Emergency Care Textbook Professional Responders-part-3.pdf

3 Infection Prevention and Control Key Content How Infections Occur............. Disease-Causing Pathogens......................... How Diseases Are Transmitted....................... Epidemics and Pandemics.... Diseases That Cause Concern............................. Immunization......................

3 Infection Prevention and Control Key Content How Infections Occur............. Disease-Causing Pathogens......................... How Diseases Are Transmitted....................... Epidemics and Pandemics.... Diseases That Cause Concern............................. Immunization....................... Preventing Disease Transmission......................... Personal Hygiene................. Personal Protective Equipment (PPE)............... Engineering and Work Practice Controls............... Cleaning and Disinfecting Equipment......................... Spill Management................ Exposure Control Plans........ If an Exposure Occurs............. 38 38 39 41 41 45 45 46 47 48 49 49 49 50 Professional responders typically interact with ill patients on a regular basis and may also be exposed to blood and other potentially infectious fluids while treating injuries. It is important to understand how infections occur, how they are passed from one person to another, and what you can do to protect yourself and others from pathogens. Diseases that can be contracted from other people, objects, animals, or insects are referred to as infectious diseases. In this chapter, you will learn how to recognize situations with the potential for infection and how to protect yourself and others. INFECTION PREVENTION AND CONTROL Introduction 37 HOW INFECTIONS OCCUR Disease-Causing Pathogens The disease process begins when a pathogen enters the body. When this happens, it can sometimes overpower the body’s defense systems and cause an infection. Most infectious diseases are caused by one of six types of pathogens. The most common pathogens are bacteria and viruses. BACTERIA These are single-celled micro-organisms that may cause infection. Bacteria are everywhere. They do not depend on other organisms for life and can live outside the human body. Most bacteria do not infect humans; however, those that do can cause serious illness. Examples of bacterial-caused conditions include the following: Tetanus Meningitis Scarlet fever Strep throat Tuberculosis Gonorrhea Methicillin-resistant Staphylococcus aureus (MRSA) Vancomycin-resistant Enterococci (VRE) Syphilis Chlamydia Legionnaires’ disease Diphtheria Food poisoning INFECTION PREVENTION AND CONTROL The body has difficulty fighting infections caused by bacteria. Physicians may prescribe antibiotic medications that either kill the bacteria or weaken them enough for the body to eliminate them. 38 VIRUSES Unlike bacteria, viruses depend on other organisms to live and reproduce. Viruses cause many diseases, including the following: The common cold Hepatitis Measles Mumps Chickenpox Meningitis Rubella Influenza Warts Shingles Human immunodeficiency virus (HIV) Acquired immune deficiency syndrome (AIDS) Once viruses become established within the body, they are difficult to eliminate because very few medications are effective for defeating them. Antibiotics do not kill or weaken viruses. The body’s immune system is the main defence against them. FUNGI A fungus is a single-celled or multicellular organism. Some can cause conditions that are detrimental to human health. Athlete’s foot and ringworm are conditions caused by fungi. PROTOZOA Protozoa are single-celled organisms that can only divide within a host organism. Malaria and dysentery are examples of conditions caused by protozoa. RICKETTSIA Rickettsia are a group of micro-organisms that are similar to viruses in that they require other living cells for growth, but are also similar to bacteria in that they use oxygen, have metabolic enzymes and cell walls, and are susceptible to antibiotics. Some conditions that are caused by rickettsia include typhus and Rocky Mountain spotted fever. PARASITIC WORMS Some worms can be classified as parasites, which are disease-causing organisms that live on or inside a human or other animal and derive their nourishment from their hosts. Parasitic worms can cause the following complications: Abdominal pain Anemia Lymphatic vessel blockage Lowered antibody response Respiratory and circulatory complications Susceptibility Quantity Entry Site Figure 3–1: For an infection to occur, all four conditions must be present. Figure 3–2: Direct contact transmission. The Body’s Natural Defences multiply and overwhelm the immune system, causing an infection which may range from mild to serious and from brief (acute) to long-lasting (chronic). The body has a series of natural defences that prevent germs from entering. The body depends on intact skin and mucous membranes in the mouth, nose, and eyes to keep germs out. When the skin is damaged, germs can enter through