Blood Borne Pathogens and Standard Precautions

Observance of these Standard Precautions is required in all skills lab and clinical activities.

Bloodborne Diseases

The impact of Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), and Hepatitic C (HCV) have contributed to significant changes in the delivery of nursing care.
 

HIV

HIV attacks the body's immune system, causing Acquired Immune Deficiency Syndrome (AIDS). HIV is transmitted via sexual contact, blood or blood products, and from mother to newborn infant. Signs of possible HIV infection:

  • May appear anytime from several months to several years after acquiring the virus.
  • Include reduced immunity to other diseases.
  • May be unexplained persistent heavy night sweats, extreme fatigue, severe weight loss, enlarged lymph glands, persistent diarrhea, skin rashes, blurred vision, harsh dry cough, thick gray coating on tongue or throat.

HIV has been found in blood, semen, vaginal secretions, saliva, tears, breast milk, cerebrospinal fluid, amniotic fluid, and urine. The increasing prevalence of HIV increases the risk that health care workers could be exposed to blood from patients infected with HIV. (Health care workers are defined as persons, including students, whose activities involve contact with patients or with blood or other body fluids from patients in a health care setting.)
 

HBV and HCV

HCV attacks the body's liver, causing inflammation with enlargement and congestion of the liver. Signs of infection will not appear until weeks to months after exposure. Common symptoms of Hepatitis include:

  • Flu-like symptoms of fatigue, anorexia, low-grade fever, abdominal discomfort.
  • Rashes.
  • Enlarged, tender liver.
  • Light-colored stools, dark urine, and jaundice.

The primary mode of HBV and HCV transmission is contamination with blood and blood products. HBV may also be spread via the mucous membranes by contact with infected body fluid such as saliva, semen, or blood; direct contamination of an open wound; or handling of infected equipment and material.

At least 85% of persons with HCV infection become chronically infected, and chronic liver disease with persistently elevated liver enzymes develops in an average of 67%†(CDC, 1997). At least 8700 health care workers contract hepatitis B from occupational exposure each year (OSHA Bloodborne Facts).


Resistant Organisms

The development of resistant pathogens has major implications for health care delivery. Methicillin Resistant Staphylococcus Aureus (MRSA) is a prevalent nosocomial pathogen. The main mode of transmission for MRSA is via hands which have become contaminated by contact with:

  1. colonized or infected patients
  2. colonized or infected body sites of health care worker
  3. devices, items, or environmental surfaces contaminated with body fluids containing MRSA.

The incidence of Vancomycin-resistant enterococcus (VRE) has been increasing in health care facilities. This increase poses several problems:

  1. the lack of available antimicrobials for therapy of infections caused by VRE, because most VRE are also resistant to multiple other drugs.
  2. the possibility of the transfer of vancomycin resistance genes to other gram-positive microorganisms.

An increased risk of VRE infection and colonization has been associated with previous vancomycin and/or multi-antimicrobial therapy, severe underlying disease or immunosuppression, and intraabdominal surgery. Transmission of VRE can occur via direct contact or indirectly via hands of personnel or contaminated equipment.

Standard Precautions were developed by the Center for Disease Control (CDC) to prevent the transmission of resistant organisms as well as blood borne pathogens. Universal Precautions were established by the CDC in 1987 to protect health care workers from blood borne pathogens. Standard Precautions include secretions not included in Universal Precautions and are to be used in the care of all patients.


Standard Precautions

Standard Precautions apply to 1) blood, 2) all body fluid secretions and excretions except sweat, 3) nonintact skin, and 4) mucous membranes. Standard Precautions are designed to reduce the risk of transmission or microorganisms from both recognized and unrecognized sources of infection

 

 

    • Use Standard Precautions for the care of all patients.
    • Handwashing
    •  (CDC Antiseptic Technology: Access, Affordability, and Acceptance)

    1. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, regardless of whether gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross contamination of different body sites.
    2. Use a plain (non antimicrobial) soap or an alcohol hand gel (or similar product) for routine handwashing.
    3. Use an antimicrobial agent or waterless antiseptic agent for specific circumstances (e.g., control of outbreaks or hyperendemic infections) as defined by the infection control program.

