HOSPITAL BASED INFECTION, UNIVERSAL PRECAUTIONS AND HOSPITAL WASTE MANAGEMENT RULES

Wing Commander (Dr) Suresh Tahiliani skstahil@yahoo.co.in AIMA-Accredited Management Teacher

Learning Objectives
Describe strategies for preventing HIV transmission in the healthcare setting Describe universal precautions Identify key steps and principles involved in the decontamination of equipment and materials Hospital waste management rules

Basic Concepts of HIV Transmission

Primary source of HIV infection in the healthcare setting
Blood or body fluids in direct contact with an open wound, or By needle or sharp stick

High-risk MCH settings

Obstetric procedures Labour and delivery Immediate care of the infant

Average Risk of HIV Infection to HCWs by Exposure Route

Percutaneous
Mucous membrane Non-intact skin

0.3%
0.1% <0.1%

Blood-borne Pathogens
In addition to HIV, blood-borne pathogens include
Hepatitis B and C Syphilis Malaria Bacterial infections like Brucellosis

What is health care worker safety?

Protection from transmission of Blood borne pathogens (eg HIV, HBV) Respiratory zoonoses

Tuberculosis, SARS, seasonal and pandemic influenza and other infections

to staff in health workplaces

Who is at risk?
All Health Care Personnel,
Including emergency care providers, Laboratory personnel, Autopsy personnel, Hospital employees, Interns and medical students, Nursing staff and students, Physicians, surgeons, dentists, labour and Delivery room personnel, laboratory technicians, Health facility sanitary staff and clinical waste handlers and Health care professionals at all levels.

What is infectious and what is not?

Exposure to blood, semen, vaginal secretions, cerebrospinal fluid, synovial, pleural, peritoneal, pericardial fluid, amniotic fluid and other body fluids contaminated with visible blood can lead to infection. Exposure to tears, sweat, saliva, urine and faeces is non-infectious unless these secretions contain visible blood.

Principles of HCW safety

Reduce HCW susceptibility to infection Reduce potential for occupational exposures Manage occupational exposures

Maintain health of infected HCW

Elements of HCW safety

Health promotion Safe use and administration of injections Safe use and disposal of medical sharps

Infection prevention and control

Management of exposures

What is infection control?

Infection Control encompasses the processes and activities that identify and reduce the risks of acquiring and transmitting endemic or epidemic infections among individuals

How is HCW safety different from infection control?

Primary goal of infection control - to prevent infection spreading in health care environments Infection control includes prevention of infection to HCW, but the emphasis is on protecting patients HCW safety is a special topic within infection control

Infection Control Measures

Universal Precautions Management of the work environment Ongoing education of employees in all aspects of infection prevention

Universal Precautions Definition Safe or good clinical practices applied universally in caring for all patients, regardless of the diagnosis in order to minimise or avoid exposure to infection

Universal Precautions
Applied universally in caring for all patients

Hand washing
Decontamination of equipment and devices Use and disposal of needles and sharps safely (no recapping) Wearing protective items Prompt cleaning up of blood and body fluid spills Systems for safe collection of waste and disposal

Promotion of a Safe and Supportive Work Environment

Management of the work environment to promote safety includes
Implementation, monitoring and evaluation of use of UPs Procedures for reporting and treating occupational exposure to HIV infection

Attaining and maintaining appropriate staffing levels Providing protective equipment and materials

Providing appropriate disinfectants

Education in Infection Prevention

Education of HCWs includes

Making all staff aware of established infection control policies

Ongoing training to build skills in safe handling of equipment and materials

Monitoring and evaluation of practices to remedy deficiencies

Handling of Equipment and Materials

Risk reduction strategies Hand washing Assessment of condition of protective equipment Safe disposal of waste materials Ensuring that appropriate cleaning and disinfecting agents are available Decontamination of instruments and equipment Monitoring of integrity of skin

Handling and Disposal of Sharps

Use syringe or needle once only Avoid recapping, bending, or breaking needles Use puncture-proof container for disposal Clearly label container SHARPS Never overfill or reuse sharps containers Dispose of sharps so people cannot access them

Barrier Nursing
Gloves should be used for
Touching blood or other body fluids Touching mucous membrane Touching non-intact skin of all patients. For handling items or surfaces soiled with blood or body fluids Performing venepuncture

Hand Hygiene
Recommended Practice
Soap and water hand washing using friction under running water for at least 15 seconds Using alcohol-based hand rubs (or antimicrobial soap) and water for routine decontamination

What is the correct way to WASH HANDS?

