Infection Control Lecture Notes PDF

CHAPTER 3 Infection Control, Safety, First Aid, and Personal Wellness KEY TERMS Drill yourself on key term meanings with WORKBOOK Matching Exercise 3-1 BBP HIV pathogens Biohazard immune percutaneous CDC permucosal chain of infection infectious/causative agent engineering controls isolation procedures reservoir EPA microbe reverse isolation ﬁre tetrahedron MSDS standard precautions fomites neutropenic susceptible host HAI NIOSH HazCom nosocomial infection transmission-based precautions HBV OSHA vector transmission HCV parenteral vehicle transmission HICPAC pathogenic work practice controls PPE OBJECTIVES Upon successful completion of this chapter, the reader should be able to: 1 Deﬁne the key terms and abbreviations listed at the beginning of this chapter. 2 Identify the components of the chain of infection and give examples of each, describe infection-control procedures used to break the chain, and identify four functions of infection-control programs. 3 Describe proper procedures for hand hygiene, putting on and removing protective clothing, and entering the nursery or neonatal ICU. 4 Describe standard and transmission-based precautions and identify the organizations that developed them. 5 State safety rules to follow when working in the laboratory and in patient areas. 6 List examples of blood-borne pathogens and describe their means of transmission in a healthcare setting. 64 UNIT I: THE HEALTHCARE SETTING 7 Discuss the major points of the blood-borne pathogens (BBP) standard, including changes required by the Needlestick Safety and Prevention Act, and identify key elements of a BBP exposure control plan. 8 Describe hazards, identify warning symbols, list actions to take if incidents occur, and specify rules to follow for proper biological, electrical, ﬁre, radiation, and chemical safety. 9 Identify symptoms of shock, state ﬁrst aid procedures for treating external hemorrhage and shock, identify the main points of the American Heart Association (AHA) CPR and ECC guidelines, and identify the links in the AHA chain of survival. 10 Describe the role of personal hygiene, proper nutrition, rest, exercise, back protection, and stress management in personal wellness. OVERVIEW This chapter tests knowledge of infection control, safety, ﬁrst aid, and personal wellness. A thorough knowledge in these areas is necessary for phlebotomists to protect themselves, patients, coworkers, and others from infection or injury, react quickly and skillfully in emergency situations, and stay healthy both physically and emotionally, all without compromising the quality of patient care. Questions in this chapter assess the ability to describe the process of infection, and identify the components of the chain of infection, required safety equipment, and infection-control procedures. They also test the ability to recognize biological, electrical, radiation, and chemical hazards and identify the safety precautions, rules, and procedures necessary to eliminate or minimize them. First aid issues tested include control of external hemorrhage and how to recognize and treat shock victims. Wellness issues addressed include the prevention of back injury, beneﬁts of exercise, and dealing with stress. Infection Control Although important advances have been made in understanding and treating infection, the threat of infection looms as large as ever. New enemies in the battle against infection emerge, such as human immunodeﬁciency virus (HIV) and hepatitis C virus (HCV). Enemies that had once been conquered may become resistant to treatment, as in the case of Mycobacterium tuberculosis and methicillin-resistant Staphylococcus aureus. Blood collection personnel typically encounter numerous patients every day, and many of these may be harboring various infectious microorganisms. Measures to prevent the spread of infection must be taken in the course of all patient encounters. This portion of the chapter explains the infection process and describes infectioncontrol measures needed to protect blood collection personnel, patients, staff, visitors, and those doing business within healthcare facilities. Infection control involves implementing procedures and policies that prevent infection; it starts with an understanding of the process of infection. INFECTION Infection is a condition that results when a microorganism (microbe for short) is able to invade the body, multiply, and cause injury or disease. Microbes include bacteria, fungi, protozoa, and viruses. Most microbes are nonpathogenic, meaning that they do not cause disease under normal conditions. Microbes that are pathogenic (causing or productive of disease) are called pathogens. We normally have many nonpathogenic microbes on our skin and in other areas such as the gastrointestinal (GI) tract. These microbes can become pathogens if they enter and CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS BOX 3-1 65 CDC LIST OF INFECTIOUS DISEASES THAT MAY BE ACQUIRED IN HEALTHCARE FACILITIES Acinetobacter Bloodborne pathogens Burkholderia cepacia Chickenpox (varicella) Clostridium difﬁcile Clostridium sordellii Ebola (viral hemorrhagic fever) Gastrointestinal (GI) infections Hepatitis A Hepatitis B Hepatitis C HIV/AIDS Inﬂuenza Methicillin-resistant Staphylococcus aureus (MRSA) Mumps Norovirus Pneumonia Rubella SARS Tuberculosis Varicella (chickenpox) Viral hemorrhagic fever (Ebola) Vancomycin intermediate Staphylococcus aureus (VISA) Vancomycin-resistant enterococci (VRE) Reprinted from U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. List of Infectious Diseases That May Be Acquired in Healthcare Facilities. Accessed April 14, 2010, from http://www.cdc.gov/ncidod/dhqp/id.html multiply in areas of the body where they do not exist normally. Some microbes are pathogenic regardless of where they are found. Infections caused by pathogens can be local (restricted to a small area of the body) or systemic (sis-tem’ik), in which case the entire body is affected. Communicable