Universal Precautions

1. A Health Professions Module Universal Precautions

2. But first, a story… Dr. Ignaz Semmelweis, a Hungarian physician, delivered babies in the Vienna General Hospital. Nearly 20% of the mothers under the doctors’ care in that ward died following childbirth. Dr. Semmelweis instituted a practice which reduced that mortality rate to 1.3%. You take this practice for granted now, but the medical community dismissed his results. What practice do you think Dr. Semmelweis attempted to introduce to medicine?

3. Hand washing! Dr. Semmelweis made his discovery in 1847. At that time there was no germ theory to support his findings. Despite a lifetime of attempting to promote simple hand washing, his notion was rejected & ridiculed. Not living to see his work appreciated, Dr. Semmelweis eventually had a nervous breakdown & died in an insane asylum. There are no other illustrations in this presentation, so enjoy this one retrieved on 12/01/09 from http://clendening.kumc.edu/dc/pc/semmelweis01.jpg.

4. Universal Precautions Procedures for this module & objectives • This section covers: • Your task to complete this requirement • Student objectives for module

5. About this module Your task is fairly simple: • Read through this presentation • Take the automated quiz on this same D2L site. • Present proof of passing the quiz (80% or better) to your department chair. Note that throughout the presentation there are Read More notations in green which allow you to click a link for additional online information. You may come upon medical terms that are unfamiliar to you. Please consult an online or hard copy medical dictionary for clarification.

6. Objectives At the conclusion of this module, you should be able to: • List some of the most high profile healthcare-associated infections (HAI). • Identify the means by which communicable diseases are transmitted. • Describe the role of the CDC & OSHA in the prevention of HAI transmission. • State the purpose of “universal” or “standard precautions.” • List some worksite procedures relevant to exposure control. • Identify the components of universal/standard precautions including: • TB tests & immunizations for yourself • Hand hygiene • Use of protective barriers • Proper disposal of “sharps” (any device used to puncture or cut, such as needles & scapels) • Identify when Transmission-Based Precautions apply • Locate a source of precautions for specific conditions

7. Universal Precautions Putting the term in context • This section covers: • Prevalence of healthcare-associated infections (HAI) • Other terms for HAI • Examples of HAI • Transmission of HAI • Government agencies & their roles in minimizing transmission of HAI • CDC & recommended practices • OSHA & regulation of practices • Terminology review of this section

8. Healthcare-Associated Infections(HAI) The Centers for Disease Control and Prevention (CDC) provides a vast amount of information concerning Healthcare-Associated Infections. (http://www.cdc.gov/ncidod/dhqp/hai.html) The CDC estimates these account for 1.7 million infections & 99,000 associated deaths each year in American hospitals. Of these infections: • 32% are urinary tract infections • 22% are surgical site infections • 15% are lung infections (pneumonia) • 14% are bloodstream infections

9. HAI What would a medical term be without a Greek derivation? Healthcare-Associated Infections (HAI) are also known as Hospital-Acquired Infections and as Nosocomial Infections (from the Greek words for disease & to take care of). Those in the profession will know what you’re talking about no matter which term you use, but if you need to sound impressive, nosocomial wins hands down. Those should be washed hands.

10. Types of HAI • Bloodborne pathogens (including HIV/AIDS, Hepatitis B & C) • MRSA (Methicillin-Resistant Staphylococcus Aureus) • Pneumonia • Influenza • Norovirus • Varicella (chickenpox), mumps, Clostridium difficile (C. diff), TB, & a host of others. If you would like to see a more complete list, visit the CDC at http://www.cdc.gov/ncidod/dhqp/id.html.

