standard workplace precautions-waste management

guidelines for HIV protection for doctors

1. NACO HCP - ORIENTATION PROGRAMME FOR DOCTORS Venue : Government Thiruvarur Medical College and Hospital, Thiruvarur Date : 26-12-2013 & 27-12-2013 Resource Persons : Dr . Asika Beham , M.D ., H.O.D . - Microbiology, GTMCH , Thiruvarur Dr. T.S . Santhi , M.D ., H.O.D . – Medicine, GTMCH , Thiruvarur Dr. A. Annamalai Vadivoo, M.B.B.S ., F.H.M ., ART Medical Officer, Thiruvarur

2. Standard Workplace Precaution Waste Segregation & Disposal and Post Exposure Prophylaxis (PEP) Standard Workplace Precaution & PEP 1

3. Session Objectives By the end of the session participants will be able to: Learn the importance of Standard Workplace Precautions Enumerate the illnesses transmissible occupationally Discuss the Standard Operating Procedures involved in Bio-medical Waste Management Evaluate a health care worker sustaining an injury and prescribe the appropriate PEP Emphasise the needed follow up procedures after PEP Standard Workplace Precaution & PEP 2

4. Standard Workplace Precautions Universal Precautions were introduced in Health Care Settings as early as in 1985 In 1996, the terminology was modified into Standard Workplace Precautions Definition: A set of precautions to protect Health Care Workers (HCW) from occupational exposure to blood borne pathogens Standard Workplace Precaution & PEP 3

5. Story Time A nurse gets a needle stick while giving an injection to an HIV-positive patient. Her glove was punctured. She applies first aid to clean her injury. She panics and calls the doctor… What precautions if any, did the nurse follow while doing the procedure? What was the first step taken by the nurse after the injury? How can you relate to this incident from your work? Standard Workplace Precaution & PEP 4

6. Relative Risk of Seroconversion with Percutaneous Injury Standard Workplace Precaution & PEP Source: CDC. MMWR 2001;50(RR11): 1-42 5

7. Who are at risk? Nursing staff and students Laboratory staff Emergency care provider Interns & medical students Laboratory staff Labour & delivery room staff Physicians Dentists Cleaning staff & mortuary staff & waste handler Surgeon & OT staff Standard Workplace Precaution & PEP 6

8. Exposure to body fluid Considered “at risk” Exposure to body fluid Considered “not at risk” Blood Tear Semen Sweat Vaginal Secretion Urine/ Faeces CSF Saliva Synovial,Pleural, Pericardial, Peritoneal fluid Sputum Amniotic fluid Vomitus Any body fluid contaminated with “visible blood” Shall be considered “ atrisk ” Potentially Infectious Body Fluid Standard Workplace Precaution & PEP 7

9. Environmental Transmission What is the risk for environmental transmission of HIV? No environmental transmission reported HIV inactivated quickly outside the body HIV does not multiply outside the body Infectivity is lost quickly after fluid dries Standard Workplace Precaution & PEP 8

10. Infectious Wastes Specifically Are Blood and blood products in a free flowing, unabsorbed state, Body organs Contaminated sharps Isolation Wastes Laboratory wastes Unfixed pathological tissues Standard Workplace Precaution & PEP 9

11. Hand Hygiene Hands are the most common mode of pathogen transmission Hand washing is an extremely important step in overall infection control Hand washing significantly removes the bacterial flora and HIV from the skin surface Hand washing protects you and your patients from the pathogen transmission Standard Workplace Precaution & PEP 10

12. Standard Workplace Precaution & PEP When should you wash your hands? Before, during, and after preparing food Before eating food Before and after caring for someone who is sick Before and after treating a cut or wound After using the toilet After changing diapers or cleaning up a child who has used the toilet After blowing your nose, coughing, or sneezing After touching an animal, animal feed, or animal waste After touching garbage 11

13. What is the right way to wash your hands? Wet your hands with clean running water (warm or cold) and apply soap Rub your hands together to make a lather and scrub them well; be sure to scrub the backs of your hands, between your fingers and under your nails Continue rubbing your hands for at least 20 seconds. Need a timer? Hum the "Happy Birthday" or “Twinkle , Twinkle” song from beginning to end twice Rinse your hands well under running water. Dry your hands using a clean towel or air dry. Standard Workplace Precaution & PEP Image Courtesy GHTM/I-TECH, Tambaram, Chennai 12