openings such as cuts and sores. Mucous membranes protect the body from intruding germs by trapping them so that they can then be killed or forced out (e.g., by a cough or sneeze). However, mucous membranes are less effective than skin for keeping blood-borne pathogens out of the body. If these natural barriers fail and a pathogen enters the body, the body’s immune system begins working to fight the disease. The immune system’s basic tools are white blood cells and antibodies. Special white blood cells travel around the body and identify invading pathogens. Once they detect a pathogen, white blood cells gather around it and release antibodies that attack the pathogens to weaken or destroy them. Antibodies can usually rid the body of pathogens. The combination of preventing pathogens from entering the body and destroying them after they have entered is necessary for good health (homeostasis). Sometimes, however, a pathogen enters the body and the body cannot fight it off. When this occurs, an invading pathogen can thrive inside the body and, under ideal conditions, Common signs and symptoms that signal that the body is fighting off an infection include the following: Headaches Fever Exhaustion Nausea Vomiting How Diseases Are Transmitted Four factors must coincide for an infection to occur: 1. A pathogen is present. 2. There is enough of the pathogen to cause disease. 3. A person is susceptible to the pathogen. 4. There is a route of entry (Table 3–1). If any one of these conditions is missing, an infection cannot occur (Figure 3–1). Pathogens enter the body in four ways: 1. DIRECT CONTACT Direct contact transmission (Figure 3–2) occurs when a person touches bodily fluids from an infected person. INFECTION PREVENTION AND CONTROL Pathogen 39 2. INDIRECT CONTACT Indirect contact transmission (Figure 3–3) occurs when a person touches objects that have touched the bodily fluids of an infected person. These objects could be soiled dressings, equipment, or work surfaces that an infected person came into contact with. Sharp objects, such as needles, present a particular risk. If sharp objects have contacted the blood or bodily fluids of an infected person and are handled carelessly, they can pierce the skin and transmit infection. Figure 3–3: Indirect contact transmission. TABLE 3–1: EXAMPLES OF INFECTIOUS DISEASES INFECTION PREVENTION AND CONTROL DISEASE 40 MODE OF TRANSMISSION DESCRIPTION ROUTE OF ENTRY SIGNS AND SYMPTOMS Herpes Direct contact Family of viruses; infection with one of the human herpes viruses, especially herpes simplex types 1 and 2 Broken skin, mucous membranes Lesions, general ill feeling, sore throat Meningitis Airborne, direct and indirect contact Inflammation of the membranes that envelop the central nervous system (meninges), usually due to a bacterial infection but sometimes from viral, protozoan, or other causes Food and water, mucus Respiratory illness, sore throat, nausea, vomiting Tuberculosis Airborne, direct and indirect contact A highly contagious infection caused by the bacterium Mycobacterium tuberculosis Mucus, broken skin Weight loss, night sweats, occasional fever, general ill feeling Hepatitis Direct and indirect contact Inflammation of the liver from any cause; most often viral due to infection with one of the hepatitis viruses (A, B, C, D, and E) or another virus Blood, saliva, semen, feces, food, water, other products Flu-like, jaundice HIV/AIDS Direct and indirect contact Disease due to infection with the HIV virus Blood, semen, vaginal fluid Fever, night sweats, weight loss, chronic diarrhea, severe fatigue, shortness of breath, swollen lymph nodes, lesions © iStockphoto.com/Michael Pettigrew Figure 3–4: Airborne transmission. Figure 3–5: Vector-borne transmission. 3. AIRBORNE A pandemic is an epidemic that involves multiple countries, usually affecting a large number of people. 4. VECTOR-BORNE Vector-borne transmission (Figure 3–5) occurs when an animal or an insect transmits a pathogen into the body through a bite. A bite from an infected human can also result in vector-borne transmission. The carrier is the vector and passes the infection to another animal or person. Rabies and Lyme disease are transmitted this way. Epidemics and Pandemics Occasionally an illness will spread quickly among a population and across geographical boundaries, affecting large numbers of people simultaneously. This may be referred to as an epidemic or a pandemic, depending on the scope of the area affected. An epidemic occurs when there is an increase, especially a sudden increase, in the number of cases of a disease in a given group of people or geographical area, above what is normally expected for that population or area. Diseases That Cause Concern HEPATITIS Hepatitis is an infection of the liver. There are five types of hepatitis, each caused by a different virus. Hepatitis A Hepatitis A is caused by the hepatitis A virus (HAV). This disease is spread primarily through food or water that has