reservoir and enters the host.
Reservoir: Any person, animal, arthropod, plant, soil or substance (or combination of these) in
which an infectious agent normally lives and multiplies, on which it depends primarily for
survival, and where it reproduces itself in such a manner that it can be transmitted to a
susceptible host.
Susceptible Host: A person or animal lacking effective resistance to a particular infectious
agent.
Common vehicle: Contaminated material, product, or substance that serves as an intermediate
means by which an infectious agent is transported to two or more susceptible hosts.
Transmission: Any mechanism by which a pathogen is spread by a source or reservoir to a
person.
I. OVERVIEW OF TRANSMISSION OF PATHOGENIC ORGANISMS
A. Concept of "The Chain of Infection"
Three elements of infection: pathogen, mode of transmission, and susceptible host.
1. Presence of a pathogen, or infectious agent, is required for infection.
(Pathogens found in patient, HCWs, environment, etc.)
a. Bacteria: single celled microorganisms (TB, MRSA, streptococcus, E. Coli,
pseudomonas, C. difficile)
b. Viruses: sub microscopic elements that require a host to grow, similar to a seed
(herpes, influenza, HIV, HBV, HBC, varicella voster)
c. Fungi: molds or yeasts that live on plants and animals (candida, aspergilla,
cryptococcus)
d. Parasites: (protozoa, tapeworm, lice, ticks)
2. Role and nature of "reservoirs" - habitat for the pathogen
a. Animate: living being (people or animals)
b. Inanimate: objects or things which are not living (tourniquet or bathtub)
c. Acute v. Carrier State:
The acute phase is a state of illness where the infection is apparent. Carrier
state means the virus is present with no apparent signs of disease. A carrier
can continue to transmit after acute infection/disease is over. An intermittent
transmitter can not transmit the organism continuously, but intermittently.
3. Portals of exit: vehicles and mechanisms by which pathogens leave the body.
a. coughing, sneezing respiratory/oral secretions
b. draining lesions
c. diarrhea
d. drainage of blood and other body substances
4. Modes by which pathogens are transmitted to a susceptible host.
a. Contact
1) Direct: person to person touch
2) Indirect: contact with an inanimate object carrying the pathogen
3) Droplet: passage through the air attached to a large respiratory droplet from a
cough or sneeze
b. Airborne
Passage of an infectious agent through the air. The size and density of the air
particles determines how far the pathogen can travel.
c. Common vehicle
The pathogen contaminates a vehicle such as shared food and is spread to
many susceptible hosts.
d. Vectorborne
The pathogen is carried to a host through insects.
5. Portals of entry: sites and mechanisms by which pathogens are introduced
a. Entry sites - site where the microorganism is introduced to the host (mucous
membranes, non-intact skin, gastrointestinal, respiratory, genitourinary tracts,
placenta)
b. Mechanical introduction - ways in which the pathogen is introduced to the host
(percutaneous injury, vascular access and other invasive devises, surgical incision,
permucosal contact)
B. Factors which influence the outcome of an exposure
1. Impairment of host defenses, e.g., age, prematurity, chronic disease, as mediated by
changes in:
a. natural barriers, e.g.,
1) Intact skin
first line of defense against pathogens
2) Respiratory cilia
remove organisms that invade the respiratory tract
3) Gastric acid
helps to kill bacteria
4) Tears
wash contaminants away from eyes
b. Immune system, e.g.,
1) Inflammatory response, e.g., neutrophils
2) Humoral immunity, e.g., antibodies
3) Cell-mediated immunity, e.g., macrophages, T-lymphocytes
2. Virulence of the pathogenic organism
Potency or strength of the pathogen; its power to cause infection (the more
virulent the organism, the easier it will be to cause infection).
3. Size of inoculum - the larger the size, the greater the exposure.
4. Route of exposure - certain portals of entry are more effective than others at causing
disease.
5. Duration of exposure - the longer the exposure, the greater the risk of becoming
infected.
II. CONCEPTS OF PREVENTION (BREAKING “THE CHAIN OF TRANSMISSION”)
A. Recognition and control of reservoirs
1. Recognition:
a. Observing for signs and symptoms of disease such as fever, swelling, or redness.
b. Laboratory, radiological, and other diagnostic testing or procedures.
2. Control:
a. Antimicrobial therapy (antibiotics)
b. Eliminating or controlling inanimate environments that support the growth of
pathogenic organisms.