14. Effective Hand Washing Areas commonly missed in hand washing 13

15. Effective Hand Washing 14

16. Hand Hygiene and Gloves Gloves are not the substitute for Hand Washing Always wash hands before/after removing gloves, after handling all materials known or suspected to be contaminated Good hand washing: 20 seconds with running water, soap & friction Gloves need to be removed between patients Dispose of single-use items correctly after use Standard Workplace Precaution & PEP 15

17. What is the alternate way? Washing hands with soap and water is the best way to reduce the number of germs on them If soap and water are not available, use an alcohol- based hand sanitiser, contains at least 60% alcohol Alcohol-based hand sanitisers can quickly reduce the number of germs on hands in some situations, but sanitizers do not eliminate all types of germs Apply the product to the palm of one hand Rub your hands together Rub the product over all surfaces of your hands and fingers until your hands are dry Hand sanitisers may not be as effective when hands are visibly dirty Standard Workplace Precaution & PEP 16

18. Personal Protective Equipments (PPE) Used in Healthcare Settings Gloves: Protect hands Gowns/aprons: Protect skin and/or clothing Masks and respirators: Protect mouth/nose Respirators: Protect respiratory tract from airborne infectious agents Goggles: Protect eyes Face shields: Protect face, mouth, nose and eyes Standard Workplace Precaution & PEP 17

19. Standard Workplace Precaution & PEP Factors Influencing PPE Selection Type of exposure anticipated Splash / spray versus touch Category of isolation precautions Durability and appropriateness for the task Fit to the user 18

20. One or two pair Single use or reusable Hand Protection: Gloves Minimise the risk of acquiring infections from patients Prevent microbial flora from being transmitted from health care providers to patients Glove material – vinyl, latex, nitrile Sterile or non-sterile Gloves are not the substitutes for Hand washing Standard Workplace Precaution & PEP 19

21. Gloves Should be available in a variety of sizes and types May causes hand fatigue, if gloves don’t fit correctly Glove integrity may be compromised Injury is more likely to occur due to an ill fitting glove Standard Workplace Precaution & PEP 20

22. Example of Gloves that are too TIGHT Pulls too tightly across the palm; Will cause fatigue at thumb joint Will cause fatigue as fingers try to flex Standard Workplace Precaution & PEP 21

23. Example of Gloves that are too LOOSE Gloves that are too large pose a danger as excess glove material can catch on something and tear Tactile sensitivity during procedures is greatly reduced as well Standard Workplace Precaution & PEP 22

24. Do’s and Don’ts of Glove Use Work from “ clean to dirty ” Limit opportunities for “ touch contamination ” - protect yourself, others and the environment Don’t touch your face or adjust PPE with contaminated gloves; Don’t touch environmental surfaces except as necessary during patient care Change gloves During use if torn and when heavily soiled (even during use on the same patient); After use on each patient Discard in appropriate receptacle Never wash or reuse disposable gloves Standard Workplace Precaution & PEP 23

25. Gowns or Aprons Purpose of use Material: Natural or man-made Reusable or disposable Resistance to fluid penetration Clean or sterile Standard Workplace Precaution & PEP 24

26. Standard Workplace Precaution & PEP Face Protection Masks – protect nose and mouth Place over nose, mouth and chin. Fit flexible nose piece over nose bridge. Secure on head with ties or elastic and adjust to fit Should fully cover nose and mouth and prevent fluid penetration Goggles – protect eyes Should fit snuggly over and around eyes Personal glasses not a substitute for goggles 25

27. Standard Workplace Precaution & PEP Sequence for Donning PPE Gown first Mask Goggles or face shield Gloves 26

28. Standard Workplace Precaution & PEP Sequence for Removing PPE Gloves Face shield or goggles Gown Mask 27

29. Biomedical Waste Disposal Standard Workplace Precaution & PEP 28

30. Definition Bio-medical waste means any waste which is generated during the diagnosis, treatment (or) immunization of human beings (or) animals or in research activities pertaining thereto or in the production (or) testing of biological. Standard Workplace Precaution & PEP 29

31. Standard Workplace Precaution & PEP Health care waste facts…. it means all waste generated from hospital 85% non-hazardous wastes 10% infectious wastes 5% non-infectious but hazardous Persons at risk: Medical doctors, nurses, health care, auxiliary and hospital maintenance personnel Workers in support service – lab, imaging services, laundries and transportation Workers in waste disposal facilities – hospital workers Patients in health care institutions Visitors to health care institutions 30