11. Bloodborne pathogens:The Big Three Much of the driving force for the recommendations & regulations regarding HAI has stemmed from concern over these three diseases (though they certainly aren’t the only infections with the potential to circulate in healthcare settings): • HIV/AIDS • Hepatitis B virus (HBV) • Hepatitis C virus (HCV)

12. Transmission of HAI Communicable diseases, that is those diseases which are transmitted to a recipient from a host, make their “leap” through one or more of the following pathways: • Direct physical contact – including touching & sexual means • Indirect contact via an inanimate object (fomite) • Vector – recipient is bitten by an insect or animal (the vector) • Fecal-oral – from contaminated food or drink • Droplet – expelled through coughing, sneezing, talking • Airborne – pathogen hitches a ride on dust or evaporated droplets • Note that bloodborne pathogens (those in blood or other bodily fluids) may be transmitted by sexual or direct contact or through fomites (e.g., surgical instruments or dried blood on an object)

13. Example of an HAI transmission Norovirus has made the headlines several times for sickening passengers on cruise ships, kids at school, and residents of nursing homes. Take a guess at the means of transmission for this highly contagious disease. Go on…guess: A. Direct contact B. Indirect contact C. Vector D. Fecal-oral E. Droplet F. Airborne

14. Example (continued) It’s almost hard to be wrong. The answers are: A. Direct contact B. Indirect contact C. Vector D. Fecal-oral E. Droplet F. Airborne The point is that there can be and often are several routes of transmission which means that you must be exceptionally aware of your surroundings and practices.

15. Who’s looking out for you? The answer is ultimately you, but there are a couple of federal agencies deeply committed to setting standards & regulating healthcare practice for the safety of your patients & you. The Centers for Disease Control & Prevention (CDC, if your memory is short) has this mission statement (retrieved 12/1/09 from http://www.cdc.gov/about/): “To collaborate to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.”

16. CDC: Recommendations In the 1983 the CDC authored the Guidelines for Isolation Precautions in Hospitals. Later in the decade, and particularly in response to the HIV/AIDS epidemic, “universal precautions” were instigated to prevent the spread of pathogens responsible for diseases such as HIV/AIDS, HBV & HCV transmitted in blood, other bodily fluids containing visible blood, semen, & vaginal secretions. The precautions also apply to tissues, cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Saliva is included if visibly contaminated with blood. Read more at: http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html.

17. CDC (continued) The more recent CDC recommendations for hospitals are called the “standard precautions.” To quote directly from page 66 of 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, (http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf , retrieved 12/1/09) “Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI)* and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered.” * Defined in the Review of Terms slides at the end of this section.

18. OSHA: Regulation It’s one thing to receive good advice but quite another to be required to adopt it. Do you think that everyone started wearing seat belts when they first came out? Hmm? (Quick quiz: Which state does not have a seat belt law for adults? Hint: The official state motto is “Live free or die.” How interesting.) The Occupational Safety & Health Administration (OSHA) is all about regulating (issuing rules & enforcing them) standards of occupational health including those related to injuries, fatalities, & illnesses. It is an agency of the U.S. Department of Labor. If you don’t think they mean business, you ought to take even a brief look at their website: http://www.osha.gov/index.html. Please do.

19. OSHA (continued) Bloodborne Pathogens Standard 29 CFR 1910.1030 Does that not sound like a government decree? OSHA initially issued 1910.1030 in 1991 and updated it in 2001. With this, “universal precautions” became not just a recommendation but an enforceable set of regulations concerning infection control & bloodborne pathogens in particular.

20. More on the evolution of precaution practices. The following sources would be interesting to those who want to learn more about how isolation & precaution practices entered into the realm of healthcare: • “Standard Precautions” by Bjerke, N. B. (http://www.infectioncontroltoday.com/articles/281bpract.html) is a thorough & well-written history reaching back from the 19th century to the present. • This table from the American Dental Association summarizes the development of isolation precautions: http://jada.ada.org/cgi/content/full/134/5/569/T2)

21. Review of Terms This & the following couple of slides have a review of terms to set the stage for laying out what it actually means to practice universal precautions. If you would like to delve into the OSHA Standard 1910.1030 for a complete glossary and enumerated subparagraphs from here to eternity, you will find them at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Put your feet up; it’s a long read.