been contaminated by feces from an infected person. HAV causes inflammation and swelling of the liver. The patient may feel ill, with flu-like symptoms, or may experience no symptoms at all. Symptoms of HAV usually disappear after several weeks. This disease rarely causes permanent damage or chronic illness. HAV can be prevented with the hepatitis A vaccine, which is a series of two injections administered at least 6 months apart. The most effective prevention, however, is maintaining healthy habits. Always wash your hands thoroughly before preparing food, after using the toilet, and after changing a diaper. International travellers should be careful about drinking tap water. INFECTION PREVENTION AND CONTROL Airborne transmission (Figure 3–4) occurs when a person breathes in droplets that become airborne when an infected person coughs or sneezes. Generally, an exposure to these droplets will be too brief for transmission to take place; however, a transmission may occur if a person is coughing heavily. 41 Hepatitis B Hepatitis B is caused by the hepatitis B virus (HBV). Hepatitis B may be severe or even fatal. Signs and symptoms may include flu-like symptoms such as fever, fatigue, abdominal pain, loss of appetite, nausea, vomiting, and joint pain, as well as dark urine and pale bowel movements. Laterstage symptoms include jaundice, which causes a yellowing of the skin and eyes. Medications are available to treat chronic hepatitis B infection, but they do not work for everyone: Some people remain chronically infected, though they may not always experience symptoms. The most effective means of prevention is the hepatitis B vaccine. Given in a series of three doses, this vaccine provides immunity to the disease. Organizations should make hepatitis B vaccinations available to all employees whose responsibilities could expose them to hepatitis B, in accordance with local regulations and legislation. Hepatitis C Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). Symptoms are similar to those of hepatitis B infection, including fever, fatigue, abdominal pain, loss of appetite, nausea, vomiting, dark urine, clay-coloured stool, joint pain, and jaundice. INFECTION PREVENTION AND CONTROL Hepatitis C has an acute phase, lasting approximately 6 months, followed by a chronic infection. Since the symptoms vary widely (and may not be present at all), people may be infected without their knowledge. 42 There is no vaccine against hepatitis C. For these reasons, hepatitis C is more serious than hepatitis B. Hepatitis C is the leading cause of liver transplants. Hepatitis D Hepatitis D is a serious liver disease caused by the hepatitis D virus (HDV). HDV relies on HBV to replicate, so hepatitis D only occurs in people who are already infected with hepatitis B. It is uncommon in Canada. It is transmitted through contact with infectious blood, similar to how HBV is spread. There is no vaccine for hepatitis D, but the hepatitis B vaccine provides indirect protection. Hepatitis E Hepatitis E is caused by the hepatitis E virus (HEV). It is commonly transmitted via the fecal-oral route and is associated with ingestion of drinking water contaminated with fecal material in countries with poor sanitation. It occurs primarily in adults. There is no evidence of transmission by percutaneous (through the skin) or sexual exposures. HIV/AIDS HIV is the virus that causes AIDS. HIV attacks white blood cells and destroys the body’s ability to fight infection. Infections that strike people with weakened immune systems are called opportunistic infections. Some opportunistic infections that occur in people with AIDS include severe pneumonia, tuberculosis (TB), and unusual cancers such as Kaposi’s sarcoma. People infected with HIV may not feel or appear sick. A blood test, however, can detect the HIV antibody. When an infected person has a significant drop in a certain type of white blood cell or shows signs of having certain infections or cancers, the person may be diagnosed as having AIDS. Common effects of infections associated with AIDS include fever, fatigue, diarrhea, skin rashes, night sweats, loss of appetite, swollen lymph glands, and significant weight loss. In the advanced stages, AIDS is a very serious condition. Most people with AIDS eventually develop lifethreatening infections. Currently, there is no vaccine against HIV. TUBERCULOSIS Tuberculosis (TB) is an infection caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they may also damage other parts of the body, such as the brain, kidneys, or spine. TB is spread through the air when an infected person coughs, sneezes, or talks. Anyone who may have been exposed to TB should be tested. People with weakened immune systems are more likely to contract TB. Symptoms of TB in the lungs may include: Significant coughing lasting 3 weeks or longer. Pain in the chest. Weight loss. Loss of appetite. Coughing up blood or bloody sputum (phlegm from inside the lungs). Weakness and/or fatigue. Fever