Infections Some pathogenic microbes cause infections that are communicable (able to spread from person to person); the diseases that result are called communicable diseases. An agency of the U.S. Department of Health and Human Services called the Centers for Disease Control and Prevention (CDC) is charged with the investigation and control of various diseases, especially those that are communicable and have epidemic potential. The CDC develops guidelines and recommends safety precautions to protect healthcare workers and others from infection. Nosocomial and Healthcare-Associated Infections Approximately 5% of patients in the United States are exposed to and contract some sort of infection after admission to a hospital or other healthcare facility. The term nosocomial infection applies to infections acquired in hospitals. The term healthcare-associated infection (HAI) applies to infections associated with healthcare delivery in any healthcare setting, including home care. According to the CDC, HAIs account for an estimated 1.7 million infections and 99,000 associated deaths each year. Healthcare facility–acquired or associated infections can result from contact with various sources, including infected personnel, other patients, visitors, and contaminated food, drugs, or equipment. The Healthcare Infection Control Practices Advisory Committee (HICPAC) advises the CDC on updating guidelines regarding the prevention of infections in hospitals and other healthcare facilities. See Box 3-1 for CDC-listed of infectious diseases that may be acquired in healthcare facilities. KEY POINT According to the CDC, urinary tract infection (UTI) is the most common nosocomial infection in the United States, accounting for 32% of all healthcare-associated infections. THE CHAIN OF INFECTION Infection transmission requires the presence of a number of components, which make up what is referred to as the chain of infection (Fig. 3-1). Six key components, or “links” in the chain are an infectious agent, a reservoir, an exit pathway, a means of transmission, an entry pathway, and a susceptible host. The chain must be complete for an infection to occur. 66 UNIT I: THE HEALTHCARE SETTING Infectious Agent bacteria, fungus protozoon, rickettsia, virus Susceptible Host Reservoir animal, human, equipment, food, soil, water elderly, newborn, acute/chronically ill, immune suppressed, unvaccinated Entry Pathway body orifices, mucous membranes, broken skin Exit Pathway blood, exudates, excretions, secretions Means of Transmission airborne, contact, droplet, vector, vehicle Figure 3-1 The chain of infection. If the process of infection is stopped at any component or link in the chain, an infection is prevented. If a pathogen successfully enters a susceptible host, the chain is completed, the host becomes a new source of infectious microorganisms, and the process of infection continues. KEY POINT A phlebotomist, whose duties involve contact with many patients, must be fully aware of the infection process and take precautions to prevent the spread of infection. Infectious Agent The infectious agent, also called the causative agent, is the pathogenic microbe responsible for causing an infection. Reservoir The source of an infectious agent is called a reservoir. It is a place where the microbe can survive and grow or multiply. Reservoirs include humans, animals, food, water, soil, and contaminated articles and equipment. An individual or animal infected with a pathogenic microbe is called a reservoir host. Human reservoir hosts can be patients, personnel, or visitors and include those with an active disease, those incubating a disease, and chronic carriers of a disease. Another reservoir for potentially infectious microbes is a person’s own normal ﬂora (microorganisms that normally live on the skin and other areas of the human body). Contaminated articles and equipment can be a major source of infectious agents. The ability of these inanimate objects to transmit infectious agents depends upon the amount of contamination, the viability or ability of the microbe to survive on the object, the virulence or degree to which the microbe is capable of causing disease, and the amount of time that has passed since the item was contaminated. For example, HBV, the virus that causes hepatitis B, is much more virulent than human immunodeﬁciency virus (HIV), the virus that causes AIDS, because a smaller amount of infective material is capable of causing disease. It is also more viable because it is capable of surviving longer on surfaces than HIV. However, if enough time CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 67 Figure 3-2 N95 respirator. (Courtesy of 3M Occupational Health and Environmental Safety Division. St. Paul, MN.) elapses from the time of contamination until contact by a susceptible host, it is no longer alive and therefore unable to transmit disease. Exit Pathway An exit pathway is a way an infectious agent is able to leave a reservoir host. Infectious agents can exit a reservoir host in secretions from the eyes, nose, or mouth; exudates from wounds; tissue specimens; blood from venipuncture and skin puncture sites; and excretions of feces and urine. Means of Transmission The means of transmission is the method an infectious agent uses to travel from a reservoir to a susceptible individual. Means of infection transmission include airborne, contact, droplet, vector, and vehicle. The same microbe can be transmitted by more than one route. Airborne Transmission Test your knowledge of Key Points with WORKBOOK Knowledge Drill 3-1. Airborne transmission involves dispersal of infectious agents that can remain infective for long periods of time in particles that are typically less than 5 m in diameter and can be inhaled, such as droplet nuclei (residue of evaporated droplets). The particles, generated by sneezing, coughing, talking and activities that produce aerosols, can remain suspended in the air or in dust particles and become widely dispersed and eventually inhaled