B. Control of routes of transmission
1. Hand washing - ESSENTIAL
2. Use of barriers - gloves, masks, goggles, etc.
3. Sterilization or disinfection of patient care equipment
4. Isolation/cohorting communicable individuals (consider all patients as potentially
infectious and use universal precautions at all times; implement other precautions as
necessary)
5. Environmental practices
a. Housekeeping
b. Ventilation - adequate exchange patterns.
c. Waste management
d. Linen and laundry management
C. Support and protection of the host
1. Vaccination (influenza, hepatitis B, MMR, pneumococcal, DPT, HIB, Polio)
2. Pre- and post-exposure prophylaxis
3. Protecting skin and immune system integrity
III. APPLICATION OF CERTAIN PREVENTION CONCEPTS
A. Hand washing
Consistent hand washing is the single most effective way to guard against
infection—simple, inexpensive, and highly effective.
Unfortunately there is a low level of compliance in many settings.
i.
People aren't aware of the importance
ii.
Not emphasized as a priority
iii.
HCWs don’t see themselves at risk.
iv.
Can be inconvenient because of lack of sinks or towels
v.
Soaps and scrubs can irritate skin
vi.
Not part of the hospital culture—other's don't do it
1. Selection of hand washing agents based on need for safe patient care:
b. In non-patient care areas, plain soap is sufficient. It removes transient flora but
does not kill microorganisms.
c. In high-risk and patient care areas, antiseptic or antimicrobial agents should be
used to reduce colonizing flora.
2. Factors which influence hand washing efficacy
a. mechanical friction: removes large amounts of visible contamination
b. warm running water: rinses away loosened debris and pathogens
c. Soap: removes matter by disolving oils that contain pathogens
3. Sources of potential contamination or cross-contamination of and washing materials.
a. Bars of soap might sit in pools of stagnating water that can hold and spread
pathogens. It is recommended to dispose of used soap bars frequently.
b. Refillable soap dispensers should not be filled before they are emptied and
cleaned. Topping off at low levels can allow pathogens to fester.
c. Disposable, non-refillable soap dispenser pumps are the best option.
To increase efficiency when hand washing:
1) Designated hand-washing sinks should be located close to patient care areas.
2) Foot pedals make sinks easier to use and reduce the risk of crosscontamination.
3) Even if you are wearing gloves, be sure to wash your hands before and after
any patient contact.
4) Always wash after touching contaminated materials.
5) Use waterless soaps when water is unavailable, but be sure to wash with water
as soon as you can.
B. Precaution/isolation strategies
1. Interaction-driven approaches
Considers contact with blood and body fluids without regard to diagnosis.
a. Rationale for interaction-driven strategies: infections can be present without a
diagnosis or knowledge of the health care provider.
b. Types of systems
1) Universal Precautions (UP) - treats all blood and body fluids as potentially
infectious. (blood, amniotic fluids, pericardial, peritoneal, synovial and
cerebrospinal, semen, vaginal secretions)
2) Body Substance Isolation (BSI) - precautions with all body fluids. (includes
all UP fluids plus urine, feces, sputnum, saliva, and wound drainage)
3) Segregating individuals with similar symptoms
2. Diagnosis-driven approaches
a. Types of systems
1) Isolation by disease or category, based either on mode of transmission or
etiology.
2) Cohort individuals infected with same pathogen to the same room.
3) Transfer or discharge infected individuals if your hospital is unable to provide
adequate isolation strategies.
b. Application in specific health care settings
1) You must be aware of your Hospital's specific policies and procedures relating
to infection control.
2) The infection control department is available for questions and help.
ELEMENT III - REDUCING EXPOSURE
USE OF ENGINEERING AND WORK PRACTICE CONTROLS TO REDUCE THE
OPPORTUNITY FOR PATIENT AND HEALTH CARE WORKER EXPOSURE TO
POTENTIALLY INFECTIOUS MATERIAL.
DEFINITIONS
Engineering Controls: equipment, devices, or instruments that remove or isolate a hazard.
Work Practice Controls: controls that reduce or eliminate the likelihood of exposure by
altering the manner in which a task is performed
I. HIERARCHY OF CONTROLS TO PREVENT EXPOSURE OF PATIENTS AND
HEALTH CARE WORKERS (HCW) TO POTENTIALLY INFECTIOUS
MATERIALS
A. Engineering controls
Equipment or instruments that remove or isolate health care professionals and
patients from pathogens. Examples include puncture resistant sharps disposal
containers, needleless systems, and air exchange ventilation systems.
B. Work practice controls
Habits or methods by which tasks are performed that reduce or eliminate the
likelihood of exposure. Examples include hand washing and respiratory protection.