32. Standard Workplace Precaution & PEP Operationalisation of Waste Disposal Key Strategies Segregation of Waste Collection and Storage Transportation Treatment and Disposal 31

33. Standard Workplace Precaution & PEP Operationalisation of Waste Disposal Strategies in the institutions Generation of waste Source segregation in color coded bags Collection from all the hospital facilities Onsite treatment (where ever necessary) Storage in the designated storage room Weighing Transportation by private / govt. agency 32

34. Types of Bio-Medical Hazardous Waste Infectious All Body Fluids Anatomical parts and lab specimens Sharps Toxic Chemicals and pharmaceuticals Genotoxic waste Radioactive Genotoxic waste Standard Workplace Precaution & PEP 33

35. Waste Category No WasteCategoryType Treatmentand DisposalOptions 1 Human Anatomical Waste Incineration / deep burial 2 Animal Waste Incineration/deep burial 3 Microbiology and Biotechnological Waste Autoclaving / microwaving / incineration 4 Waste Sharps Incineration / destructionand Disposal in secured landfills 5 Discarded Medicines & Cytotoxic drugs Incineration / destruction and Disposal in secured landfills Categories of waste Standard Workplace Precaution & PEP Courtesy: Tamilnadu Health System Project 34

36. Waste Category No WasteCategoryType Treatmentand DisposalOptions 6 Soiled wastes Incineration / deepburial 7 Solid wastes Disinfection/auto/ Microwaving and mutilation/shredding 8 Liquid wastes Disinfection and discharge Into drains 9 Incineration ash Disposal municipal landfill 10 Chemical waste Disinfection and discharge Into drains Categories of waste Standard Workplace Precaution & PEP Courtesy: Tamilnadu Health System Project 35

37. Colour coding for bags/bins Waste category Type Container Type Treatmentat Hospital Final Disposal Blue 15L 25L 50L Waste sharps Broken glass, Ampoules, vials & sutures Plastic bag 1%sodium hypochlorite solution autoclaving/ microwaving and mutilation/ shredding Broken needles, needles,blades,scalpels, lancet,etc Puncture proof Container (twin Bin system) Red(big) 50L Solid waste Disposable wast eitems like tubing’s,catheters,intra Venous sets, plastic saline bottles, pouche setc ., Plastic bag 1%sodium hypochlorite solution autoclaving/ microwaving and mutilation/ shredding Red(small) 15L 25L Microbiology and Biotechnology waste 6.Soiled waste Blood and body fluid Contaminated items Plastic bag NIL Incineration/ Deep burial Colour Coding Standard Workplace Precaution & PEP 36

38. Colour codingfor bags/bins Wastecategory Type Container Type Treatmentat Hospital Final Disposal Yellow 15L 25L 50L Human waste Animal waste Plastic bag NIL Incineration/ Deep burial Black 15L 25L Expiry drugs, Cytotoxic drugs Incineration ash Chemical waste Plastic bag NIL Disposal in secured landfill Green 15L 25L 50L Municipal Waste Plastic bag NIL As undertaken By municipal agencies Colour Coding Standard Workplace Precaution & PEP 37

39. different categories of waste • Personnel should use protective gear while handling the waste Image Courtesy GHTM, Tambaram, Chennai Follow the colour codes, as advised by the respective state governments Segregation of Waste • Make available colour-coded bins and bags in patient care areas • Segregation should take place at source • Follow colour-codes for Standard Workplace Precaution & PEP 38

40. Safety Precautions for Waste Management Training and education of waste handlers and drivers Strict protocols on sharps handling and disposal Written protocols/colourful posters as reminders for the health care staff Limit access to only trained persons with personal protective gear Eliminate steps that require unnecessary handling hazardous wastes Standard Workplace Precaution & PEP 39

41. Commonly used disinfectants in the laboratory Technicians should know the procedures to prepare the following disinfectants: Ethyl alcohol (70%) Glutarldehyde (2%) Sodium hypochlorite solution (1%, 10%) Polyvidone Iodine (PVI) 10% Standard Workplace Precaution & PEP 40

42. 43 Recommended strength of the Sodium hypochlorite solution Spills [10%] Surface contamination 1% (smooth surface) 10% (porous surface) Liquid infectious waste (with large amount of organic matter) [10%] Sharp container for sharps [1%] 41