by susceptible individuals. Patients with airborne infections require airborne infection isolation rooms (AIIRs) that have special air handling and ventilation. Anyone who enters an AIIR should wear a National Institute for Occupational Safety and Health (NIOSH) certiﬁed N95 (N category, 95% efﬁciency) or higher-level respirator (Fig. 3-2). KEY POINT Mycobacterium tuberculosis, rubeola virus, and varicella virus are examples of infectious agents spread by airborne transmission. Contact Transmission Contact transmission is the most common means of transmitting infection. There are two types of contact transmission: direct and indirect. Direct contact transmission is the physical transfer of an infectious agent to a susceptible host through close or intimate contact such as touching or kissing. Indirect contact transmission can occur when a susceptible host touches contaminated objects such as patient bed linens, clothing, dressings, and eating utensils. It includes contact with phlebotomy equipment such as gloves, needles, specimen tubes, testing equipment, and trays. It also includes less obvious contaminated objects such as countertops, 68 UNIT I: THE HEALTHCARE SETTING computer keyboards, phones, pens, pencils, doorknobs, and faucet handles. The transfer of infectious agents from contaminated hands to a susceptible host is also considered indirect contact transmission. Inanimate objects that can harbor material containing infectious agents are called fomites (fo’mi-tez). Droplet Transmission Droplet transmission is the transfer of an infectious agent to the mucous membranes of the mouth, nose, or conjunctiva of the eyes of a susceptible individual via infectious droplets (particles 5 m in diameter or larger) generated by coughing, sneezing, or talking or through procedures such as suctioning or throat swab collection. KEY POINT Droplet transmission differs from airborne transmission in that droplets normally travel less than 10 feet and do not remain suspended in the air. Vector Transmission Vector transmission is the transfer of an infectious agent carried by an insect, arthropod, or animal. Examples of vector transmission include the transmission of West Nile virus by mosquitoes and bubonic plague (Yersinia pestis) by rodent ﬂeas. Vehicle Transmission Vehicle transmission is the transmission of an infectious agent through contaminated food, water, or drugs. Examples of vehicle transmission are Salmonella infection from handling contaminated chicken and Shigella infection from drinking contaminated water. KEY POINT The transmission of hepatitis viruses and HIV through blood transfusion is also considered vehicle transmission. Entry Pathway The entry pathway is the way an infectious agent is able to enter a susceptible host. Entry pathways include body oriﬁces; mucous membranes of the eyes, nose, or mouth; and breaks in the skin. Patients’ entry pathways can be exposed during invasive procedures such as catheterization, venipuncture, ﬁngersticks, and heel puncture. Entry pathways of healthcare personnel can be exposed during spills and splashes of infectious specimens or created by needlesticks and injuries from other sharp objects. Susceptible Host A susceptible host is someone with a decreased ability to resist infection. Factors that affect susceptibility include age, health, and immune status. For example, newborns are more susceptible to infection because their immune systems are still forming, and the elderly are more susceptible because their immune systems weaken with age. Disease, antibiotic treatment, immunosuppressive drugs, and procedures such as surgery, anesthesia, and insertion of catheters can all leave a patient more susceptible to infection. A healthy person who has received a vaccination against an infection with a particular virus or recovered from one has developed antibodies against that virus and is considered to be immune, or unlikely to develop the disease. KEY POINT Individuals who are exposed to the hepatitis B virus (HBV) are less likely to contract the disease if they have previously completed an HBV vaccination series. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS BOX 3-2 69 EXAMPLES OF WAYS TO BREAK THE CHAIN OF INFECTION Effective hand hygiene procedures Good nutrition, adequate rest, and reduction of stress Immunization against common pathogens Insect and rodent control Isolation procedures Proper decontamination of surfaces and instruments Proper disposal of sharps and infectious waste Use of gloves, gowns, masks, respirators, and other personal protective equipment (PPE) when indicated Use of needle safety devices during blood collection A microorganism that primarily infects individuals with weakened immune systems is called an opportunist. One classic opportunist that is becoming more and more of a threat is a type of bacterium called Acinetobacter baumannii. It is found most commonly in hospitals, infecting the chronically ill, the elderly, patients with HIV, and transplant patients. BREAKING THE CHAIN OF INFECTION Breaking the chain of infection involves stopping infections at the source, preventing contact with substances from exit pathways, eliminating means of transmission, blocking exposure to entry pathways, and reducing or eliminating the susceptibility of potential hosts. Examples of ways to break the chain and prevent infections are shown in Box 3-2. INFECTION-CONTROL PROGRAMS The Joint Commission requires every healthcare institution to have an infection-control program responsible for protecting patients, employees, visitors, and anyone doing business within healthcare institutions from infection. A typical infection-control program implements procedures aimed at breaking the chain of infection, monitors and collects data on all infections occurring within the institution, and institutes special precautions in the event of outbreaks of speciﬁc infections. Employee Screening and Immunization An important way in which infection-control programs prevent infection is