C. Personal Protective Equipment (PPE)
Protection to supplement engineering and work practice controls if risk still exists.
Includes gloves, masks, gowns, and eye wear. Discussed further in Element IV.
II. APPLICATION OF A HIERARCHY CONCEPT TO BLOODBORNE PATHOGENS
AND CONTACT EXPOSURE
A. Circumstances and practices which increase opportunities for exposure
1. Percutaneous exposures
A piercing of the skin barrier, causing a point of entry for blood or other infectious
material
a. Injury through handling, disassembly, disposal, or reprocessing of needles and
other sharps (manipulating needles and other sharps by hand, recapping using a
two-handed technique, removing scalpel blades).
b. Procedures in which there is opportunity for injury, particularly where there is
poor visualization which can expose the patient as well as the HCW:
1) blind suturing
2) non-dominant hand opposing or next to a sharp
3) bone spicules, metal fragments
2. Mucous membrane/non-intact skin exposures
a. Direct contact with blood or body fluid
b. Splashes or sprays of blood or body fluid
3. Parenteral exposures
a. Injection with infectious material.
b. Infusion of contaminated blood products.
c. Transplantation of contaminated organs/tissues.
B. Identification of those at risk for exposure
1. Direct provider
2. Assistants
3. Ancillary personnel
4. Patients
C. Engineering controls which eliminate or isolate the hazard
1. Safer devices for needlestick prevention
a. Strategies for preventing needlestick injuries
1) Eliminate the needle or sharp.
2) Provide continuous protection of the needle or sharp.
3) Provide a mechanism to safely cover the sharp immediately after use.
b. Important concepts
1) Passive vs. active safety features
i.
passive - the safety feature is activated automatically
ii.
active - the safety device must be activated by the HCW
2) Integrated safety equipment vs. accessory
i.
integrated - safety device is part of the equipment
ii.
accessory - requires additional devices
Examples:
3) Needleless needles
4) Self sheathing needles
5) Blunt suture needles
6) Mechanical pipette
2. Puncture-resistant containers for the disposal and transport of needles and other
sharps.
3. Splatter shields on medical equipment, such as locking centrifuge lids.
D. Work practice controls
1. Avoiding unnecessary use of needles and other sharps.
2. Using care in the handling and disposal of needles and other sharp devices:
a. Either not recapping or, when necessary, using an appropriate one-handed
technique
b. Passing sharp instruments by use of designated "safe zones"
c. Disassembling sharp equipment by use of forceps or other device
d. Conveniently located and frequently emptied sharps disposal containers
3. Modifying procedures to avoid injury, e.g.,
a. Using forceps, suture holder, or other instruments for suturing
b. Not holding tissue with fingers
c. Not leaving sharps on a field
4. Hand washing
5. Prompt cleaning of blood and body fluid spills
6. Worker training education and monitoring of others to aid them in compliance
III. APPLICATION OF A HIERARCHY CONCEPT TO AIRBORNE PATHOGENS
Exposure to airborne pathogens occurs just by being present - contact is not necessary.
A. Circumstances which increase opportunities for exposure
1. Inadequate ventilation
2. Lack of source control
3. Unrecognized or undiagnosed cases
B. Engineering controls for prevention
1. Appropriate air exchange and ventilation
2. Negative pressure rooms to facilitate proper air flow
3. HEPA filters (isolation booths, demistifier tents)
C. Personal Respiratory Protection (see Element IV)
1. Current recommendations require use of NIOSH-approved HEPA filter particulate
respirators
D. Source control
1. Early recognition and treatment
2. Covering mouth when sneezing or coughing—HCWs and patients
3. Triage and separation of possibly infectious individuals from others at risk (isolation,
triaging clinic patients)
E. Role of adjunctive measures (i.e., ultraviolet light)
F. Application of infection controls to reduce risk of exposure to TB.
1. Engineering controls
a. Isolation rooms
1) 6 air exchanges per hour (portable ventilators should be used if appropriate
rooms are not available)
2) Negative pressure (room door kept closed)
b. HEPA filter respirators should be worn while:
1) Entering rooms of patients with suspected or confirmed TB
2) Performing high hazard procedures on patients with suspected or confirmed
TB (aerosolized medication administration, bronchcoscopy, spectrum
induction)
3) Transporting patient with suspected or confirmed TB in a closed vehicle, even
if patient is wearing a mask.