Wet your hands with warm water Apply soap Rub hands together and scrub really well (under nails and between fingers) Scrub for 15 -30 seconds (sing alphabet) Rinse hands of soap Dry hands with clean towel or cloth Turn off faucet with paper towel

Personal Protective Equipment

Basic personal protective equipment Glovescorrect size Apronsas a waterproof barrier Eyewearto avoid accidental splash Footwearrubber boots or clean leather shoes

Safe Decontamination of Equipment

Cleaning Removes high proportion of micro organisms and contaminants Disinfection Eliminates most recognized pathogenic micro organisms, inactivates HIV

Sterilization Destroys all micro organisms, inactivates HIV

Safe Work Practices

To reduce occupational risks

Assess high-risk situations and areas

Develop safety standards and protocols Institute measures to reduce occupational stress Orient new staff to safety protocols Provide ongoing staff education and supervision Develop protocols for post-exposure prophylaxis (PEP) and general first aid

Risk Reduction in the Obstetric Setting

Minimize high risk of exposure to HIV-infected blood and body fluids in labour room Cover broken skin with watertight dressing Practice universal precautions Wear proper protective clothing Double-glove during procedures Long-cuffed gloves during manual removal of placenta Dispose of solid waste according to recommended protocols

Managing Occupational Exposure to HIV Infection

Post-Exposure Prophylaxis (PEP):

PEP Following occupational HIV exposure, short-course of ARV drugs can be used to reduce the likelihood of infection Register occupational exposures
Ensure that HIV counseling, testing, and ARV drugs are available Educate healthcare workers

First aid in management of exposure

For skin if the skin is broken after a needle-stick or sharp instrument
Immediately wash the wound and surrounding skin with water and soap, and rinse. Do not scrub. Do not use antiseptics or skin washes (bleach, chlorine, alcohol, betadine).

After a splash of blood or body fluids on unbroken skin:

Wash the area immediately Do not use antiseptics

For the eye Irrigate exposed eye immediately with water or normal saline. Sit in a chair, tilt head back and ask a colleague to gently pour water or normal saline over the eye. If wearing contact lens, leave them in place while irrigating, as they form a barrier over the eye and will help protect it. Once the eye is cleaned, remove the contact lens and clean them in the normal manner. This will make them safe to wear again Do not use soap or disinfectant on the eye.

 For mouth:
Spit fluid out immediately Rinse the mouth thoroughly, using water or saline and spit again. Repeat this process several times Do not use soap or disinfectant in the mouth Consult the designated physician of the institution for management of the exposure immediately.

Donts
Do not panic Do not put pricked finger in mouth Do not squeeze wound to bleed it Do not use bleach, chlorine, alcohol, betadine, iodine or any antiseptic or detergent

Guidelines for PEP

Ideally, initiate PEP treatment within 2 hours of exposure If source patient is HIV negative, discontinue PEP and retest at 6 weeks, 3 months, and 6 months If source patient is HIV positive, counsel, support, and refer the HCW for continued treatment

Guidelines for PEP (continued)

Follow approved PEP regimen Examples
ZDV 200 mg 3 times daily for 4 weeks Combivir tablet (300 mg ZDV and 150 mg lamivudine) twice daily +

Indinavir 800 mg 3 times daily for 4 weeks

Key Points
Universal precautions apply to all patients, regardless of diagnosis Key components of UPs include
Hand washing Safe handling and disposal of sharps Use of personal protective equipment Decontamination of equipment Safe disposal of infectious waste materials Safe environmental practices

Key Points (continued )

Needle-stick injuries from HIV-infected patients are the most common source of HIV transmission in the workplace During labour and delivery, safe care reduces the risk of occupational exposure Short-term ARV treatment reduces risk of HIV infection after occupational exposure

Key Points (continued)

Clean, disinfect, and sterilise all instruments used in invasive procedures Burnout syndrome is related to intense, prolonged job stress

 I am a lab tech. I worked 11-7 shift for the past 9 and half years. My job includes drawing blood, testing blood and urine samples in a hospital laboratory, and preparing blood transfusions for patients who need blood products. On 31/12/93 at 3.55am I was called to the emergency room to draw blood on an hiv+ drug abuser, it seems she was out of cash but wanted more 'pain meds". The doctors wanted blood tests first to find out what was she sick with.