and chills. Night sweats. within 24 to 48 hours of the onset of symptoms. Bacterial meningitis results in brain damage, hearing loss, or other permanent disabilities in 10 to 20% of people. Viral meningitis is less severe and usually resolves without specific treatment. Bacterial meningitis is potentially fatal and is a medical emergency. Admission to a hospital or health centre is necessary. There are vaccines available to prevent meningitis and antibiotics available to treat it. TB must be treated with medication or it can be fatal. It can usually be cured with several medications over a long period of time. People with latent (asymptomatic) TB can take medicine to prevent the development of active TB. MRSA AND COMMUNITY-ASSOCIATED MRSA Multidrug-resistant tuberculosis (MDR TB) is TB that is resistant to at least two of the most effective anti-TB drugs, isoniazid and rifampin. These drugs are the most widely used to treat TB. MDR TB is more likely to occur in people who: Do not take their TB medicine regularly or who do not take all of the prescribed medication. Develop active TB after having taken medication to treat it in the past. Come from areas of the world where MDR TB is prevalent. Spend time with someone known to have MDR TB. MENINGITIS Meningitis is a contagious meningococcal infection that attacks the meninges, which are the protective coverings that surround the brain and spinal cord. Several different bacteria can cause meningitis, but it can also be caused by a virus. The bacteria is transmitted from person to person through droplets. Close and prolonged contact and living in close quarters or dormitories facilitate the spread of the disease. Meningitis can infect anyone but is more commonly found in those who have compromised immune systems and have trouble fighting infections. The most common symptoms are a stiff neck, high fever, confusion, headache, nausea, sleepiness, vomiting, and sensitivity to light. Bacterial meningitis is a serious infection; even when diagnosed early and properly treated, 5 to 10% of people die, typically When MRSA occurs in groups of people who have not been recently hospitalized or have not had a medical procedure, it is referred to as communityassociated MRSA (CA-MRSA). For example, MRSA can occur among young people who have cuts or wounds and who are in close contact with one another, such as members of a sports team. VANCOMYCIN-RESISTANT ENTEROCOCCI (VRE) Enterococci are bacteria that live in the human intestine and urinary tract and are often found in the environment. Generally, these bacteria do not cause illness, and when illness does occur, it can usually be treated with antibiotics. Vancomycin is an antibiotic generally prescribed to treat serious infections caused by organisms that are resistant to other antibiotics such as penicillin. Vancomycin-resistant Enterococci (VRE) are strains of enterococci bacteria that are resistant to the antibiotic vancomycin. Vancomycin is not effective in treating a VRE infection. INFECTION PREVENTION AND CONTROL Multidrug-Resistant Tuberculosis Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium. As with other kinds of staph bacteria, it often lives on the skin and in the nose without causing any adverse health effects, but if it enters the body it can become a source of infection. These bacteria can be spread from one person to another through casual contact or contaminated objects. MRSA infections are more difficult to treat than ordinary staph infections because they are resistant to many types of antibiotics. Infections can occur in wounds, burns, and sites where tubes have been inserted into the body. 43 A person can have VRE present in his or her body without being infected. A person with VRE who does not have symptoms is merely colonized with VRE. A person is considered to be infected with VRE when symptoms are present (e.g., an infection of the urinary tract or bloodstream). Often, VRE spreads within healthcare facilities. It can spread from patient to patient when bacteria are carried on the hands of healthcare workers and, occasionally, through contact with contaminated equipment or other surfaces (e.g., toilet seats, bedrails, door handles, soiled linens, or stethoscopes). CORONAVIRUS INFECTION PREVENTION AND CONTROL Coronaviruses are a group of six viruses that typically cause upper respiratory-tract illnesses. They are quite common, with most people becoming infected at some point in their lives without serious consequences. However, because coronaviruses are constantly evolving and poorly understood, they can pose serious health risks, even to healthy individuals, and in some cases they can be fatal. Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) are both caused by coronavirus infections. 