OSHA/INFECTION CONTROL 1 HOUR UPDATE 1.0 CE Hr.
Successful completion of this packet meets requirements for Healthcare Providers.

PROGRAM GOALS AND OBJECTIVES

• Identify when contaminated areas should bedecontaminated.
• Discuss the transmission of Hepatitis B Virus (HBV) and importance of Vaccination.
• Explain proper disposal and handling of sharps.
• Explain the proper procedure for reporting exposure incidents.
• Identify personal protective equipment and it’s proper disposal.
• Discuss prevention techniques for Needlesticks and Other Sharps Injuries

Who Is Covered?

Healthcare facilities provide an environment conducive to the spread of infectious diseases.  Healthcare professionals must understand and carry out their role in protecting patients and themselves from infectious agents with adherence to the established infection control practice as required and set fourth by The Occupational Safety and Health Administration (OSHA).  This in-service will verse you in OSHA’s Guidelines on contamination, Hepatitis B Vaccine, reporting exposures, personal protective equipment and handling contaminated sharps.

"Occupational exposure" means a reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or “other potentially infectious materials” (OPIM) that may result from the performance of the employee's duties. "Bloodborne pathogens" means pathogenic microorganisms present in human blood that can cause disease. "Other potentially infectious materials” include certain human body fluids, including saliva in dental procedures, and any body fluid visibly contaminated with blood. The Bloodborne pathogens standard describes how to determine who is covered and the ways to reduce workplace exposure to Bloodborne pathogens. The first step is a written exposure control plan.

Exposure Control Plan

As required under the standard, a written exposure control plan is required that provides documentation of the following key elements:

• Identification of job classifications and, in some cases, tasks where there is exposure to blood and other potentially infectious materials.
• A schedule of how and when the provisions of the standard will be implemented, including schedules and methods for communication of hazards to employees, hepatitis B vaccination and post-exposure evaluation and follow-up, record keeping and implementation of the methods of compliance, such as

—Engineering and work practice controls,
—Personal protective equipment,
—Housekeeping, and

• Procedures for evaluating the circumstances of an exposure incident.

The schedule of how and when the provisions of the standard will be implemented may be a calendar with brief notations describing the methods, or an annotated copy of the standard, or part of another document, such as the infection control plan.

The written exposure control plan must be accessible to employees and must be updated at least annually and when alterations in procedures create new occupational exposure. Planning begins with identifying employees who have occupational exposure.

Who Has Occupational Exposure?

The exposure determination must be based on the definition of occupational exposure without regard to the use of personal protective clothing and equipment. Reviewing job classifications within the practice setting, and then making a list divided into two groups makes the exposure determination. The first group includes job classifications in which all of the employees have occupational exposure, such as clinical dental hygienists. Where all employees have occupational exposure, it is not necessary to list specific work tasks. The second group includes those classifications in which some of the employees have occupational exposure. Where only some employees have exposure, specific tasks and procedures or groups of tasks and procedures causing exposure must be listed. An example would be a dental practice with two or more receptionists, where one of the receptionists might be assigned the task of filling in for the dental assistant. When employees with occupational exposure have been identified, the next step is to communicate the hazards to these employees.

Communicating Hazards to Employees

The initial training for dental employees must be provided within 90 days of the effective date of the Bloodborne pathogens standard, at no cost to the employee, and during working hours. Training is also required for new employees at the time of initial assignment to tasks with occupational exposure or when job tasks change, causing a change in occupational exposure. Annual retraining for all affected employees must be provided. If employees have received training on Bloodborne pathogens in the year preceding the standard, only training in those areas required by the standard and which was not included in the previous training needs to be provided. This training could be included in training on other aspects of office safety, such as infection control and chemical hazards.