43. Management of spills Put absorbent material down on spillage area Flood with 10% sodium hypochlorite solution upon & around the spill and leave for 30 minutes Place the absorbent material in the biohazard bag meant for infectious waste Reapply the disinfectant solution to all exposed surfaces Thorough wash of the area with soap and water Standard Workplace Precaution & PEP 42

44. No to Recapping of Needles Standard Workplace Precaution & PEP 43

45. Sharps safety Standard Workplace Precaution & PEP 44

46. Splashes to the EYE • Demonstrate how to do it • Flush the eye for 5 minutes with clean water (for microorganisms) • Flush at least for 15 minutes (for chemicals) Standard Workplace Precaution & PEP 45

47. • • • • Standard Workplace Precaution & PEP Handling & Disposal of HIV positive dead body Avoid direct contact with blood and body fluids. Wear protective gear- gloves, apron. Disinfect with 1% sodium hypochlorite all needle puncture holes, wound drainage and dress with impermeable dressings. Plug all orifices with swabs soaked in 1% sodium hypochlorite solution. Wash and disinfect the body with 1% sodium hypochlorite solution. Do not embalm the body. Cover the body with robust plastic sheet (150 um thick) and cover it tightly with tapes or zipper. 46

48. • It should be disinfected with sodium hypochlorite before washing. Hands should be washed thoroughly after removing gloves and protective clothing. Standard Workplace Precaution & PEP Handling & Disposal of HIV positive dead body • Clean the outside plastic sheet with 0.1% sodium hypochlorite if soiled. Soiled linen should be bagged and sent to laundry. 47

49. Post-Exposure Prophylaxis Standard Workplace Precaution & PEP 48

50. Management of Exposure site Do not panic Skin Wash wound & surrounding with soap and water Rinse well Do not squeeze Do not use Antiseptic or Skin washes Standard Workplace Precaution & PEP 49

51. Management of Exposure site • Splash of Blood / Other Potentially Infected Material – Unbroken skin • Wash area immediately • Do not use antiseptic – Eye • Eye irrigation with water • If using contact lens leave them in place while irrigating Remove once eye is cleaned remove them & clean – Mouth • Spit fluid immediately • Rinse mouth thoroughly with water / saline repeatedly • Do not use soap or disinfectant Standard Workplace Precaution & PEP 50

52. Category Definition Mild Exposure • Mucous Membrane / non intact skin with small volume (e.g. Superficial wound with a low calibre needle • Contact with eyes or mucous membrane • Subcutaneous injections following small-bore needles) Moderate Exposure • Mucous Membrane / non intact skin with large volume • Percutaneous superficial exposure with a solid needle ( e.g.Cut or needle stick injury penetrating glove) Severe Exposure • Percutaneous with large volume • An accidental injury with high calibre needle (e.g.18G) with Visibly contaminated blood • A deep wound • Transmission of significant volume of blood • Anaccidental needle stick injury with previously used IV needle/ IV cannula Categories of Exposure Standard Workplace Precaution & PEP 51

53. Sourceof HIV DefinitionofRiskinSource HIV Negative Source is not HIV infected; but consider HBV & HCV Testing in all injury cases Low Risk HIV Positive and clinically Asymptomatic High Risk HIV Positive and clinically Symptomatic Unknown • Status of the patient unknown; • Neither patient nor his/her blood available for testing • The risk assessment will be based only up on the Exposure (HIV Prevalence in the geographical area Should be considered) HIV status of source of Exposure Standard Workplace Precaution & PEP 52

54. Mucous Membrane or Skin integrity compromised Volume No PEP required Intact Skin No PEP required Less severe- solid needle, Superficial scratch EC 2 Small volume- few drops / short duration EC1 Large volume- major splash / long duration EC 2 No What Type of exposure has occurred? More severe- hollow bore, deep injury EC 3 Percutaneous exposure Severity Yes HIV Exposure code Is the Source material is blood, bloody fluid or Other Potentially Infected Material (OPIM) or an instrument contaminated with one of these substances? Standard Workplace Precaution & PEP 53

55. HIV negative No PEP required Status/Source unknown HIV SC unknown HIV positive Low titer exposure Asymptomatic, high CD4 High titer exposure Advanced disease, low CD4 HIV SC1 HIV SC2 HIV Source code HIV status of exposure source Standard Workplace Precaution & PEP 54

56. EC HIVSC PEPrecommendation 1 1 May not be warranted 1 2 Consider basic regimen ( Twodrugs ) 2 1 Recommend basic regimen ( Twodrugs ) 2 2 Recommend expanded regimen ( Threedrugs ) 3 1or2 Recommend expanded regimen ( Threedrugs ) 2/3 Unknown Consider basic regimen if HIV prevalence is High in the given population Determining PEP recommendation Standard Workplace Precaution & PEP 55