44 The method of transmission is not fully known, but it is believed that the viruses are transmitted through the air when an infected person coughs or sneezes and through physical contact (e.g., shaking hands). The viruses may also be contracted when a person touches a contaminated surface and then touches his or her mouth, nose, or eyes. There are no specific treatments for coronaviruses, so prevention in the form of proper handwashing and use of personal protective equipment is the only defence. Severe Acute Respiratory Syndrome (SARS) Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by the SARS-associated Coronavirus (SARS-CoV). It was first reported in Asia in February 2003. Over the following months, it spread to more than two dozen countries in North America, South America, Europe, and Asia before the outbreak was contained. SARS usually begins with a high fever—a temperature greater than 38°C (100.4°F). Patients may also experience a headache, an overall feeling of discomfort, and body aches. They may have mild respiratory symptoms at the outset. After 2 to 7 days, SARS patients may develop a dry cough, and most develop pneumonia. SARS spreads mainly through close personto-person contact. The virus that causes SARS is thought to be transmitted most easily by respiratory droplets produced when an infected person coughs or sneezes and the droplets are deposited on the mucous membranes of the mouth, nose, or eyes of people nearby. It can also spread when a person touches a surface or an object contaminated with infectious droplets and then touches the mouth, nose, or eyes. MIDDLE EAST RESPIRATORY SYNDROME CORONAVIRUS (MERS-CoV) Since April 2012, cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) have been identified in a number of countries in the Middle East. Several other countries have also reported MERS-CoV cases in individuals who have travelled to the Middle East. These individuals acquired the disease through limited local transmission among close contacts, including healthcare workers. No cases have been confirmed in Canada. The symptoms of MERS-CoV are similar to severe pneumonia and include fever, cough, shortness of breath, and other breathing difficulties. Since MERS-CoV was first identified, serious illness and death have been associated with patients having underlying medical conditions as well as older individuals. The illness can be less severe in younger, healthy people. INFLUENZA Seasonal influenza is a respiratory illness caused by both human influenza A and human influenza B viruses, which can be transmitted from person to person. Most people have some immunity to influenza, and there is a vaccine available. Seasonal influenza usually has a sudden onset, with symptoms of fever (usually high), headache, extreme tiredness, dry cough, sore throat, runny or stuffy nose, and muscle aches. Abdominal Influenza is transmitted from person to person via large, virus-laden droplets projected by coughing or sneezing. These large droplets can settle on the mucosal surfaces of the upper respiratory tracts of a susceptible person. Transmission can also occur through direct or indirect contact with respiratory secretions—for example, when touching surfaces contaminated with influenza virus and then touching the mouth, nose, or eyes. Immunization Most people receive immunization as infants in the form of vaccinations against common childhood diseases (e.g., measles and mumps). Immunization is the introduction of a substance that contains specific weakened or killed pathogens into the body. The body’s immune system then builds resistance to the specific type of infection that was injected. The most common vaccinations include the following: DPT (diphtheria, pertussis, tetanus) Polio Hepatitis B MMR (measles, mumps, rubella) Influenza Chickenpox You may not have been immunized against all of these diseases as a child. If you are uncertain which immunizations you have received or may need to update, contact your physician or local community health nurse. PREVENTING DISEASE TRANSMISSION It is easy to make assumptions about the risks that are posed by a given patient or environment. You might unconsciously expect a person with dirty clothes to pose a greater risk of infection, for example, or assume that a tidy home does not contain many pathogens. Often you will not know the health status of the people you work with or care for. Even situations that seem clean could contain deadly viruses or bacteria, and the one time you stop being careful may be the very time that you become infected. Each time you provide care, you must follow basic infection-control precautions, including: Wearing personal protective equipment (PPE) (Figure 3–6). Practising good personal hygiene. Cleaning and disinfecting equipment. Following other occupational or workplace procedures. Figure 3–6: There are many ways to protect yourself from disease transmission. INFECTION PREVENTION AND CONTROL symptoms such as nausea, vomiting, and diarrhea may also be present, but these symptoms occur more often in children than in adults. 