Training sessions must be comprehensive in nature, yet appropriate for the educational level, literacy, and language of employees, and provide the opportunity for interactive questions and answers. The person conducting the training must be knowledgeable in the program components as they relate to dentistry. Specifically, the training program, as a minimum, must include the following:

• An accessible copy of the regulatory text of the standard and an explanation of its content.
• An explanation of the epidemiology and symptoms of Bloodborne diseases.
• An explanation of the modes of transmission of Bloodborne pathogens;
• An explanation of the employer's written exposure control plan and how to obtain a copy.
• How to recognize occupational exposure;
• The methods to control occupational transmission of Bloodborne pathogens;
• How to select, use, remove, handle, decontaminate, and dispose of personal protective clothing and equipment;
• Information on the hepatitis B vaccine and vaccination, the availability of vaccine, and that vaccination is available at no cost to the employee.
• Information on emergencies involving blood and other potentially infectious materials;
• an explanation of the reporting mechanisms for exposure incidents.
• Information on the post-exposure evaluation and follow-up available by a health care professional when an exposure incident occurs;
• an explanation of labels, signs, and other markings for contaminated materials, such as instruments and laundry; and
• A question and answer session on any aspects of the training.

In addition to communicating hazards to dental employees and providing training to identify and control hazards, other preventive measures must be taken to ensure employee protection.

Preventive measures such as hepatitis B vaccination, universal precautions, engineering controls, safe work practices, personal protective equipment, and housekeeping measures help reduce the risks of occupational exposure.

The Needlestick Safety and Prevention Act requires employers, who have exposure control plans in accordance with 1910.1030 © (1) (iv), “to review and update such plans to reflect changes in technology that eliminate or reduce exposure to Bloodborne pathogens.”  The exposure control plan must also “document consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.”   Employers required to have exposure control plans must also “solicit input from non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in the Exposure Control Plan.”  The Needlestick Safety and Prevention Act also require employers, who currently maintain a log of occupational injuries and illnesses under 29 CFR 1904, to “establish and maintain a sharps injury log for the recording of percutaneous injuries from contaminated sharps.”  The information in the sharps injury log must be recorded and maintained so that the confidentiality of the injured worker is protected.  The log must contain at least the following information: “(A) the type and brand of device involved in the incident; (B) the department or work area where the exposure incident occurred; and (C) an explanation of how the incident occurred.”

Preventive Measures Hepatitis B Vaccination

Treatment

*A person, such as a physician or nurse practitioner, whose legal scope of practice allows them to perform the hepatitis B vaccination and post-exposure and follow-up required in the standard.

Universal Precautions

The single most important measure to control transmission of HBV and HIV is to treat all human blood and other potentially infectious materials AS IF THEY WERE infectious for HBV and HIV. Application of this approach to infection control is referred to as "Universal Precautions." Blood and saliva from all dental patients are considered potentially infectious materials [2]. These fluids cause contamination defined in the standard as, "the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface."

Control Measures
Engineering and work practice controls are the primary methods used to control the transmission of HBV and HIV in the dental setting. Personal protective clothing and equipment are also necessary when occupational exposure to Bloodborne pathogens remains even after instituting these controls.

Engineering controls, as they apply to the dental operatory, isolate or remove the hazard from employees. Rubber dams, high-speed evacuators, and special containers for contaminated sharp instruments are examples of engineering controls. Engineering controls must be examined and maintained, or replaced, on a scheduled basis. These engineering controls are used in combination with work practice controls.