I ended up trying to draw her blood and she became violent, jerking her arm around after I had a needle in her vein and was getting blood out of her arm. She managed to get the dirty needle stabbed into my left thumb. When I saw that needle in my hand I felt a chill go down my spine and dreaded I would become positive too. Well by march of 1994 I was hiv+. Since then I have tried many of the hiv meds on the market. Many have given me allergic reactions, some have simply been ineffective, others the virus has grown resistant to.

It's a month to month battle. So far my t counts are holding and my viral load is between non detected and 10,000. I am married and had a son aged 18 months at the time I was infected. He's now 9.5 years old and the pride of my life. How can I ever tell him mom may not be around much longer? On October 28, 2000 we were blessed with the birth of a daughter. Beautiful is her description by anyone who has seen her. Tonight I received the results of her 1 year hiv test. It is positive."

BIOMEDICAL WASTE (MANAGEMENT & HANDLING) RULES 1998

AMENDED IN 2000

 The powers confirmed by section 6,8 & 25 of the Environment (Protection) Act 1986, the Central Govt. has made The Biomedical Waste (management & Handling) Rules to safeguard the Public & health care workers from the risk arising due to Biomedical Waste. The penalties are same as specified in Environment (Protection) Act 1986

Application of Rules
These rules apply to all persons who
Generate, Collect, Receive, Store , Transport, Treat, Dispose, or Handle biomedical waste in any form.

Defination
Bio-medical waste- Any waste, which is generated during the diagnosis, treatment or immunisation of human beings or animals or in research activities pertaining to in the production of testing of biologicals, and including categories mentioned in schedule 1.

 Biologicals- Any preparation made from organisms or micro organisms or product of metabolism and biochemical reaction intended for use in the diagnosis, immunization or the treatment of disposal of human beings or animals or in research activities pertaining to. Occupier- in relation to any institution generating bio-medical waste, which includes a hospital, nursing home, clinic, dispensary, veterinary institutions, animal house, pathological laboratory, blood bank by whatever name called, means a person who has control over that institution and/or its premise.

Duty of Occupier
It shall be the duty of every occupier of an institution generating biomedical waste, to take all steps to ensure that such waste is handled without any adverse effect to human health and the environment.

Categories of Bio-Medical Waste, Treatment & Disposal

Category 1 Biomedical Waste Human Anatomical Waste Animal Waste Microbiology & Biotechnology Waste Waste Sharps Treatment & Disposal Incineration/Deep burial

2 3

Incineration/Deep burial Autoclaving/ Microwaving

Chemical/ disinfection autoclave/microwave/ shredding

Discarded Medicines & Cytotoxic Drugs Soiled Waste (Items contaminated with blood & body fluids) Solid Waste (waste generated from disposable items)

Incineration/destruct & drugs disposed in secured landfills Incineration & autoclaving/microwaving Disinfection with chemical treatment/autoclaving/ microwaving

Liquid waste (waste from lab, washing, cleaning, housekeeping

Incineration Ash Chemical waste

Disinfection by treatment /discharge into drains

9 10

Disposal in municipal landfill Chemical treatment /discharge in drain

Colour Coding & Type of Disposal

Colour coding Yellow Red Type of container category Plastic bag 1,2,3,6 Disinfected container /plastic bag 3,6,7 Plastic bag/puncture proof 4,7 Treatment option Incineration/deep burial Autoclaving/ Microwaving/ Chemical treatment Autoclaving/ Microwaving/Chemical treatment & destruction/ shredding Disposal in secured landfill

Blue/White translucent

Black

Plastic bag 5,9,10

Segregation, Packing, Transportation & Storage

Bio-medical waste shall not be mixed with other waste. BMW shall be segregated into containers/bags at the point of generation If containers is transported to other facility for disposal it should be labeled. Untreated BMW shall be transported only in such vehicle as may be authorised. Untreated BMW shall not be kept stored beyond a period of 48 hrs.

Penalty
(1) Whoever fails to comply with, shall in respect of each such failure, be punishable with imprisonment for a term which may extend to five years with fine which may extend to one lakh rupees, or with both, and in case the failure continues, with additional fine which may extend to five thousand rupees for every day during which such failure continues after the conviction for the first such failure . (2) If the failure referred to in sub-section (1) continues beyond a period of one year after the date of conviction, the offender shall be punishable with imprisonment for a term which may extend to seven years.