through employee screening and immunization programs. Screening for infectious diseases typically takes place prior to or upon employment and on a regular basis throughout employment. Screening commonly includes tuberculosis (TB) testing, also called puriﬁed protein derivative (PPD) testing. Employees with positive TB test results receive chest x-ray evaluations to determine their status. Screening may also include rapid plasma reagin (RPR) testing for syphilis and screening for diarrhea and skin diseases. Employees with certain conditions or infections may be subject to work restrictions. (Conditions requiring work restrictions are listed in Appendix D.) Immunizations typically required include current hepatitis B virus (HBV); measles, mumps, rubella (MMR); diphtheria; and tetanus vaccinations or proof of immunity. Most employers provide vaccinations free of charge. KEY POINT OSHA regulations require employers to offer HBV vaccine free of charge to employees whose duties involve risk of exposure. Evaluation and Treatment An infection-control program also provides for the evaluation and treatment of employees who are exposed to infections on the job. This includes OSHA-mandated conﬁdential medical evaluation, treatment, counseling, and follow-up as a result of exposure to blood-borne pathogens. 70 UNIT I: THE HEALTHCARE SETTING BOX 3-3 SITUATIONS THAT REQUIRE HAND HYGIENE PROCEDURES Before and after each patient contact Between unrelated procedures on a patient such as wound care and drawing blood Before putting on gloves and after taking them off Before leaving the laboratory Before going to lunch or on break Before and after going to the restroom Whenever hands become visibly or knowingly contaminated Surveillance Another major function of an infection-control program is surveillance, or monitoring. This involves monitoring patients and employees at risk of acquiring infections as well as collecting and evaluating data on infections contracted by patients and employees. Infection-control measures are updated and new policies instituted based on this information. The CDC has developed the National Surveillance System for Healthcare Workers (NASH) to collaborate with healthcare facilities in the collection of information important in preventing occupational exposure and infection among healthcare workers. INFECTION CONTROL METHODS Hand Hygiene Hand hygiene is one of the most important means of preventing the spread of infection provided that it is achieved properly and when required. Hand hygiene measures include the frequent use of antiseptic hand cleaners or hand washing, depending upon the degree of contamination. It is important that all healthcare personnel learn proper hand hygiene procedures and recognize situations when they should be performed. Box 3-3 lists situations that require hand hygiene procedures. KEY POINT As part of the CDC Guidelines for Hand Hygiene in Health Care Settings, it is recommended that artiﬁcial ﬁngernails or extenders not be worn when having direct contact with high-risk patients, such as infants or those in ICU. Natural nails should preferably be less than 1⁄4 inch long. Use of Alcohol-Based Antiseptic Hand Cleaners CDC/HICPAC guidelines recommend the use of alcohol-based antiseptic hand cleaners (gels, foams, and rinses) in place of hand washing as long as the hands are not visibly soiled. These products have been shown to have superior microbiocidal (destructive to microbes) activity. Sufﬁcient cleaner must be used to cover all surfaces of the hands, including between the ﬁngers, and the alcohol must be allowed to evaporate to achieve proper antisepsis. KEY POINT If hands are heavily contaminated with organic material and hand-washing facilities are not available, it is recommended that hands be cleaned with detergent-containing wipes, followed by the use of an alcohol-based antiseptic hand cleaner. Test your knowledge of proper hand-washing procedure with WORKBOOK Skills Drill 3-3. Hand Washing There are different methods of hand washing, depending on the degree of contamination and the level of antimicrobial activity required. A routine hand-washing procedure uses plain soap and water to mechanically remove soil and transient bacteria. Hand antisepsis requires the use of an antimicrobial soap to remove, kill, or inhibit transient microorganisms. A 2-minute surgical hand scrub uses an antimicrobial soap or equivalent to remove or destroy transient microorganisms and reduce levels of normal ﬂora prior to surgical procedures. Proper routine hand-washing procedure is described in Procedure 3-1. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 71 Personal Protective Equipment View the Donning and Removal of Protective Equipment video at http://thepoint.lww. com/McCall5e. Protective clothing and other items worn by an individual to protect mucous membranes, airways, skin and clothing from contact with infectious substances is called personal protective equipment (PPE). PPE provides a barrier against infection. Used properly, it protects those wearing it. Disposed of properly, it prevents spread of infection to others. PPE includes the following. View the Hand Washing/Hand Antisepsis video at http://thepoint.lww.com/McCall5e. PROCEDURE 3-1 Hand-Washing Technique PURPOSE: Decontaminate hands to prevent the spread of infection EQUIPMENT: Liquid soap, disposable towels, trash can Step Explanation/Rationale 1. Stand back so that you do not touch the sink. The sink may be contaminated. 2. Turn on the faucet and wet hands under warm running water. Water should not be too hot or too cold and hands should be wet before applying soap to minimize drying, chapping, or cracking of hands from frequent hand washing. 3. Apply soap and work up a lather. A good lather is needed to reach all surfaces. 4. Scrub all surfaces, including between the ﬁngers and around the knuckles. Scrubbing is necessary to dislodge micro-organisms from surfaces, especially between ﬁngers and around knuckles. 