Work practice controls reduce the likelihood of exposure by altering the manner in which the task is performed. All procedures must be performed in such a manner as to minimize splashing, spraying, spattering, and generating droplets of blood or other potentially infectious materials. This can be as simple as readjusting the position of the dental chair. Work practice requirements include the following:

• Washing hands immediately, or as soon as feasible, after skin contact with blood or other potentially infectious materials occurs and after removing gloves or other personal protective equipment;
• Flushing mucous membranes immediately or as soon as feasible if they are splashed with blood or other potentially infectious materials;

• Prohibiting recapping, bending, or removing contaminated needles from syringes—unless required by the dental or medical procedure or no alternative is feasible—in which case must be done by mechanical means, such as the use of forceps, or using a one-handed technique. For example, recapping is permitted when administering multiple injections of local anesthesia.
• Eliminating the shearing and breaking of contaminated needles
• Discarding contaminated needles, disposable sharps (such as endodontic files or dental wires with exposed ends) in containers that are closable, puncture-resistant, leak proof, colored red or labeled with the biohazard symbol*shown in Figure 1. (These containers must be easily accessible, maintained upright, and not allowed to overfill);
• Placing contaminated, reusable sharp instruments in containers that are puncture-resistant, leak proof, colored red or labeled with the biohazard symbol until properly processed. (Reusable sharps must not be stored or processed in such a way that employees are required to reach by hand into the container to retrieve the instruments);
• Prohibiting eating, drinking, smoking, applying cosmetics, and handling contact lenses in areas where there is occupational exposure, such as in a dental operatory or reprocessing areas;
• Eliminating the storage of food and drink in refrigerators, cabinets or shelves, or on counter-tops where blood or other potentially infectious materials are present; and
• Storing, transporting, or shipping blood or other potentially infectious materials—such as extracted teeth, tissue, and impressions that have not been decontaminated—in containers that are closed, prevent leakage, colored red, or affixed with the biohazard label.
• In addition to instituting engineering and work practice controls, the standard requires that appropriate personal protective equipment also be used to reduce worker risk of exposure.

'Labeling requires a fluorescent orange or orange-red label with the biological hazard symbol, along with the word "BIOHAZARD" in a contrasting color, affixed to the bag or container.

Figure 1 Biohazard Symbol

Personal Protective Equipment

Personal protective equipment is specialized clothing or equipment worn by employees to protect themselves from exposure to blood or other potentially infectious materials. Personal protective equipment must not allow blood or other potentially infectious materials to pass through to clothing, skin, or mucous membranes.

The employer has the following responsibility for personal protective equipment, at the employer's expense:

• Providing, maintaining, and replacing;
• Ensuring accessibility in appropriate sizes;
• Providing hypoallergenic gloves, glove liners, powderless gloves or other similar alternatives if the employee has an allergy to the gloves usually provided;
• Ensuring employee use; and
• Laundering and discarding.

Gloves, clinic jackets, lab coats, and chin-length face shields, or the combination of masks with eye protection (such as glasses with solid side shields or goggles) must be worn whenever splashes, spray, spatter, or droplets of blood or other infectious materials may be generated. Cotton or cotton/polyester clinic jackets or lab coats are usually satisfactory barriers for routine dental procedures.

When surgical procedures are performed involving large quantities of blood, additional personal protective equipment is required. Remem­ber: The selection of appropriate personal protective equipment is based upon the quantity and type of exposure expected.

Requirements for personal protective equipment also include the following:

• Face protection can be accomplished using a chin-length face shield or a combination of mask with eye protection.
• Goggles or  eye glasses with solid side shields or face shields can provide adequate eye protection.
• Clinic jackets, lab coats, gowns, and other protective clothing and equipment must be removed immediately or as soon as feasible when penetrated by blood or other infectious materials, and prior to leaving the work area.
• Gloves must be worn when it is reasonably anticipated that an employee will have hand contact with blood or saliva during procedures; when performing vascular access procedures; or when handling instruments, materials, and surfaces that are contaminated.
• Disposable gloves must be replaced upon the completion of the dental procedure, or if torn or punctured during the procedure.
• Disposable gloves are not to be reused.
• Utility gloves used for cleanup may be decontaminated for reuse, but must be discarded if they are deteriorated or fail to function as a barrier.
• Contaminated personal protective equipment must be placed in an appropriately designated area or container for storing, washing, decontaminating, or discarding.