2. Work Practice Controls
a. Diagnosis and awareness
b. Early isolation
c. Education of patient and family
d. Proper use of Personal Protective Equipment
ELEMENT IV - PROTECTIVE EQUIPMENT
SELECTION AND USE OF BARRIERS AND/OR PERSONAL PROTECTIVE EQUIPMENT
FOR PREVENTING PATIENT AND HEALTH CARE WORKER CONTACT WITH
POTENTIALLY INFECTIOUS MATERIAL
DEFINITIONS:
Barrier: A material object that separates a person from a hazard
Personal Protective Equipment (PPE): specialized clothing or equipment worn by a healthcare worker (HCW) for protection against a hazard.
I. TYPES OF PPE/BARRIERS AND CRITERIA FOR SELECTION
A. Gloves
Single use, disposable gloves that must be changed between patients
Reduce likelihood of infection of HCW from a host
Reduce likelihood of infection of patients from the HCW
Reduce likelihood of colonization of microorganisms on the HCW
1. Sterile v. non-sterile
Based on medical procedure being performed
a. Medical Asepisis using non-sterile gloves
1) patient care activities
2) non-surgical procedures such as oral care or tube feeding
3) care of patients with communicable diseases
b. Surgical Asepisis using sterile gloves
1) surgical procedures
2) procedures involving sterile body cavities
3) procedures with susceptible hosts
4) preparation and administration of medications and fluids
2. Materials
a. Characteristics to consider when choosing gloves:
1) flexibility
2) durability
3) dexterity
4) convenient application
5) chemical resistance
6) imperviousness to contaminated material
b. Types of materials
1) Latex: disposable natural rubber gloves
*Note: repeated latex exposure poses dangers to health care workers and
increases the risk of allergic reactions. Use of latex gloves should be
minimal, and when used they should always be powder free.
2) Vinyl: synthetic polymer work gloves
3) Nitrite/rubber: synthetic rubber utility gloves
4) Polyethylene: clear thin plastic film as used for food handling
5) Hypoallergenic
B. Cover garb
Protects clothing of health care workers when caring for patients. Should be worn only
once if cover garb becomes soiled with body fluids. Dispose or launder when used.
1. Types of Cover Garb
a. gowns: surgical or protective
c. aprons
d. laboratory coats
3. Characteristics
a. impervious
b. fluid resistant
c. permeable
C. Masks
Prevents transmission of airborne pathogens or droplets.
1. Types
a. non-surgical (fluid shield for the face)
b. surgical (impermeable, gauze/paper single use disposable)
c. particulate respirators such as HEPA filters
1) should be fit-tested regularly and used by only one individual
2) annual employee training and ongoing monitoring
D. Face shields
E. Eye protection (goggles, safety glasses, etc.)
F. Shoe and head covers
G. Other Barriers
1. Wound dressings
2. Procedure drapes
3. Specimen/waste bags
II. CHOOSING PPE BASED ON REASONABLY ANTICIPATED INTERACTION
You can find guidance and regulations from agency policies.
A. Blood or body fluid splash
Use gloves, gown, face shield or mask, and protective eye wear
B. Contact with minimal bleeding/drainage
Use gloves
C. Contact with large volume bleeding or drainage that is likely to soak through contact area
Use gloves and gown
D. Respiratory droplets and airborne pathogens
Use mask, face shield, eye protection, and HEPA filter if TB is suspected.
III. CHOOSING BARRIERS/PPE BASED ON NEED FOR PATIENT PROTECTION
A. Sterile barriers for invasive procedures—gowns, gloves, dressings
B. Prevention of droplet contamination—masks
C. Barriers to prevent drainage or lesions of HCW from contacting patient—dressings,
gowns, gloves
IV. GUIDANCE ON PROPER APPLICATION OF PPE/BARRIERS FOR PROTECTION
A. Proper fit
B. Integrity of barrier
Quality control standards for impermeability must be regularly updated.
C. Disposable vs. reusable barriers
Consider cost, convenience, barrier integrity, and medical waste regulations.
D. Potential for cross-contamination if not changed between patients
1. HCWs are responsible for their practices and could be charged with misconduct
2. Subordinate employees should be monitored to ensure compliance as well
E. Implications of over- and under-utilization of barriers/PPE
1. cost
2. patient isolation
3. cross contamination
4. worker exposure
ELEMENT V - SAFE PATIENT CARE ENVIRONMENT
CREATION AND MAINTENANCE OF A SAFE ENVIRONMENT FOR PATIENT
CARE THROUGH APPLICATION OF INFECTION CONTROL PRINCIPLES AND
PRACTICES FOR CLEANING, DISINFECTION, AND STERILIZATION
DEFINITIONS
Cleaning - The removal of all foreign material (e.g., soil, organic debris) from objects.