5. Rub your hands together vigorously. Friction helps loosen dead skin, dirt, debris, and microorganisms. (Steps 4 and 5 should take at least 15 seconds, about the time it takes to sing the ABCs). 72 UNIT I: THE HEALTHCARE SETTING PROCEDURE 3-1 Hand-Washing Technique (Continued) Step Rationale/Explanation 6. Rinse your hands in a downward motion from wrists to ﬁngertips. Rinsing with the hands downward allows contaminants to be ﬂushed from the hands and ﬁngers into the sink rather than ﬂowing back up the arm or wrist. 7. Dry hands with a clean paper towel. Hands must be dried thoroughly and gently to prevent chapping or cracking. Reusable towels can be a source of contamination. 8. Use a clean paper towel to turn off the faucet unless it is foot or motion activated. Clean hands should not touch contaminated faucet handles. Images from Molle EA, Kronenberger J, West-Stack C. Lippincott Williams & Wilkins Clinical Medical Assisting, 2nd ed. Baltimore: Lippincott Williams & Wilkins; 2005. Gloves Clean, nonsterile gloves are worn when collecting or handling blood and other body ﬂuids, handling contaminated items, and touching nonintact skin or mucous membranes. Gloves should be pulled over the cuffs of gowns or lab coats to provide adequate protection. Three main reasons for wearing gloves are as follows: To prevent contamination of the hands when handling blood or body ﬂuids or when touching mucous membranes or nonintact skin To reduce the chance of transmitting organisms on the hands of personnel to patients during invasive or other procedures that involve touching a patient’s skin or mucous membranes To minimize the possibility of transmitting infectious microorganisms from one patient to another KEY POINT Wearing gloves during phlebotomy procedures is mandated by the OSHA blood-borne pathogens standard. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 73 Proper Glove Removal After use, gloves should be removed promptly in an aseptic manner and discarded. To remove gloves properly (Fig. 3-3), grasp one glove at the wrist and pull it inside out and off the hand, ending up with it in the palm of the still-gloved hand. Slip ﬁngers of the ungloved hand under the second glove at the wrist and pull it off the hand, ending with one glove inside the other with the contaminated surfaces inside. Hands should be sanitized immediately after glove removal and before going to another patient. Gowns Clean, nonsterile, ﬂuid-resistant gowns are worn by healthcare personnel to protect the skin and prevent soiling of clothing during patient-care activities in which splashes or sprays of blood or body ﬂuids are possible or when entering isolation rooms (see Isolation Procedures, below). Sterile gowns are also worn to protect certain patients (such as newborns and patients with compromised immune systems) from contaminants on the healthcare worker’s clothing. Most gowns are made of disposable cloth or paper, are generous in size to adequately cover clothing, have long sleeves with knit cuffs, and fasten in the back. Figure 3-3 Glove removal. A. The wrist of one glove is grasped with the opposite gloved hand. B. The glove is pulled inside out, over, and off the hand. C. With the ﬁrst glove held in the gloved hand, the ﬁngers of the nongloved hand are slipped under the wrist of the remaining glove without touching the exterior surfaces. D. The glove is then pulled inside out over the hand so that the ﬁrst glove ends up inside the second glove, with no exterior glove surfaces exposed. E. Contaminated gloves ready to be dropped into the proper waste receptacle. 74 UNIT I: THE HEALTHCARE SETTING Putting On and Removing Gowns When putting on a gown, only inside surfaces of the gown should be touched. A properly worn gown has the sleeves pulled all the way to the wrist, the belt tied, and the gown overlapped, completely closed, and securely fastened. A gown is removed from the inside by sliding the arms out of the sleeves. The gown is then held away from the body, folded with the contaminated outside surface on the inside, and rolled into a bundle for disposal. Lab Coats Lab coats, like gowns, are worn to protect skin and prevent soiling of healthcare workers’ clothing during patient-care activities in which splashes or sprays of blood or body ﬂuids are possible. They are required attire for most phlebotomy situations. Lab coats used for specimen collection and handling are generally made of ﬂuid-resistant cotton or synthetic material, have long sleeves with knit cuffs, and come in both reusable and disposable styles. Masks, Face Shields, and Goggles A mask is worn to protect against droplets generated by coughing or sneezing. To put on a mask, place it over your nose and mouth. Adjust the metal band (if applicable) to ﬁt snugly over your nose. For masks with ties, fasten the top ties around the upper portion of your head; then tie the lower ones at the back of your neck. If the mask has elastic fasteners, slip them around your ears. A face shield or a mask and goggles are worn to protect the eyes, nose, and mouth from splashes or sprays of body ﬂuids. If an activity requires goggles, it also requires a mask. Some masks have plastic eye shields attached. Respirators NIOSH-approved N95 respirators are required when entering rooms of patients with pulmonary tuberculosis and other diseases with airborne transmission. Respirators must ﬁt snugly with no air leaks (see Airborne Transmission, below). See the Donning and Removal of Protective Equipment video at http://thepoint.lww. com/McCall5e. Putting On and Removing Protective Clothing When putting on complete protective clothing such as gown, mask, and gloves, the gown is put on ﬁrst (Fig. 3-4A). The mask is put on next, making certain it covers the nose and mouth (Fig. 3-4B). Gloves are put on last and pulled over the cuffs of the gown (Fig. 3-4C). Protective clothing is removed at the door before leaving the patient room or anteroom. It must be removed in an aseptic (sterile or pathogen free) manner to prevent contamination of the wearer. Gloves are removed ﬁrst, being careful not to touch contaminated surfaces with Figure 3-4 Protective clothing. A. Phlebotomist slips arms into a protective gown. B. A mask is applied by slipping the elastic band over the ears. C. Gloves are put on last and pulled over the gown cuffs. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 75 ungloved hands. The gown is removed next, pulling it from the shoulders toward the hands so that it turns inside out. It must be held away from the body and rolled into a bundle before discarding. The mask is removed last touching only the strings. Hands must then be immediately decontaminated. Nursery and Neonatal ICU Infection-Control Technique Newborns are more susceptible to infections than healthy older children and adults because their immune systems are not yet fully developed. Consequently, anyone who enters the nursery or other neonatal unit should use special infection-control techniques. Most neonatal units have a separate anteroom where hand washing, gowning, and so forth are performed before entering. Typical nursery and neonatal ICU infection-control technique includes the following: Wash hands and put on clean gloves, gown, and mask. Gather only those items necessary to perform the specimen collection. Leave the blood collection tray in the anteroom outside the nursery. Remove gloves, decontaminate hands, and put on new gloves between each patient. ISOLATION PROCEDURES One way in which an infection-control program minimizes the spread of infection is through the establishment of isolation procedures. Isolation procedures separate patients with certain transmissible infections from contact with other patients and limit their contact with hospital personnel and visitors. Isolating a patient requires a doctor’s order and is implemented either to prevent the spread of infection from a patient who has or is suspected of having a contagious disease or to protect a patient whose immune system is compromised. Patients are most commonly isolated in a private room. A card or sign indicating the type of isolation along with a description of required precautions is typically posted on the patient’s door. A cart containing supplies needed to enter the room or care for the patient is typically placed in the hall outside the door. CAUTION: Different types of isolation require the use of different types of personal protective equipment. The best thing to do before entering an isolation room is to follow the directions on the precaution sign on the door or check with the patient’s nurse if instructed to do so. Protective/Reverse Isolation Protective or reverse isolation is used for patients who are highly susceptible to infections. In this type of isolation, protective measures are taken to keep healthcare workers and others from transmitting infection to the patient rather than vice versa. Patients who may require protective isolation include those with suppressed or compromised immune function, such as burn patients, organ transplant patients, AIDS patients, and neutropenic (having a low neutrophil count) chemotherapy patients. A neutrophil is a type of white blood cell. Traditional Isolation Systems At one time, the CDC recommended either of two types of isolation systems: the category-speciﬁc system and the disease-speciﬁc system. The category-speciﬁc system had seven different isolation categories covering many diseases and often resulted in overisolation of patients and needless extra costs. The disease-speciﬁc system was based on the modes of transmission of common diseases. A chart listed the diseases and identiﬁed speciﬁc isolation precautions recommended for each. A diagnosis or suspicion of the presence of a transmissible disease was needed to institute either system. 76 UNIT I: THE HEALTHCARE SETTING Universal Precautions Isolation practices were altered dramatically in 1985, when the CDC introduced a strategy called universal precautions (UP) after reports of healthcare workers being infected with HIV through needlesticks and other exposures to HIV-contaminated blood. UP replaced blood/body ﬂuid precautions and were followed for all isolation categories. Under UP, the blood and certain body ﬂuids of all individuals were considered potentially infectious. The introduction of UP changed the focus of infection control from prevention of patient-to-patient infection transmission, to prevention of patient-to-personnel transmission, and was a required part of an overall infection control plan. Body Substance Isolation Because infection transmission can occur before a diagnosis is made or even suspected, another system called body substance isolation (BSI) gained acceptance. BSI incorporated elements of disease-speciﬁc and category-speciﬁc precautions and was followed for every patient without need for a diagnosis or suspicion of a transmissible disease. BSI went beyond universal precautions by requiring that gloves be worn when contacting any moist body substance. Guideline for Isolation Precautions Widespread variation in the use of UP or BSI, confusion over which body ﬂuids required precautions, lack of agreement on the importance of hand washing after glove use, and the need for additional precautions to prevent transmission of infectious agents in addition to blood-borne pathogens led to a new guideline issued jointly by the CDC and HICPAC. This guideline, which is still in effect, but has since been updated and expanded to include precautions for preventing transmission of infectious agents in all healthcare settings, contains two tiers of precautions. The ﬁrst tier, standard precautions, speciﬁes precautions to use in caring for all patients regardless of diagnosis or presumed infection status. The second tier, transmission-based precautions, speciﬁes precautions to use for patients either suspected or known to be infected with certain pathogens transmitted by airborne, droplet, or contact routes. The guideline also lists speciﬁc clinical conditions that are highly