Infection Control

Infection control practices are designed to prevent transmission of microbial agents and to provide a wide margin of safety for health care workers. These practices were developed for hospital employees and other workers in health care facilities as a result of epidemiologic knowledge of blood-borne exposures and transmission rates.3d5 and 6 Emergency personnel should utilize these practices to minimize infection due to contact with contaminated body secretions, devices, objects, or surfaces. Infection control practices include hand washing; use of personal protective equipment (PPE); cleaning, disinfecting, and sterilizing patient care equipment and environmental surfaces; decontamination and laundering of soiled uniforms, clothing, and patients' linens; disposal of needles, sharps, and infectious waste; and patient placement. Infection control measures that are simple, part of the routine work environment, and uniform across all situations have the greatest likelihood of compliance.

Basic infection control principles serve as a starting point for the prevention of infectious disease transmission. These principles are implemented in concert with other practices to prevent or mitigate exposure to transmissible infectious diseases. A complete infection control program includes administrative controls, equipment engineering, work practice controls, education of the work force, and medical management.

Administrative controls are designed to organize, define, and direct infection control activities. The most important of these activities is the development of a written infection control (exposure) plan. This plan defines all policies, procedures, and activities related to the education, prevention, and management of infectious diseases in the work force. Jobs and specific work tasks are identified and evaluated for potential exposure to infectious diseases. Initial and recurrent training in infectious disease hazards and risk activities must be provided to all health care workers. Risk reduction training and activities must be documented and monitored for adequate compliance. Other administrative controls include written policies and procedures for all infection control activities. Infection control monitoring, compliance, evaluation, modification, and quality improvement are to be clearly defined in policy and procedure documents.

Equipment engineering serves to reduce employee exposure by removing the hazard or isolating the health care provider from exposure. Examples of such equipment include self-sheathing needles, needleless drug administration devices, sharps containers, pocket masks, disposable airway equipment, syringe splash guards, and PPE. PPE is "specialized clothing or equipment which does not permit blood or potentially infectious substances to pass through or reach worker clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use."2

PPE includes such items as examination gloves, face masks, eye protection, face shields, and impervious gowns and aprons. The American Society for Testing and Materials has published specifications for examination gloves and protective clothing materials (gowns and shoe, sleeve, and leg covers). 1 2 ¿i222 2 and 25 In addition, the National Fire Protection Association (NFPA) specifies the minimum documentation, design and performance criteria, and test methods for emergency medical clothing.2 27 Package labeling for PPE must describe components of the medical garment and indicate compliance with NFPA standards. Several sources make recommendations on the types of PPE to be worn during specific patient care activities.72829

The most common barrier devices for infection control and prevention of blood exposures in the ED include examination gloves, eye and face protection, and disposable resuscitation equipment. Disposable, single-use examination gloves are standard in all health care settings. They are utilized when patient care activities involve potential exposure to blood, blood-containing body fluids, or other potentially infectious materials or contact with mucous membranes, tissues, or nonintact skin. Adequate supplies of gloves should be available to allow glove changes if significant contamination or loss of integrity (tears or punctures) occurs. Health care providers should avoid handling personal or common-use items (e.g., telephone, door handles, drinking cups, and combs) while wearing gloves to prevent environmental contamination. Gloves should fit tightly and extend above the wrist to provide maximal barrier protection for the wrist and lower forearm. Choice of glove ultimately depends upon individual preference and task performance needs. The potential for hypersensitivity reactions to glove component materials (latex, powder, etc.) must be taken into account when furnishing PPE for health care workers.

Emergency medical personnel who operate in the out-of-hospital environment (emergency medical services, air medical services, and interfacility transport services) may be exposed to situations where broken glass or sharp metal is exposed. In such cases, gloves with additional protective characteristics are needed. Structural firefighters' gloves are optimal and can be used during rescue and extrication activities. Firefighters' gloves can be replaced by examination gloves when patient care activities commence.