Decontamination - The process of removing disease-producing microorganisms and rendering
the object safe for handling.
Disinfection - A process that results in the elimination of many or all pathogenic
microorganisms on inanimate objects with the exception of bacterial endospores.
Sterilization - A process that completely eliminates or destroys all forms of microbial life.
I. EVIDENCE OF TRANSMISSION OR POTENTIAL FOR TRANSMISSION BY
CONTAMINATED EQUIPMENT
A. Equipment or device contamination coupled with patient exposure can cause transmission
of disease, so it is crucial to ensure that equipment is kept free of pathogens.
B. Factors that have contributed to contamination in reported cases:
1. Inadequate cleaning
2. Inadequate disinfection or sterilization processes
3. Contamination of disinfectant or rinse solutions
4. Reuse of disposable equipment
5. Failure to reprocess or dispose of equipment between patients
II. POINTS IN REPROCESSING OR HANDLING WHERE BREAKS IN INFECTION
CONTROL PRACTICES CAN COMPROMISE THE INTEGRITY OF EQUIPMENT
OR DEVICES
A. Handling and cleaning contaminated items
OSHA guidelines for prevention of blood borne pathogen transmission:
1. Handling
a. Designated collection points should be labeled "biohazard"
b. Contaminated items should be transported in puncture resistant and clean
containers
c. Keep designated cleaning areas away from sterile and cleaned items
d. Do not place contaminated items on unprotected surfaces
e. Always use proper Personal Protective Equipment
2. Decontamination
a. Begin with manual cleaning of visible contamination
3. Pre-soaking
a. Presoak items immediately after their use in designated areas
b. Items have specified times for presoaking—keep it minimal in accordance with
specifications
4. Cleaning
a. Use warm running water to contain microorganisms
b. Always use the manufacturer's cleaning recommendations
c. Use nonabrasive cleansing tools and cleaning brushes when needed
d. Rinse thoroughly with either deinonized water or running tap water
e. Ensure that the item is dry before disinfecting or sterilizing
f. Always perform cleaning in designated areas away from patient care areas, hand
washing sinks, and clean or sterile areas
B. Choice of reprocessing method
1. Level of reprocessing method based on intended use
a. Critical—requires sterilization
Use for instruments that have been directly introduced into the body (blood
stream or other normally sterile areas of the body)
b. Semi-critical—requires high level disinfection
Use for instruments that have come in contact with mucous membranes or nonintact skin
c. Non-critical—requires physical or mechanical cleaning
Use for instruments that have come in direct contact with unbroken skin
d. Environmental surface—requires routine cleaning
Use for surfaces with the least risk of disease transmission
2. Desired level of antimicrobial activity
a. High: destroys all viruses and bacteria, and most spores
b. Intermediate: destroys most viruses and fungi, and all bacteria
c. Low: destroys most bacteria
3. Manufacturer's recommendations for reprocessing must be followed
C. Effectiveness of disinfection process
1. Selection and use of disinfectants, including surface and immersion products
Depends on level of antimicrobial activity needed
a. high: glutaraldehyde, 3%-6% hydrogen peroxide, bleach
b. intermediate: alcohol, bleach, phenolics
c. low: phenobics, iodophor, quaternary ammonium
Common Chemical Disinfectants
Chemical
disinfectant
Glutaraldehyde
Formaldehyde
Required
Concentration
2%
1-8%
Antimicrobial
Activity
High
High-low
H2O2
Alcohol
Iodophor
6%
70%
Variable
High-Intermediate
Intermediate
Intermediate-Low
2. Monitoring activity of disinfectants
a. All chemicals used should be EPA approved
b. Read the label carefully before selecting and using a chemical
c. Strictly follow the manufacturer’s recommendations
d. Be aware of the expiration dates
e. Be sure the area is well ventilated when using chemicals
f. Avoid contact with skin or mucous membranes
3. Post-disinfection storage and handling
a. Rinse the chemicals thoroughly (with sterile water if high-level disinfection)
b. Dry the instrument with sterile towels or compressed, filtered air
c. Store in designated "clean" cabinets, covered containers, or bags to avoid
recontamination
D. Effectiveness of sterilization process
1. Selection and use of sterilization methods
Consider cost and the availability of equipment, facilities, and trained users when
selecting a sterilization method. The method must be compatible with the physical
properties of the item requiring sterilization.