Housekeeping

Equipment. The employer must ensure a clean and sanitary workplace. Work surfaces, equipment, and other reusable items must be decontaminated with disinfectant upon completion of procedures when contamination occurs through splashes, spills, or other contact with blood and other potentially infectious materials.

If surfaces, equipment, and other items (such as light handles or trays) have been protected with coverings (such as plastic wrap or foil), these materials must be replaced when contaminated or at the end of the work shift. Reusable receptacles such as bins, pails, and cans that have a likelihood for becoming contaminated, must be inspected and decontaminated on a regular basis and when visibly contaminated. Broken glass that may be contaminated may be cleaned up with a brush or tongs; but never picked up with hands, even if gloves are worn.
Equipment that has had contact with blood or other potentially infectious materials and serviced either on-site or shipped out of the facility for maintenance or other service, must be decontaminated to the extent feasible or labeled as a biohazard indicating which parts were not able to be decontaminated.
Waste. A combination of local, state, and federal laws may regulate waste removed from the facility. To comply with the Bloodborne pathogens standard special precautions are necessary when disposing of contaminated sharps and other regulated waste. *
Contaminated disposable sharps must be placed in containers that are closable, puncture resistant, leak proof, and are colored red or labeled. Other regulated waste generated from dental procedures also must be contained in closable bags or containers that prevent leakage and are colored red or labeled. A secondary container is necessary for containers that are contaminated on the outside. The secondary container also must be closable, prevent leakage, and be color-coded or labeled (see Table 2).
Laundry. Contaminated laundry shall be handled as little as possible with minimum agitation. Laundering contaminated articles, including employee clinic jackets and lab coats used as personal protective equipment, is the responsibility of the employer. This can be accomplished through the use of a washer and dryer in a designated area on-site, or the contaminated articles can be sent to a commercial laundry that processes contaminated laundry.

'Liquid or semi-liquid blood or other potentially infectious materials; items contaminated with blood or other potentially infectious materials that would release these substances in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. Alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance with Universal Precautions.
The care and laundering of general work clothes, for example, uniforms used to provide a professional appearance and not used as personal protective equipment, are not the responsibility of the employer.

• Contaminated laundry must be placed in bags or containers that are red or that are marked with the biohazard symbol. If the office uses Universal Precautions in handling all soiled laundry, alternative labeling is permitted, provided that all employees are appropriately trained and recognize that the bags contain contaminated laundry.
• if the laundry is sent off site for cleaning, it must be in bags or containers that are clearly marked with the biohazard symbol, unless the laundry facility utilizes Universal Precautions in the handling of all soiled laundry.
• if contaminated laundry is wet, the bags or containers must prevent leakage and soak-through.
• Gloves and other appropriate personal protective equipment must always be worn when handling contaminated laundry.

As already indicated, the above preventive measures are intended to eliminate or minimize the risks of occupational exposure in dental facilities. In the event that an exposure incident occurs, however, there are certain required procedures to use.

What to do if an Exposure Incident Occurs

An exposure incident is a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties. An example of an exposure incident would include a puncture from a contaminated sharp instrument.
The employer is responsible for establishing the procedure for evaluating exposure incidents. When evaluating an exposure incident, thorough assessment and confidentiality are critical issues. Employees should immediately report exposure incidents to their employer to initiate a timely follow-up process by a health care professional. Such a report initiates the procedure for a prompt request for evaluation of the source individual's HBV and HIV status. The employee who has had an exposure incident must be directed to a health care professional. The employer must provide the health care professional with a copy of the Bloodborne pathogens standard.
A description of the employee's job duties as they relate to the           I incident; a report of the specific exposure incident (accident report), including routes of exposure; the results of the source individual's blood tests, if available; and relevant employee medical records, including their vaccination status. At that time, a baseline blood test to establish the employee's HIV and HBV status will be drawn, if the employee consents. The employee has the right to decline testing or to delay HIV testing for up to 90 days. During this time, the health care professional must preserve the employee's blood sample.
The "source individual" is any patient whose blood or body fluids is the source of an exposure incident to the employee. Testing the;
Source individual's blood cannot be done in most states without written consent. The results of the source individual's blood tests are confidential and should be directed only to the attending health care professional.
As soon as possible, test results of the source individual's blood must be made available to the exposed employee through consultation with the health care professional.
Following the post-exposure evaluation, the health care professional will provide a written opinion to the employer. This opinion is limited to a statement that the employee has been informed of the results of the evaluation and told of the need, if any, for further evaluation or treatment. All other findings are confidential. The employer must provide a copy of the written opinion to the employee within 15 days of the evaluation. Requirements for the medical record and training records are discussed in the next section on recordkeeping.