22. Review of Terms

23. Review of Terms

24. Universal Precautions Taking precautions to protect your patients AND yourself. • In essence, this means preventing disease transmission by consistently using infection control practices with all patients in all healthcare settings. • This section covers: • Administrative considerations • Confidentiality • TB test & vaccinations • Hand hygiene • Protective Barriers • Additional precautions

25. Administrative Considerations Whether your employer calls their program Standard Precautions in deference to the CDC or Universal Precautions as promoted by OSHA, you should become familiar with these worksite procedures: • Continuing education regarding precautions • The facility’s written exposure control plan • Post-exposure protocols (and be sure to follow these promptly if exposed!) • Record keeping regarding exposure

26. Confidentiality It should go without saying (and that is a pun as well as the truth) that whatever you might learn about a patient’s health status is private & protected information not to be shared beyond the circle of those involved in the patient’s care. The U.S. Department of Health & Human Services would like to tell you more at their site devoted to health information privacy, specifically regarding the Health Insurance Portability & Accountability Act (HIPAA). It is found at: http://www.hhs.gov/ocr/privacy/

27. TB Test & Immunizations • Tuberculin skin test. (TB is not gone! Almost 13,000 cases were reported in the U.S. in 2008.) Read more at: http://www.cdc.gov/tb/. • Vaccinations (http://www.immunize.org/catg.d/p2017.pdf) • Influenza • Hepatitis B • Measles, mumps, rubella (MMR) • Varicella (chickenpox) • Tetanus, diphtheria, pertussis (Tdap or variants as indicated) NOTE: Your school program and/or your eventual employer may require more vaccinations than those listed above. Certainly you will require additional vaccinations if you work/study abroad or with potential exposure to other diseases. (Check out http://wwwnc.cdc.gov/travel/ if you intend to travel.)

28. Hand hygiene: Just do it! With the ghost of Dr. Semmelweis hovering above you at this moment, the weight of years of CDC proclamations on your shoulders, & the watchful eye of OSHA over your shoulder, acknowledge that timely & proper hand washing is probably the single most effective way to prevent the spread of infection. Hand cleansing should be done prior to and after each patient interaction, prior to and after each procedure. (You would also faithfully cleanse your hands prior to preparing food & eating, after blowing your nose in a tissue, going to the bathroom, etc., wouldn’t you? Of course you would.) A note on professionalism: Most healthcare facilities have soap & sinks and/or hand sanitizer lotion in every room & at every station. This is obvious. So, too, should your practice of hand cleansing be obvious. Let the patient see you enter his/her domain vigorously cleansing your hands. There’s a story here…

29. Hand hygiene: A compelling story The second year medical student conducted a preliminary evaluation of her patient who was in for a routine annual physical. She (the medical student) was clearly well-versed in the examination process and took delight in carefully explaining each of the tests she performed. She chatted amicably throughout, thereby developing a fine patient rapport. At length the attending physician entered the room (rolling a dab of hand sanitizer around his fingers) introduced himself to the patient and took his turn at reviewing the records and confirming the results of the student’s evaluation. Now there is perhaps no way to conduct the final step of the examination to everyone’s complete satisfaction, but the physician introduced the digital rectal exam as kindly as any human could, explaining that this was still an important method of detecting prostate irregularities. (If you cannot now guess the gender of the patient, perhaps you should review anatomy.) As he and the medical student prepared for this last step, the medical student brightly chirped: “I guess I should have washed my hands prior to entering the room.” This is a regrettable show stopper. The patient, himself a healthcare provider and the author of this module, did not retrieve his eyebrows from the “oh my!” position for quite some time.