45 Personal Hygiene INFECTION PREVENTION AND CONTROL Good personal hygiene habits (e.g., frequent handwashing) (Figure 3–7, a-f) are as important for preventing infection as any equipment you might use. These practices can prevent infectious materials from staying in contact with your body long enough to cause an infection. 46 When it is not possible to wash your hands, use a gel disinfectant with a minimum alcohol content of 70%. Gel disinfectants are not a substitute for proper handwashing; even if they are used, you should still wash your hands at the earliest opportunity. a b c d e f Figure 3–7, a-f: Washing your hands properly helps protect you against disease transmission. Personal Protective Equipment (PPE) blood or other bodily fluids that may splash (Figure 3–8). Cover any cuts, scrapes, or skin irritations you may have with clothing or bandages. Use breathing devices, such as resuscitation masks, with one-way valves. PPE should be used to prevent skin and mucousmembrane exposure (Table 3–2). PPE protects you from direct contact with infected materials. Examples include disposable medical examination gloves, gowns, masks, protective eyewear, and resuscitation devices. To minimize your risk of contracting or transmitting an infectious disease, follow these universal precautions: Handle all blood and other bodily fluids as if they are infectious. Handle all patients in a way that minimizes exposure to blood and other bodily fluids. Wear disposable medical examination gloves whenever you are interacting with a patient: ◆ Do not clean or reuse disposable gloves. ◆ Avoid handling items such as pens, combs, or radios while wearing soiled gloves. ◆ Use fresh gloves for each patient. Use protective coverings (e.g., mask, eyewear, and gown) whenever you are likely to contact Figure 3–8: Wear appropriate protective coverings whenever you may come into contact with bodily fluids. TABLE 3–2: RECOMMENDED PERSONAL PROTECTIVE EQUIPMENT FOR PRE-HOSPITAL SETTINGS DISPOSABLE GOWN MASK GLOVES PROTECTIVE EYEWEAR (ALWAYS WORN) Hemorrhaging control with spurting blood Yes Yes Yes Yes Bleeding control with minimal bleeding Yes No No Yes Childbirth Yes Yes Yes Yes Helping with an intravenous (IV) line Yes No No Yes Oral/nasal suctioning, manually clearing airway Yes No Yes Yes Handling and cleaning contaminated equipment and clothing if bodily fluids are present Yes No, unless soiling is likely No, unless cleaning after transporting a patient with transmissible respiratory illness Yes Transporting or caring for a patient with signs of transmissible respiratory illness Yes No Yes Yes INFECTION PREVENTION AND CONTROL TASK OR ACTIVITY 47 Donning and Doffing PPE When donning and doffing PPE, follow a specific order to avoid indirect contact with pathogens. To put on the appropriate PPE (see Table 3–2), follow this process: 1. Wash your hands. 2. Put on your gown. 3. Put on your mask. 4. Put on protective eyewear. 5. Put on disposable gloves. When removing PPE, follow this process: 1. Remove your disposable gloves. 2. Remove your gown. 3. Wash your hands. 4. Remove protective eyewear. 5. Remove your mask. 6. Wash your hands. Remove gloves by turning them inside out, beginning at the wrist and peeling them off. When removing the second glove, do not touch the soiled surfaces with your bare hand. Hook the inside of the second glove at the wrist and peel the glove off (Figure 3–9, a-c). Always wash your hands with soap and water after removing gloves. Engineering and Work Practice Controls INFECTION PREVENTION AND CONTROL Engineering controls isolate or remove a hazard from the workplace. Examples include punctureresistant containers for sharp equipment and mechanical needle-recapping devices. Engineering controls should be examined and maintained or replaced on a regular basis. 48 a Figure 3–9, a-c: Glove removal. b Work practice controls reduce the likelihood of exposure by specifying how a task is to be carried out. The protection provided by work practice controls is based on the way people behave rather than on physical devices or structures. Engineering controls and work practice controls are established to ensure good occupational hygiene. Everyone in the workplace should be trained in these practices. Following certain guidelines for engineering controls and work practice controls can greatly reduce your risk of contracting or transmitting an infectious disease: Check response kits regularly to ensure that they are fully stocked. Keep all PPE in good working order. Immediately dispose of any PPE that is peeling, discoloured, torn, or punctured. Use dressings and bandages to minimize direct contact with blood, other bodily fluids, and wounds. If possible, have the patient wash the wound first and assist you with holding a dressing in place or applying pressure if necessary. Avoid needle-stick injuries by not trying to bend or recap any needles. If a procedure requires the recapping of a needle, use mechanical devices or one-handed techniques to recap. Never recap contaminated needles. Place sharp items (e.g., needles, scalpel blades) in