Face masks, eye protection, face shields, and gowns should be present in all EDs and emergency response vehicles. These barrier devices are used when anticipated exposure includes the possibility of splashes, sprays, arterial bleeding, or exsanguinating hemorrhage or when airway management techniques are undertaken. Face masks and eye protection should be worn simultaneously or a face shield employed to protect the ocular, oral, and nasal mucous membranes. Impervious aprons or gowns are appropriate if massive exposures are anticipated. Appropriately sized and adequate numbers of barrier devices should be available if gross contamination or loss of barrier integrity occurs. Additional uniform or work clothing and shower facilities should be available if contamination of clothing or dermal surfaces occurs.

Disposable resuscitation equipment should be readily available for all patient encounters requiring rescue breathing. Most bag-valve-masks, oxygen reservoirs, and tubing are meant to be discarded after each use. Reusable equipment must be cleaned and disinfected after each use. Disinfecting procedures for all reusable equipment (laryngoscope blade and handle, pocket mask, gurney, and patient care area) should be documented in policy and performed after each use.

Pocket masks are designed to isolate the health care provider from contact with blood, saliva, respiratory secretions, and vomitus. These masks vary in type and can be cleaned and disinfected for reuse or discarded after a single use. All personnel who may be called upon to render resuscitative efforts should have ready access to pocket masks.

Work practice controls modify the performance of a task to minimize exposure to blood and blood-containing body fluids and infectious materials. Work practice controls necessitate delineated policies concerning proper disposal of needles and sharps containers (i.e., avoid shearing, bending, recapping, or breaking); proper disposal of contaminated linens, clothing, and infectious waste; appropriate disinfection techniques for reusable equipment; and restriction of employee activities (e.g., avoidance of eating, drinking, smoking, and application of cosmetics) while in work areas that entail a reasonable likelihood of exposure to blood and body fluids.

Education of the work force on topics of infectious disease transmission, epidemiology, disease symptoms, portals of exposure, control methods, administrative compliance mechanisms, appropriate use and cleaning of medical equipment, use of PPE (barrier precautions), and medical management of infectious disease is necessary. In addition, there must be an awareness of the types of PPE to utilize and methods of risk reduction. Health care providers must also be aware that utilization of these devices does not totally eliminate infection risk. —i31 Members of the work force are more likely to comply with infection control guidelines when they understand the purpose and reasoning that underlie recommendations for the use of PPE and specific risk reduction practices. Mandatory compliance with the utilization of PPE must be established in departmental or hospital policy and enforced in daily practice.

Medical directors and administrators of EDs should classify their work force (e.g., clerical personnel, coders, billers, supervisors, nurses, doctors, physicians' assistants, nurse practitioners, emergency medical technicians, paramedics, electrocardiogram technicians, radiography technicians, etc.), identify risky activities (e.g., hemorrhage control, intravenous access, phlebotomy, suctioning, intubation, etc.), and devise infection control plans. EDs should ensure initial and repeated infection control training programs; establish engineering and workplace controls; and administer postexposure medical evaluation, counseling, prophylaxis, and referral for health care workers with infectious disease exposures.

Medical management practices include preventive vaccinations, acute postexposure medical evaluation, infectious disease counseling, disease prophylaxis, and medical follow-up. Vaccines should be readily available to all health care personnel who may be exposed to infectious disease. OSHA mandates vaccines at initial employee training and within 10 days of employment for all personnel at risk of exposure.2 In addition, mechanisms for postexposure medical management should be well defined and readily available to health care providers 24 h/day. Once a blood exposure has occurred, policies and procedures for exposure management must be understood and followed by all employees. An exposure incident is a "specific eye, mouth, or other mucous membrane, nonintact skin, or parenteral contact with blood or other potentially infectious materials."2 An established reporting policy for exposed personnel should include medical assessment, prophylaxis, and follow-up appropriate to the type and source of the exposure.2 32 As with any medical evaluation, the confidentiality of the source patient and employee must be strictly maintained.33

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