30. Hand hygiene: Three options The “Guideline for Hand Hygiene in Health-Care Settings” CDC document at http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf will answer virtually any question you might have on the topic. Hand hygiene includes the following practices: • Hand washing with plain soap & water • The choice for visibly dirty hands • Little to no antimicrobial activity • Hand washing with antimicrobial soap (soap with antiseptic agent) & water • See table of antiseptic agents on next slide • Using an antiseptic hand rub • Waterless, typically alcohol-based solutions • See table of antiseptic agents on next slide Not all of these are interchangeable, meaning that there are some situations in which one method is preferred over the other. An individual must also consider any history of allergic reaction to various products & the potential for contact dermatitis resulting from chronic use of a product.

31. Hand hygiene: Antiseptic agents Table excerpted from the CDC’s “Guidelines for Hand Hygiene in Health-Care Settings ,” p. 45 retrieved 12/1/09 at http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.

32. Hand hygiene: Still a complex issue Clostridium difficile, a bacterium transmitted by contact with feces (as in: diarrhea) is a major problem in healthcare institutions particularly affecting older adults & especially those who have been on a course of antibiotics. (Read more at the Mayo Clinic site devoted to the topic: http://www.mayoclinic.com/health/c-difficile/DS00736). Here’s a sobering note from the Guidelines for Hand Hygiene in Health-Care Settings regarding C. difficile (p. 17 at http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf ): “None of the agents (including alcohols, chorhexidine, hexachlorophene, iodophors, PCMX, and triclosan) used in antiseptic handwash or antiseptic hand-rub preparations are reliably sporicidal against Clostridium…” As a presumably healthy individual you may not get ill, but you may be a carrier. The CDC encourages you to: • Wear gloves (this presumes you suspect C. difficile!) • After removing the gloves, wash your hands with a non-antimicrobial or an antimicrobial soap & water or disinfect with an alcohol-based hand-rub.

33. Hand hygiene: Soap & water Wash Your Hands: The Right Way When washing hands with soap and water: • Wet your hands with clean running water and apply soap. Use warm water if it is available. • Rub hands together to make a lather and scrub all surfaces. • Continue rubbing hands for 15-20 seconds. Need a timer? Imagine singing "Happy Birthday" twice through to a friend. • Rinse hands well under running water. • Dry your hands using a paper towel or air dryer. If possible, use your paper towel to turn off the faucet. • Always use soap and water if your hands are visibly dirty. The above is directly from the CDC at http://www.cdc.gov/Features/HandWashing/ (retrieved 12/1/09). If you would like to see pictures of hand washing or review their video, please visit that site. Noteworthy in the script for the video is the statement that up to 80% of all infections are transmitted by hand.

34. Hand hygiene: Hand sanitizer gels Also from the CDC is this regarding the use of hand sanitizers: When using an alcohol-based hand sanitizer: • Apply product to the palm of one hand. • Rub hands together. • Rub the product over all surfaces of hands and fingers until hands are dry. Alcohol-based hand sanitizers are NOT effective when hands are visibly dirty or contaminated with blood or fecal matter as examples. (In these instances, washing with an antimicrobial soap & water might be indicated.)

35. Protective Barriers (PPE) Personal protective equipment (PPE) or personal protective attire (PPA) are selected and worn based upon the nature of the patient interaction* and the likely mode of pathogen transmission.** PPE include: • Gloves • Masks • Gowns & other apparel • Eye, face, mouth, & inhalation protection *Naturally the CDC has recommendations on when to use PPE. TheYale-New Haven Hospital (http://www.med.yale.edu/ynhh/infection/precautions/intro.html) offers more on the use of PPE along with instruction on how to don (put on) the equipment & remove the equipment. This is presented in the following slides. **A presentation of Transmission-Based Precautions follows the PPE information.

36. PPE: When to use CDC: 2007 Guidelines for Isolation Precautions, p. 134, retrieved 12/1/09 from http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf.