puncture-resistant, leak-proof, labelled containers. c Cleaning and Disinfecting Equipment Clean and disinfect equipment and work surfaces promptly if they are (or could be) soiled by blood or other bodily fluids. Always wear proper PPE when cleaning equipment and surfaces. Surfaces such as floors, woodwork, vehicle seats, and countertops must be cleaned with soap and water first, using disposable towels, and then disinfected. To disinfect equipment soiled with blood or bodily fluids, wash thoroughly with a solution of chlorine bleach and water. Each EMS system may have protocols and solution ratios for various decontamination techniques. Many commercial decontamination solutions are available. Follow the manufacturer’s directions when using these. Wash and dry protective clothing and work uniforms according to the manufacturer’s directions. Scrub soiled boots, leather shoes, and other leather goods, such as belts, with soap, a brush, and hot water. Work areas should be kept in a clean and sanitary condition based on a written schedule for cleaning and decontamination. The schedule must meet all applicable legislation, regulations, and protocols for the region and type of workplace. Spill Management Any spill should be cleaned up as soon as possible. There should be a plan in place to deal with any spill that might occur. The plan should specify the system for reporting a spill and the actions taken to resolve it. It should also include a list of people responsible for containment and instructions for cleanup and disposal (including any required equipment) of the spilled material. The first step in dealing with a spill is containment. Spill containment units for hazardous materials are commercially available. Follow your spill management plan, along with the following guidelines: Put on applicable PPE for the type of spill. If the spill is mixed with sharp objects, such as broken glass and needles, use equipment such as tongs or a broom and dustpan to clean them up. Dispose of the absorbent material used to collect the spill in a labelled biohazard container. Flood the area with disinfectant solution and allow it to stand for at least 20 minutes. Use paper towels to absorb the solution and put the towels in the biohazard container. Exposure Control Plans Preventing infectious disease transmission begins with preparation and planning. An exposure control plan is an important step for eliminating or reducing exposure to blood and other possibly infectious materials. The exposure control plan should be developed for a particular workplace. It should be kept where it can easily be accessed and be made available to all workers. The plan should be updated regularly (at least annually) in accordance with applicable regulations. INFECTION PREVENTION AND CONTROL Perform all procedures in a way that cuts down on splashing, spraying, splattering, and producing droplets of blood or other potentially infectious materials. Remove soiled protective clothing as soon as possible. Avoid eating, drinking, smoking, applying cosmetics or lip balm, handling contact lenses, and touching your mouth, nose, or eyes in work areas where exposure to infectious materials may occur. Handle all soiled equipment, supplies, and other materials with great care until they are properly cleaned and disinfected. Place all contaminated disposable items in labelled containers. Place all soiled clothing in properly marked plastic bags for disposal or disinfection. Wash your hands thoroughly with soap and water immediately after providing care. Use a utility or restroom sink, not one in a food preparation area. Disposable waste or soiled laundry should be stored in appropriate containers with warning labels such as biohazard until they are disposed of or disinfected. 49 The plan must identify the individual or individuals who will receive exposure control training, PPE, and vaccinations. Exposure determination is one of the key elements of an exposure control plan. It includes identifying and making a written record of tasks in which exposure to blood or other bodily fluids can occur. The plan should also specify how a possible exposure incident will be evaluated and describe the system whereby soiled materials can be easily identified and disposed of. INFECTION PREVENTION AND CONTROL The exposure control plan should specify the reporting procedures for any first aid incidents. The procedures must ensure that incidents are reported before the end of the shift in which they occur. Reports of first aid incidents should include the names of all responders involved and the details of the incident (including the date and time). Exposure reports should be included on lists of first aid incidents. Professional responders must always follow their organization’s reporting procedures. 