3. Gloves

Wear gloves (clean nonsterile gloves are adequate) when touching blood, body fluids, secretion, excretions, and contaminated items; put on clean gloves just before touching mucous membranes and non intact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

      

4. Mask, eye protection, face shield

Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.

5. Gown

Wear a gown (a clean nonsterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients or environments.

6. Patient-care equipment

Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed and single-use items are properly discarded.

7. Environmental control

Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces and that these procedures are being followed.

8. Linen

Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other patients and environments.

9. Occupational health and blood-borne pathogens

  1. Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Never recap used needles or otherwise manipulate them using both hands , or any other technique that involves directing the point of a needle toward any part of the body; rather, use either a one-handed scoop†technique or a mechanical device designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area.
  2. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.

10. Patient placement

Place a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in a private room. If a private room is not available, consult with ICPs regarding patient placement or other alternatives.
 


Transmission-Based Precautions

Transmission-Based Precautions are for patients who are documented or suspected or being infected with a highly transmissible or epidemiologically important pathogen. Transmission-Based Precautions are to be used when Standard Precautions alone may not interrupt the transmission of the pathogen.
 

1. Airborne Precautions

Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other patients and environments.

  1. Patient placement. Place the patient in a private room that has (1) monitored negative air pressure in relation to the surrounding areas, (2) six to 12 air changes per hour, and (3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital. Keep the room door closed and the patient in the room. When a private room is not available, place the patient in a room with a patient who has active infection with the same microorganism, unless otherwise recommended, but with no other infection. When a private room is not available and cohorting is not desirable, consultation with ICPs is advised before patient placement.
  2. Respiratory protection. Wear respiratory protection when entering the room of a patient with known or suspected infectious pulmonary tuberculosis. Susceptible persons should not enter the room of patients known or suspected to have measles (rubeola) or varicella (chickenpox) if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have measles (rubeola) or varicella, they should wear respiratory protection. Persons immune to measles (rubeola) or varicella need not wear respiratory protection.
  3. Patient transport. Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a surgical mask on the patient, if possible.
  4. Additional precautions for preventing transmission of tuberculosis.

2. Droplet Precautions

In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for a patient known or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 mm in size] that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures).

  1. Patient placement. Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism, but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, maintain spatial separation of at least 3 feet between the infected patient and other patients and visitors. Special air handling and ventilation are not necessary, and the door may remain open.
  2. Mask. In addition to Standard Precautions, wear a mask when working within 3 feet of the patient. (Logistically, some hospitals may want to implement the wearing of a mask to enter the room.)
  3. Patient transport. Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplets by masking the patient, if possible.

3. Contact Precautions

In addition to Standard Precautions, use Contact Precautions, or the equivalent, for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment.

  1. Patient placement. Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism, but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, consider the epidemiologic pattern of the microorganism and the patient population when determining patient placement; consultation with ICPs is advised before patient placement.
  2. Gloves and hand washing. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean non-sterile gloves are adequate) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). Remove gloves before leaving the patient's environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent.
    After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments.
  3. Gown. In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean nonsterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent, or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. Remove the gown before leaving the patient's environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments.
  4. Patient transport. Limit the movement and transport of the patient from the room to essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.
  5. Patient-care equipment. When possible, dedicate the use of noncritical patient-care equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable then adequately clean and disinfect them before use for another patient.
  6. Additional precautions for preventing the spread of vancomycin resistance.

From: Center for Disease Control (Nov. 2005). Guideline for isolation precautions in hospitals. Part II: Recommendations for isolation precautions in hospitals.


Exposure Incidents

An exposure incident is any specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials is considered an exposure incident.

Immediately report exposure incident. This allows for immediate follow up. Follow up procedures can include testing the blood of the source individual & injured student to determine HBV & HIV status if needed and permission is granted.

Obtain the form for reporting a clinical injury or bloodborne pathogen exposure from your clinical instructor.


OSHA Guidelines:

OSHA

Bloodborne Pathogens and Acute Care Facilities

Needlestick Safety and pRevention Act, P.L. 106-430

Needlestick PowerPoint Presentation

Health Topics A to Z (Great Site)