Infection Control Guidelines

Disclaimers

The guidelines set forth below are intended simply as informal guidelines. Osteopathic physicians and surgeons must comply with all applicable standards for professional practice. These informal guidelines are not to be considered a substitute for the formal recommendations, guidelines and standards contained in the 11 publications referenced below.

Guidelines: Universal Precautions

Universal precautions are an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for Human Immunodeficiency Virus, Hepatitis B Virus, and other blood-borne pathogens. Universal precautions must be used in the care of all patients.

The Osteopathic Medical Board of California and Cal-OSHA have the authority to adopt and enforce regulations with respect to minimizing the transmission of blood-borne pathogens in health-care settings.

I. Protective Attire

II. Barrier Precautions

Protective barriers reduce the risk of exposure of the health-care worker's skin or mucous membranes to potentially infective materials. Universal precautions are those intended to prevent parenteral exposure of health worker's mucous membranes and non-intact skin to blood-borne pathogens.⁶

Examples of protective barriers include gloves, gowns, masks, and protective eyewear, as indicated above.

Universal precautions apply to blood and other body fluids containing visible blood. These precautions also apply to semen and vaginal secretions. Other substances that are applicable are cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid. The risk of transmission of HIV and HBV from these fluids is unknown.⁵

Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine and vomitus unless they contain visible blood. The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent.^{2 ,5, 7}

The type of protective barrier should be appropriate for the procedure being performed and the type of exposure anticipated.

III. Hand Washing and Care of Hands

Hands must be washed before and after treating each patient and after bare-handed touching of inanimate objects likely to be contaminated with body fluids.

At a minimum, soap and water should be used between patients. Alcohol-based hand rubs may be used for decontamination if the hands are not visibly soiled. Antimicrobial surgical handscrub must be used for surgical procedures.⁷

Hands should be washed:

1. Before and after treating each patient
2. Before glove placement and after glove removal
3. After barehanded touching of inanimate object likely to be contaminated with blood or body fluid

Health- care workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment until condition resolves.³

IV. Use and Care of Sharp Instruments and Needles

Compliance with the Needlestick Safety and Prevention Act is required by all health care personnel as set forth by OSHA. Employers must maintain a log of occupational injuries and illness under existing recordkeeping rules. At minimum, the log must contain the following:¹¹

• The brand and type of device involved in the incident
• The location of the incident
• The description of the incident

An Exposure Control Plan needs to be implemented to include the following:

• Annual consideration and implementation of appropriate engineering controls
• Solicitation of non-managerial healthcare workers in evaluating and choosing devices

Plan must be reviewed and updated annually.

Used needles should never be recapped or manipulated using both hands or by any other technique that involves directing the point of the needle towards any part of the body.

After they are used, disposable syringes and needles, scalpel blades, and other sharp items should be placed in puncture-resistant containers for disposal. These containers should be located as close as is practical to the use area.²

For procedures involving multiple injections with a single needle, the unsheathed needle should be placed in a location where it will not become contaminated or contribute to unintentional needle sticks between injections.

V. Sterilization and Disinfection of Instruments

Before sterilization or high-level disinfection, instruments should be cleaned thoroughly by scrubbing with soap and water or detergent solution or with a mechanical devise ultrasonic cleaner. The use of covered ultrasonic cleaners is recommended to increase efficiency of cleaning and to reduce the handling of sharp instruments. Utility gloves should be worn when handling contaminated instruments.

Single-use disposable instruments must be used for only one patient and discarded appropriately. Single disposable instruments are neither designed nor intended to be cleaned, disinfected or sterilized for reuse.

VI. Housekeeping and Laundry

Environmental surfaces that have become contaminated with patient material shall be cleaned and disinfected after treatment of each patient and the completion of daily work activities.

Countertops and other surfaces should be cleaned with disposable toweling and appropriate cleaning agent. After cleaning, surfaces should be disinfected with a suitable chemical germicide that is approved for use as a hospital disinfectant.

Environmental surfaces such as walls and floors should be cleaned daily or when visibly soiled.

Soiled linen should be handled as little as possible and with minimum agitation to prevent leakage.³

Visible material should be removed and the area decontaminated with a suitable chemical germicide that is approved as a hospital disinfectant and is tuberculoid when used at the recommended dilution. Gloves should be worn during the clean-up procedures.²

VII. Infected Waste Universal Precautions

Policies for collecting, storing, decontaminating and disposing of infected waste are generally determined by institutions in accordance with state and local regulations. Infected waste should be disposed of according to the regulations.²

VIII. Immunization and Infection Control

Mandatory immunizations should be made available to all health-care personnel. OSHA bloodborne pathogen standards mandate that vaccines for Hepatitis B be made available to all health-care personnel at the employer's expense. OSHA standards and guidelines for post-exposure evaluation and follow-up should be followed.⁶

Current infection control guidelines include:

1. Personnel health and safety education
2. Maintain records on job-related illnesses and exposures
3. Immunization of health-care personnel
4. Prophylaxis and follow-up after exposure
5. Personnel restriction due to infectious illness and special conditions

All health-care workers must adhere to the 1998 CDC infection control guidelines and to the 1991 OSHA standards, including HBV vaccination and the use of universal precautions in all health-care settings.6 Adherence to proper infection control procedures, including vaccinations as indicated, is a minimum standard of care.⁴

References

1. Centers for Disease Control and Prevention. "Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures". MMWR 1991;40(No. RR-8).
2. Centers for Disease Control and Prevention. "Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus and Other Blood-borne Pathogens in Health-Care Settings". MMWR 1988;37(No. 24):377-382, 387-388.
3. Centers for Disease Control and Prevention. "Recommendations for Prevention of HIV Transmission in Health-Care Settings". MMWR 1987;36(2S).
4. "Guidelines for preventing the Transmission of Bloodborne Pathogens in Health Care Settings". California Department of Health Services, May 1993.
5. Centers for Disease Control and Prevention. "Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis". MMWR 2001;50(No. RR-11):1-54.
6. Centers for Disease Control and Prevention. "Guideline for Infection Control in Health Personnel". CDC Personnel Health Guideline, 1998: 289-354.
7. Centers for Disease Control and Prevention. "Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force". MMWR 2002;51(No. RR-16):1-44.
8. Centers for Disease Control and Prevention. "Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health Care Settings". MMWR 1998;37(24):377-388.
9. Centers for Disease Control and Prevention. "Exposure to Blood: What Health-Care Workers Need to Know". Department of Health and Human Services.
10. Part I - "Communicable Disease Control Measures." Los Angeles County Department of Health Services, November 2000.
11. "Revision to OSHA's Bloodborne Pathogens Standard: Technical Background and Summary". OSHA, April 2001.

Federal Law and The Patient Protection Act of 1991 requires all states to develop guidelines equivalent to the Center for Disease Control and Guidelines for preventing the transmission of the Human Immunodeficiency Virus, (HIV) and Hepatitis B Virus, (HBV).

Licensees must follow the above recommendations and precautions in order to minimize the transmission of blood-borne pathogens in health-care settings.

July 2003