50 Health Canada’s recommendations for healthcare providers can be applied to individuals at risk in any environment. These include the following: There should be initial orientation and continuing education provided for all workers regarding modes of transmission and prevention of infections, and the need for routine use of PPE. Equipment and supplies that are required to minimize the risk of infection should be provided. Adherence to recommended protective measures should be monitored. When monitoring reveals a failure to follow recommended precautions, counselling, education, or retraining should be provided. Specific relevant vaccinations (e.g., hepatitis B) should be offered to all susceptible healthcare providers, particularly those who work in highrisk areas. IF AN EXPOSURE OCCURS If you suspect that you have been exposed to an infectious disease, wash any area of contact as quickly as possible and record the circumstances of your exposure. Exposures usually involve contact with potentially infectious blood or other fluids through a needle stick, broken or scraped skin, or the mucous membranes of the eyes, nose, or mouth. An exposure may also consist of inhaling potentially infected airborne droplets. Most organizations have protocols for reporting infectious disease exposure. Be aware of provincial/territorial Occupational Health and Safety guidelines and Workers’ Compensation guidelines that apply to you. Reporting procedures should be easy to access and user-friendly. They should ensure confidentiality and instill confidence in the exposed worker. As a minimum, reporting procedures should include: A list of events covered by the procedure. A list of immediate actions to be taken by the exposed individual to reduce the chances of infection. Direction as to when or how quickly the individual should report the exposure incident. Direction as to where and to whom the individual should report the exposure incident. An indication of which forms the individual should complete. Directions for investigating the incident. Information required from healthcare providers. An outline of the required medical follow-up, including post-exposure vaccination. If you think you have been exposed to an infectious disease, you should report the exposure immediately. A test may be done to see if the infection is present. Even before a disease is confirmed, you should receive medical evaluation, counselling, and post-exposure care. Your medical personnel or supervisor is responsible for notifying any other personnel who might have been exposed. If your system does not have a designated physician or nurse at a local hospital for follow-up care, see your personal physician. SUMMARY DISEASE-CAUSING PATHOGENS Bacteria Single-celled micro-organisms that do not depend on other organisms for life Viruses Non-cellular organisms that depend on other organisms to live and reproduce Fungi Single-celled or multicellular organisms Protozoa Single-celled organisms that can only divide within a host organism Rickettsia Micro-organisms that require other living cells for growth but use oxygen, have metabolic enzymes and cell walls, and are susceptible to antibiotics Parasitic Worms Macroscopic parasites that can live inside the body and derive nourishment from the host Four Factors Necessary for Infection to Occur 1. 2. 3. 4. A pathogen is present. There is enough of the pathogen to cause disease. A person is susceptible to the pathogen. There is a route of entry. Direct Contact A person touches bodily fluids from an infected person. Indirect Contact A person touches an object that has touched the bodily fluids of an infected person. Airborne A person inhales droplets that become airborne when an infected person coughs or sneezes. Vector-borne An animal or insect transmits pathogens through a bite. Precautions to Prevent Disease Transmission Practise good personal hygiene. Wear personal protective equipment (PPE). Follow other occupational/workplace procedures. Clean and disinfect equipment. INFECTION PREVENTION AND CONTROL MODES OF DISEASE TRANSMISSION 51 SUMMARY RECOMMENDED PERSONAL PROTECTIVE EQUIPMENT FOR PRE-HOSPITAL SETTINGS Disposable Gloves Gown Mask Protective Eyewear (always worn) Hemorrhaging control with spurting blood Yes Yes Yes Yes Bleeding control with minimal bleeding Yes No No Yes Childbirth Yes Yes Yes Yes Helping with an intravenous (IV) line Yes No No Yes Oral/nasal suctioning, manually clearing airway Yes No Yes Yes Yes No, unless soiling is likely No, unless cleaning after transporting a patient with transmissible respiratory illness Yes Yes No Yes Yes Task or Activity Handling and cleaning contaminated equipment and clothing if bodily fluids are present Transporting or caring for a patient with signs of transmissible respiratory illness INFECTION PREVENTION AND CONTROL DONNING AND DOFFING PPE 52 Donning PPE Doffing PPE 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 6. Wash your hands. Put on your gown. Put on your mask. Put on protective eyewear. Put on disposable gloves. Remove your disposable gloves. Remove your gown. Wash your hands. Remove protective eyewear. Remove your mask. Wash your hands.