57. Effectiveness of PEP depends on… • Efficacy of PEP is best, if administered within two hours of exposure • PEP needs to be given within 72 hours of exposure • Do not delay the first dose of PEP while waiting for result of HIV testing of source or injured HCP • Informed consent must be obtained before testing a source as per National guidelines • Negative result (in source) doesn’t exclude HIV infection • Base line rapid HIV testing of HCW before PEP • Positive HIV result in HCW helps in stopping the PEP and referral to ART centre for evaluation for ART Standard Workplace Precaution & PEP 56

58. Assessment of Exposed Person Confidential counselling and assessment by experienced physician Assess for pre-existing HIV infection Importance of HIV testing & post-test counselling Psychological support Documentation of injury and HIV testing in PEP Register Standard Workplace Precaution & PEP 57

59. Counselling for PEP • Duration of PEP (4 weeks) • Importance of drug adherence • What is known about the efficacy of PEP • Common side effects, likely to be experienced • Prevention practices at the time of PEP (Barrier protection / contraception) • Provider should correct misconceptions during all times of counselling sessions Standard Workplace Precaution & PEP 58

60. PEP Prescription • Decide PEP regimens – Basic regimen – Expanded regimen : 2 drug combination : 3 drug combination • Decision of starting PEP based on Exposure type and HIV status of source • If source person is on ART drugs expert should be consulted after starting 2 drugs Standard Workplace Precaution & PEP 59

61. Regimen Drugs Basic Regimen (Twodrugs) Zidovudine + Lamivudine (if Hb is >9 G%) Tenofovir + Lamivudine (if Hb is <9 G%) Expanded Regimen (Three drugs) Zidovudine / Tenofovir + Lamivudine + Ritonavir boosted Atazanavir If Protease Inhibitor is not available, EFV600mg May be considered as an option (third drug) in the Expanded PEP. Monitored for CNS side effects (nightmares,insomnia) PEP Prescription Standard Workplace Precaution & PEP 60

62. Percent of HCWs Tolerability of HIV PEP in Health Care Workers Incidence of Common Side Effects Zidovudine + Lamivudine Source: Wang SA. Infect Control Hosp Epidemiol 2000;231:780-5 61

63. For Expert reference / consultation • Delay in reporting exposure more than 72 hours • Unknown source – Local epidemiology & severity of exposure • Known or suspected pregnancy; Do not delay PEP • Breast feeding issues • Source person on ART or possibility of drug resistance • Major toxicity of PEP regimen • Non tolerance or Non adherence • Any doubt or complicated case like psychological problems Standard Workplace Precaution & PEP 62

64. Timing InpersonstakingStandardPEP Weeks2&4 Complete Blood Count (For AZT patients) Weeks6 HIV-Ab Weeks12 (Month3) HIV-Ab Weeks24 (Month6) HIV-Ab Laboratory follow-up Standard Workplace Precaution & PEP 63

65. Prevention • Primary prevention: – Avoid unprotected exposure to blood & Other Potentially Infected Material (OPIM) • Use Personal Protective Equipments (PPE) Consistently • Universal precautions must be followed for all patients at all times Standard Workplace Precaution & PEP 64

66. Consider all blood samples infectious Standard Workplace Precautions Prevention is the key step! universal precaution needle destroyer Always Always protective protective gear use use gear Consider all blood samples infectious Follow Universal Precaution Standard Workplace Precaution & PEP Handling of of Sharps Use Needle Destroyer Safe handling sharps 65

67. Story Time A nurse gets a needle stick while giving an injection to an HIV-positive patient. Her glove was punctured. She applies first aid to clean her injury. She panics and calls the doctor… – What precautions if any, did the nurse follow while doing the procedure? – What was the first step taken by the nurse after the injury? – How can you relate to this incident from your work? Standard Workplace Precaution & PEP 66

68. Key Points • Consider all patients / samples as potentially infectious • Implement Standard Workplace Precaution plan • Use barriers to prevent blood / body fluid contact • Prevent percutaneous injuries • Document and Report injury or exposure • Implement PEP Plan and sensitise all the Health Care Workers (HCW) • Promote hepatitis B vaccination • Hands that Heal should never harm…! Standard Workplace Precaution & PEP 67