Recordkeeping

There are two types of employee-related records required by the Bloodborne pathogens standard: medical and training.
A medical record must be established for each employee withoccupational exposure. This record is confidential and separate from other personnel records. This record may be kept on-site or may be retained by the health care professional that provides services to the dental health care employees. The medical record contains the hepatitis B vaccination status, including the dates of the hepatitis B vaccination and the written opinion of the health care professional regarding the hepatitis B vaccination.
If an occupational exposure incident occurs, reports are added to the medical record to document the incident and the results of testing following the incident, as well as the written opinion of the health care
Professional. The medical record also must indicate what documents have been provided to the health care provider. Medical records must be maintained 30 years past the last date of employment of the employee.
The confidentiality of medical records must be emphasized. No medical record or part of a medical record is to be disclosed except to the employee or anyone having written consent of the employee; to representatives of the Secretary of Labor, upon request; or as required or permitted by state or federal law.
Training records document each training session and must be kept by the employer for 3 years. Training records must include the date of the training, a content outline, the trainer's name and qualifications, and names and job titles of all persons attending the training sessions.
If the employer ceases to do business, medical and training records are transferred to the successor employer. If there is no successor employer, the employer must notify the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, for specific directions regarding disposition of the records at least 3 months prior to their intended disposal.
Upon request, both medical and training records must be made available to the Assistant Secretary of Labor, Occupational Safety and Health. Training records must be available to employees or employee representatives upon request. The employee or anyone having the employee’s written consent can obtain medical records.

New Information regarding BBP Standard

OSHA estimates that almost 600,000 Needlesticks occur each year among our nation’s 5.6 million healthcare workers. In response to this President Clinton signed the “Needlestick Safety and Prevention Act (H.R. 5178) into law on November 6, 2000 to be published in the spring of 2001 in the Federal Register.  Below are the four easy steps to compliance:

1. Make a list of all sharps used in your workplace and locate alternate “safe sharps”
2. Have front line employees evaluate “safe sharps” for effectiveness-Document findings
3. Put the sharps evaluation into the OSHA Manual. Train workers to use new products.
4. Complete a sharps injury log whenever a needlestick occurs to track problematic devices.

References

"Occupational Exposure to Bloodborne Pathogens," Title 29 CFR 1910.1030, Federal Register 56 (235): 64004-64182, December 6, 1991.

CDC. Table 17. Health care workers with documented and possible occupationally acquired AIDS/HIV infection, by occupation, reported through June 2000, United States. Available at: www.cdc.gov/hiv/stats/ hasr1201/table17.htm. Accessed May 10, 2002.

CDC, unpublished data, 1998. [As cited in Centers for Disease Control and Prevention. Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Post exposure Prophylaxis. MMWR (May 15), 1998; 47(RR-7); 1-28.]

Centers for Disease Control. "Recommendations for the Prevention of HIV Transmission in Health Care Settings." MMWR, August 21, 1987, Vol. 36, No. 2S.

CDC. Viral hepatitis B — frequently asked questions. Available at: www.cdc.gov/ncidod/diseases/ hepatitis/b/fact.htm. Accessed Aug. 2, 2002

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