Methods of Sterilization
a. Autoclave—moist heat with steam under pressure
The high temperatures and pressure must be maintained over some period of time,
and the instrument must be cleaned,decontaminated, and wrapped prior to
autoclaving
b. Flash sterilization—270 - 275 degree steam for four minutes
High temperatures and pressure allow flash sterilization to be fairly quick. This
method is best used for unwrapped metal instruments.
c. Ethylene oxide chamber
This method is suitable for heat sensitive materials such as plastic, rubber, and
scopes. Specific temperatures and times are required.
d. Glutaraldehyde—2% alkaline and acid
Good for instruments that are heat sensitive or can’t withstand gas. As always,
review labels to unsure proper use, and rinse only with sterile water.
Advantages: broad spectrum of antimicrobial activity
quickly inactivates microorganisms
easy to use
no corrosion of metal, rubber, or cement
Disadvantages: unpleasant odor
negative health effects from vapor
e. Other methods
Depending on the instrument being sterilized, unsaturated chemical, sterilization
beads, other chemicals and dry heat may be used as alternate techniques.
2. Monitoring the Sterilization Process
a. Steam Sterilization
1) Mechanical indicators:
i.
time and temperature charts
ii.
pressure gauges
2) Chemical/physical indicators:
i.
package strips
ii.
heat sensitive tapes
iii.
pellets
3) Biological indicators:
i.
biological monitors
ii.
spore strips
b. Ethylene Oxide (ETO) Sterilization
1) Mechanical indicators:
i.
recording graph
ii.
humidity gauge
iii.
gas
iv.
conditioner steam
v.
pressure gauge
2) Chemical and physical indicators:
i.
heat sensitive tape
ii.
chemically treated paper strips
3) Biological indicators:
i. spore strips
c. Glutaraldehyde Sterilization
1) Mechanical Indicators
i.
Dip stick monitors
ii.
Test kits
2) Biological Indicators—no specific biological monitoring
3) Chemical and physical indicators
i.
Liquid chemical indicators which change colors
ii.
Visible organic debris indicates need to discard
3. Post-sterilization handling and storage, including pre-packaged sterile items
a. Choosing appropriate packaging
1) Considerations: size, shape, and weight of item; packaging should allow
evaporation of any chemicals; package must preserve the content sterility
2) Materials: 180 - 240 thread-count, rigid sterilization containers, or non woven
disposable materials
b. Shelf life
1) Expiration date or "sterile until opened" guarantee should be listed on
packaging
2) Hospitals have specific policies and procedures
c. Storage
1) Use a clean, dry area for storage
2) Sterile items should be handled as little as possible
3) Rotate items so earlier expiration dates are used first
4) Sterile items should not be kept on the floor or within 18” of the ceiling
III. RECOGNIZING POTENTIAL SOURCES OF CROSS CONTAMINATION IN THE
PROFESSIONAL'S HEALTH CARE ENVIRONMENT
A. Identification of surfaces or equipment which require between-patient cleaning
Routine cleaning and sanitizing of work surfaces is crucial for preventing infections.
1. All equipment and surfaces that have contact with blood or body fluid should be
cleaned and sanitized after every patient.
2. All surfaces that come in direct contact with patients should be cleaned and sanitized
daily.
Detergent formulas are effective for disinfecting work surfaces
B. Identification of practices which contribute to touch contamination and the potential for
cross-contamination
1. Failure to wear gloves or wash hands effectively
2. Reuse of equipment without proper disinfection or disposal
3. Failure to thoroughly clean and sanitize between patients
C. Implications of reuse of disposable equipment or devises
If disposable equipment is to be reused, strict standards must be met
1. The FDA allows reprocessing if a hospital can show that the item:
a. Can be cleaned or sterilized adequately
b. Is not adversely affected by reprocessing
c. Remains safe and effective for its intended use
d. Is in compliance with the manufacturer’s recommendations
2. There must be specific procedures for HCWs to follow regarding reuse
D. Blood spills must be cleaned immediately
1. First contain the spill so it doesn't spread to other equipment or instruments
2. Make sure to always wear appropriate PPE when cleaning (gloves; gown or apron)
3. Mop the blood with a disposable cloth, then pour diluted bleach solution (1/4 cup
household bleach to 1 gallon water) or other EPA approved agent directly onto the
surface. After 10 minutes, wipe with a second disposable cloth.