37. PPE: GlovesRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html. Gloves are worn to prevent the health care worker's hands from becoming contaminated with blood or body substances. Gloves should be worn for: • Procedures involving direct contact with the blood and body substances of any patient. • Procedures where contact with blood and body substances might be expected to occur. • Procedures involving direct or potential contact with the mucous membranes of any patient. • Procedures involving direct or potential contact with the non-intact skin of any patient. Non-intact skin is skin that is cut, chapped, abraded, cracked, afflicted with weeping or exudative lesions, or is otherwise broken. Touching or handling any instruments, equipment, or surfaces that have been, or may have been, in contact with blood or body substances. • In addition, gloves should be worn in providing care to a patient or in managing equipment when the health care worker has cuts, scratches, or other breaks in the skin on his/her hands.

38. PPE: GlovesRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html. Sterile gloves should be used for all sterile procedures and for activities that involve contact with areas of the body that are normally sterile. There should be an adequate supply of clean disposable gloves on the standard precautions stations or in other locations that are convenient to each patient's room. Gloves used in patient's care should be worn only for contact with the patient. Once used, gloves must be discarded before leaving the patient's room.

39. PPE: GlovesRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html. Procedure for donning sterile gloves: • Remove all jewelry, including rings. • Wash hands using an antimicrobial cleansing agent. • Dry hands thoroughly with a paper towel. Use the towel to turn off the faucet. • Remove the packet of gloves from the outer wrapper. Place this packet on a clean, dry, flat surface. • Unfold the packet as if opening a book. Position the packet so that the cuffed ends of the gloves are nearest to you. • Grasp the center flaps and open. Both gloves must have folded cuffs. Position the packaging so that it lies flat. • Use one hand to glove the other. Grasp the edge of the right glove cuff with the fingers of the left hand, and slip the right hand into this glove. Pull it on by holding onto the cuff, but do not touch the outside of the glove. • Adjust both gloves so they fit properly. Make sure there are no gaps between the fingertips and the ends of the gloves. • Inspect the gloves for nicks and tears before and during the procedure. Obtain a new pair of sterile gloves if there is a break in aseptic technique or if a nick or tear occurs.

40. PPE: GownsRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.

41. PPE: GownsRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.

42. PPE: Eye, face, mouth, & inhalation protectionRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.

43. PPE: Eye, face, mouth, & inhalation protectionRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.

44. PPE: Eye, face, mouth, & inhalation protectionRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.

45. PPE: Eye, face, mouth, & inhalation protectionRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.

46. Transmission-Based Precautions The three categories of Transmission-Based Precautions come into effect when Standard Precautions are insufficient to interrupt the route(s) of transmission. (This means that Standard Precautions AND the indicated Transmission-Based Precautions should be in effect.) The categories are: • Contact precautions • Apply when excessive wound drainage, fecal incontinence, or other discharges • Ideally entails single room or spatial arrangements to protect others in shared room • Caregiver wears gown & gloves • Droplet precautions • Apply with respiratory illnesses spread through relatively close approximation to others • Ideally entails single room or spatial arrangements & curtain to protect others in shared room • Caregiver wears mask • Airborne precautions • Apply when infectious agents may be suspended in the air over long distances • Preferred placement for patient in airborne infection isolation room • Caregiver wears mask or respirator as indicated by disease-specific recommendations

47. Transmission-Based PrecautionsOne example CDC: 2007 Guidelines for Isolation Precautions, p. 121, retrieved 12/1/09 from http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf.

48. Precautions for Specific Conditions The CDC’s 2007 Guidelines for Isolation Precautions contains a 23 page Appendix listing precautions for selected infections & conditions. A sample of this (retrieved 12/1/09 from page 94 of that document at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf) is displayed below.

49. Additional Precautions: SharpsRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.

50. Additional Precautions: SharpsRetrieved 12/1/09 from the Yale-New Haven Hospital Infection Control Manual at http://www.med.yale.edu/ynhh/infection/precautions/intro.html.