IV. OSHA-REGULATED ENVIRONMENTAL CONTROLS
A. Certain types of waste must be labeled "Biohazard" and "red-bagged" for protection:
1. Blood and blood products
2. Human pathological waste
3. Discarded vaccines
4. Microbiological cultures
5. Items that are blood soaked
6. Sharps
B. Use labeled containers and licensed trash haulers that maintain tracking forms.
C. Use PPE as necessary.
D. Soiled Laundry
1. Handle with universal precautions
2. Segregate linens and PPE that have been soiled with blood or body fluids
Red-bag them or label "biohazard" or "contaminated" if universal precautions not
routinely used by outside laundry service
3. Be aware of hospital policies and schedules
V. RECOGNIZING DIFFERING LEVELS OF DISINFECTION/STERILIZATION
METHODS AND AGENTS BASED ON THE AREA OF PROFESSIONAL
PRACTICE AND SCOPE OF RESPONSIBILITY
A. Knowledge expectations of health professionals who practice in organizations where the
responsibility for handling, cleaning, and reprocessing equipment or devices is designated
to another department
1. Basic concepts and principles of cleaning, disinfection, and sterilization described
above
2. Appropriate application of safe practices for handling devices and equipment in the
area of professional practice
B. If you have primary supervisory responsibilities for equipment or device reprocessing,
you must know detailed information about the following:
1. Properties and uses of chemical disinfectants
2. Methods for achieving sterilization
3. Methods for monitoring sterilization processes & current recommendations for
monitoring frequency
ELEMENT VI - PREVENTION OF DISEASE IN HCWS
PREVENTION AND CONTROL OF INFECTIOUS AND COMMUNICABLE DISEASES
IN HEALTH CARE WORKERS
DEFINITIONS
Communicable Disease - An illness due to a specific infectious agent which arises through
transmission of that agent from an infected person, animal, or inanimate reservoir to a
susceptible host.
Infectious Disease- A clinically manifest disease of man or animal resulting from an infection.
Occupational Health Strategies - As applied to infection control, a set of activities intended to
assess, prevent, and control infections and communicable diseases in healthcare workers.
I. OVERVIEW OF OCCUPATIONAL HEALTH ACTIVITIES AS THEY APPLY TO
INFECTION CONTROL
A. Goals of occupational health strategies
1. Prevent disease transmission by health-care workers
2. Protect susceptible health-care workers from infectious or communicable diseases
B. Strategies used to assess HCWs for disease risks
1. Pre-employment and periodic health assessments
Immunizations, childhood illnesses, PPD-TB status, skin conditions, chronic diseases
2. Immunization/screening programs
a. Diseases targeted for screening/immunization include rubella, rubeola, varicella,
hepatitis B, tuberculosis, and influenza.
b. Mandated v. recommended screening and immunization requirements:
Mandated: proof of immunity to rubella and rubeola, or certificate of
immunization and pre-employment PPD test
Recommended: hepatitis B, influenza, measles, mumps, rubella.
Diseases that must be reported to the Office of Health Systems Management and
Bureau of Disease Control: rubella, rebeola, pertussis.
c. Sources of regulatory requirements:
1) OSHA/PESH (Public Employees Safety and Health)
2) New York State (Title 10 Regulations)
3. Evaluation of acute/incubating illnesses in HCWs
a. Symptoms which should prompt evaluation for work fitness:
1) fever, chills
2) cough, sputum production
3) exanthema, vesicles
4) skin lesions, weeping dermatitis
5) draining wounds, sores
6) diarrhea, nausea, vomiting
b. Post-exposure evaluation for incubating diseases in susceptibles:
1) Tuberculosis
skin tests followed by chest x-rays if positive; prophylactic Rx
2) Varicella
removal from work 10th-21st day after exposure or, if exposure date is
unknown, until all lesions have dried and crusted
3) Rubella
removal from work 7th-21st day after exposure, or, if exposure date
unknown, for five days after onset of rash
4) Rubeola
measles vaccine option within 3 days; removal from workplace 5th-21st
day after exposure or 7 days after rash appears
5) Pertussis
monitoring and antibiotics for 14 days after exposure; removal from
workplace for 3 weeks, or 5 days after the start of effective therapy
6) Mumps
removal from workplace 12th-26th day after exposure or until 9 days after
onset of parotitis
c. Interim management strategies
1) Limiting contact with susceptibles
2) Furlough until non-infectious
3) Evaluation/treatment as needed
4. Post-exposure management
a. Percutaneous/permucosal contact with blood and body fluids (HIV, HBV)
b. Airborne or droplet pathogen exposure (TB, meningococcal meningitis, pertussis)
II. SPECIFIC OCCUPATIONAL HEALTH STRATEGIES FOR PREVENTION AND
CONTROL OF BLOODBORNE PATHOGEN TRANSMISSION
A. Risk of blood borne pathogens to HCWs
1. HIV (Human Immunodeficiency Virus)
a. Risk of transmission is low (0.4%)
The Centers for Disease Control confirmed 55 HCW with occupationally
acquired HIV and 136 possible cases
b. Testing and preventive medications are provided for HCWs post-exposure
1) Baseline HIV status
2) Testing repeated at 6, 12, and 24 weeks post exposure
2. HBV (Hepatitis B virus)
a. Risk of transmission is high (6-30%).
800 HCW reported occupationally acquired HBV in 1995, down 95% since
1993 after the emergence of immunization
b. Highly safe and effective vaccine is available for all HCWs; encouraged for all
HCWs potentially exposed to blood/body fluids
3. HCV (Hepatitis C virus)
a. Risk of transmission about 3%
b. Asymptomatic
c. No recommended post-exposure treatment
d. Post-exposure immune globulin may be given
B. Elements of post-exposure management
1. Criteria for determining possible occupational exposures to bloodborne pathogens:
a. body substance involved
b. type of injury of contact
Exposures which require medical management include exposure to blood, semen, or
vaginal secretions, and percutaneous or permucosal exposure.
c. Occupational Exposure to Bloodborne Pathogens are categorized by severity
and degree of risk:
1) MASSIVE Exposure - Transfusion or injection of large volumes of blood;
parenteral exposure to lab materials containing high levels of virus
2) DEFINITE Parenteral Exposure - Deep injury or injection with a needle or
other instrument contaminated with blood or body fluid; any parenteral
inoculation of HBV or HIV virus samples (usually in research settings) not
included in Massive Exposure
3) POSSIBLE Parenteral Exposure - Superficial injury with blood/body fluid;
a wound produced by a blood/body fluid contaminated instrument; prior
wound or skin lesion contaminated with blood or body fluid; mucous
membrane inoculation with blood/body fluid
4) DOUBTFUL Parenteral Exposure - Superficial injury with a needle or
device contaminated with non-infectious or non-bloody fluids; prior wound or
skin lesion contaminated with non-infectious body fluid; mucous membrane
inoculation with non-infectious body fluid
5) NON-PARENTERAL Exposure - Intact skin visibly contaminated with
blood or body fluid
d. If a potential exposure occurs, stay calm and act immediately
1) Clean the wound with soap and water or flush mucous membrane immediately
2) Call your supervisor and other appropriate departments (Employee Health,
Infection Control, Emergency Department)
2. Recommendations for approaching source and HCW evaluation
a. Ask infection source for information and details about the exposure and inform
him or her about the transmission
b. Ask for permission to test for HIV antibodies
c. Obtain written permission to inform the exposed individual and his or her medical
provider of the details of infection
d. Explain the details of confidentiality protection
e. If the person has been exposed to HBV, evaluate him or her for hepatitis B
immunity and initiate hepatitis B prophylaxis as indicated.
3. Post-exposure management of patients or other HCWs when exposure source is a
HCW
a. Ethical obligation for reporting exposures to patients
b. Confidentiality
1) New York HIV confidentiality laws protect HCWs infected with HIV
i. Workers are not required to disclose HIV status to patients or employers
ii. Health care facilities are not required to disclose to patients
iii. Disclosure cannot be made without HCWs consent
2) Patient notification should be based on documentation of an incident during
which the worker’s blood came into direct contact with a patient’s
bloodstream or mucous membrane
i. Patient should be advised to receive testing for potential HIV or HBV
exposure
III. EVALUATION OF HCWs INFECTED WITH HIV, HBV OR OTHER
BLOODBORNE PATHOGEN
A. New York State Department of Health Policy on HIV testing of HCWs
B. Criteria for evaluating infected HCWs for risk of transmission
1. Nature and scope of professional practice
a. Techniques used in performance of invasive procedures that may pose a risk to
patients.
b. Compliance with infection control standards.
2. Presence of weeping dermatitis or skin lesions.
3. Overall health status
a. Physical health
b. Cognitive function
C. Expert panels for evaluation of health-care workers infected with blood borne pathogens
1. Hospital or institution review process
a. Evaluate need to modify employee's assignments
b. Provide a second opinion to the state-appointed review panels
c. Comprised of a public health official, disease expert, representative from the
HCW's area of practice, and the private physician
2. Review panels appointed by the state
a. Function similar to hospital review processes for HCWs not affiliated with an
institution
b. Serve as a second opinion for individuals affiliated with an institution
c. Comprised of a public health official, disease expert, representative from the
HCW's area of practice, and the private physician
3. Restrictions on practice
a. Hospitals and other facilities are responsible for ensuring that limitations are
observed in their facility
b. License review can result if the HCW does not comply