suspicious for infection and speciﬁes appropriate transmission-based precautions to use for each, in addition to standard precautions, until a diagnosis can be made. Standard Precautions Standard precautions (Fig. 3-5) are to be used in the care of all patients and are meant to be the number-one strategy for successful nosocomial infection control. They combine the major features of UP and BSI to minimize the risk of infection transmission from both recognized and unrecognized sources. Standard precautions apply to blood, all body ﬂuids (including all secretions and excretions except sweat, whether or not they contain visible blood), nonintact skin, and mucous membranes. KEY POINT The updated isolation precaution guideline added respiratory hygiene/cough ettiquette as a new standard precaution. This precaution applies to all who enter a healthcare setting and includes covering the mouth and nose with tissue when coughing, prompt disposal of used tissues, hand hygiene after contact with respiratory secretions, and 3 feet of separation from persons with respiratory infections. Transmission-Based Precautions Transmission-based precautions are to be used for patients known or suspected to be infected or colonized with highly transmissible or epidemiologically (related to the study of epidemics) signiﬁcant pathogens that require special precautions in addition to standard precautions. Table 3-1 lists clinical conditions that warrant transmission-based precautions pending diagnosis. Common diseases and conditions that require transmission-based precautions are listed in Table 3-2. Precautions may be combined for diseases that have more than one means of transmission. There are three types of transmission-based precautions: Airborne precautions (Fig. 3-6) or the equivalent, which must be used in addition to standard precautions for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (particles smaller than 5 m) CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS Figure 3-5 Standard precautions sign. (Courtesy Brevis Corp., Salt Lake City, UT.) 77 78 UNIT I: THE HEALTHCARE SETTING TABLE 3-1 Clinical Conditions Warranting Transmission-Based Precautions Pending Conﬁrmation of Diagnosis Condition Potential Pathogen Precaution Enteric pathogen Contact Clostridium Difﬁcile Contact Neisseria meningitidis Droplet Neisseria meningitidis Varicella Rubeola (measles) Droplet Airborne and contact Airborne Mycobacterium tuberculosis Airborne M. tuberculosis Airborne Bordetella pertussis Droplet Respiratory syncytial virus or parainﬂuenza virus Contact Resistant bacteria Contact Resistant bacteria Contact Staphylococcus aureus Group A streptococcus Contact Diarrhea Acute diarrhea with a likely infectious cause in an incontinent or diapered patient Diarrhea in an adult with a history of broad-spectrum or long-term antibiotics Meningitis Rash for Inﬂamed Skin Eruptions Petechial/ecchymotic with fever Vesicular Maculopapular Respiratory Infections Cough/fever/upper lobe pulmonary inﬁltrate in an HIV-negative patient and a patient at low risk for HIV infection Cough/fever/pulmonary inﬁltrate in any lung location in an HIV-infected patient and at high risk for HIV infection Paroxysmal or severe persistent cough during periods of pertussis activity Respiratory infections, particularly bronchiolitis and croup, in infants and young children Risk of Multidrug-Resistant Microorganisms History of infection or colonization with multidrug-resistant organisms Skin, wound, or urinary tract infection in a patient with a recent hospital or nursing home stay in a facility where multidrug-resistant organisms are prevalent Skin or Wound Infection Abscess or draining wound that cannot be covered TABLE 3-2 Transmission-Based Precautions for Common Diseases and Conditions Airborne Precautions Droplet Precautions Contact Precautions Herpes zoster (shingles)* Adenovirus infection** Adenovirus infection** Measles (rubeola) Diphtheria (pharyngeal) Cellulitis (uncontrolled drainage) Pulmonary tuberculosis Haemophilus inﬂuenzae meningitis Clostridium difﬁcile Varicella (chickenpox) Inﬂuenza Meningococcal pneumonia Meningococcal sepsis Mumps (infectious parotitis) Mycoplasma pneumoniae Neisseria meningitidis Parvovirus B19 Pertussis (whooping cough) Pneumonic plague Rubella (German measles) Scarlet fever** Conjunctivitis (acute viral) Decubitus ulcer (infected, major) Diphtheria (cutaneous) Enteroviral infections* Herpes zoster (shingles)* Impetigo Parainﬂuenza virus Pediculosis (lice) Respiratory syncytial virus Rubella (congenital) Scabies Varicella (chickenpox) *Widely disseminated or in immunocompromised patients. **Infants and children only. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 79 Figure 3-6 Airborne precautions sign. (Courtesy Brevis Corp., Salt Lake City, UT.) Droplet precautions (Fig. 3-7) or the equivalent, which must be used in addition to standard precautions for patients known or suspected to be infected with microorganisms transmitted by droplets (particles larger than 5 m), generated when a patient talks, coughs, or sneezes and during certain procedures such as suctioning Contact precautions (Fig. 3-8) or the equivalent, which must be used in addition to standard precautions when a patient is known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with surfaces or patient-care items. 80 UNIT I: THE HEALTHCARE SETTING Figure 3-7 Droplet precautions sign. (Courtesy Brevis Corp., Salt Lake City, UT.) Safety Providing quality care in an environment that is safe for employees as well as patients is a concern that is foremost in the minds of healthcare providers. Safe working conditions must be ensured by employers as mandated by the Occupational Safety and Health Act of 1970 and enforced by the Occupational Safety and Health Administration (OSHA). Even so, biological, electrical, radiation, and chemical hazards are encountered in a healthcare setting, often on a daily basis. It is important for the phlebotomist to be aware of the existence of hazards and know the safety precautions and rules necessary to eliminate or minimize them. General lab safety rules are listed in Box 3-4. Safety rules to follow when in patient rooms and other patient areas are listed in Box 3-5. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 81 Figure 3-8 Contact precautions sign. (Courtesy Brevis Corp., Salt Lake City, UT.) BIOSAFETY Have some fun ﬁnding biohazard exposure route terms in the WORKBOOK scrambled words drill. Biosafety is a term used to describe the safe handling of biological substances that pose a risk to health. Biological hazards can be encountered in a healthcare setting on a daily basis. Healthcare personnel must be able to recognize them in order to take the precautions necessary to eliminate or minimize exposure to them. Biohazard Anything harmful or potentially harmful to health is called a biohazard (short for biological hazard) and should be identiﬁed by a biohazard symbol (Fig. 3-9). Because most laboratory specimens have the potential to contain infectious agents, they are considered biohazards. 82 UNIT I: THE HEALTHCARE SETTING BOX 3-4 GENERAL LABORATORY SAFETY RULES Never eat, drink, smoke, or chew gum in the laboratory. Never put pencils or pens in the mouth. Never place food or beverages in a refrigerator used for storing reagents or specimens. Never apply cosmetics, handle contact lenses, or rub eyes in the laboratory. Never wear long chains, large or dangling earrings, or loose bracelets. Always wear a fully buttoned lab coat when engaged in lab activities. Never wear a lab coat to lunch, on break, or when leaving the lab to go home. Never wear personal protective equipment outside the designated area for its use. Always tie back hair that is longer than shoulder length. Always keep ﬁnger nails short and well manicured. Do not wear nail polish or artiﬁcial nails. Never bite nails or cuticles. Always wear a face shield when performing specimen processing or any activity that might generate a splash or aerosol of bodily ﬂuids. Always wear gloves for phlebotomy procedures and when processing specimens. Biohazard Exposure Routes There are many routes by which healthcare workers can be exposed to biohazards. Ingestion is probably the most easily recognized, but routes other than the digestive tract, referred to as parenteral (par-en’ter-al) routes, can also result in biohazard exposure. The most common biohazard exposure routes are as follows. Airborne Biohazards can become airborne and inhaled when splashes, aerosols, or fumes are generated. Aerosols and splashes can be created when specimens are centrifuged, when tube stoppers are removed, and when specimen aliquots are being prepared. Dangerous fumes can be created if chemicals are improperly stored, mixed, or handled. Patients with airborne diseases can transmit infection to workers unless N95 respirators are worn when caring for them. Protection against airborne biohazard exposure includes following safe handling practices, wearing appropriate PPE, and working behind safety shields or splash guards. BOX 3-5 SAFETY RULES WHEN IN PATIENT ROOMS AND OTHER PATIENT AREAS Avoid running. It is alarming to patients and visitors and may cause an accident. Be careful entering and exiting patient rooms; housekeeping equipment, dietary carts, x-ray machines, and other types of equipment may be just inside the door or outside in the hall. Do not touch electrical equipment in patient rooms while drawing blood. Electrical shock can pass through a phlebotomist and the needle and shock the patient. Follow standard precautions when handling specimens. Properly dispose of used and contaminated specimen collection supplies and return all other equipment to the collection tray before leaving the patient’s room. Replace bedrails that were let down during patient procedures. Report inﬁltrated IVs or other IV problems to nursing personnel. Report unresponsive patients to nursing personnel. Report unusual odors to nursing personnel. Watch out for and report food, liquid, and other items spilled on the ﬂoor to appropriate personnel. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 83 Figure 3-9 The biohazard symbol. Ingestion Biohazards can be ingested if healthcare workers neglect to sanitize hands before handling food, gum, candy, cigarettes, or drinks. Other activities that can lead to ingestion of biohazards include covering the mouth with hands instead of tissue when coughing or sneezing, biting nails, chewing on pens or pencils, and licking ﬁngers when turning pages in books. Frequent hand sanitization, avoiding hand-to-mouth activities, and refraining from holding items in the mouth or chewing on them provides the best defense against accidental ingestion of biohazardous substances. Nonintact Skin Biohazards can enter the body through visible and invisible pre-existing breaks in the skin such as abrasions, burns, cuts, scratches, sores, dermatitis, and chapped skin. Defects in the skin should be covered with waterproof (nonpermeable) bandages to prevent contamination, even when gloves are worn. Percutaneous Percutaneous (through the skin) exposure to biohazardous microorganisms in blood or body ﬂuid occurs through intact (unbroken) skin as a result of accidental needlesticks and injuries from other sharps including broken glass and specimen tubes. Ways to reduce the chance of percutaneous exposure include using needle safety devices properly, wearing heavy-duty utility gloves when cleaning up broken glass, and never handling broken glass with the hands. See how well you know your airborne and bloodborne pathogens with WORKBOOK Knowledge Drill 3-6. Permucosal Permucosal (through mucous membranes) exposure occurs when infectious microorganisms and other biohazards enter the body through the mucous membranes of the mouth and nose and the conjunctiva of the eyes in droplets generated by sneezing or coughing, splashes, and aerosols and by rubbing or touching the eyes, nose, or mouth with contaminated hands. The chance of permucosal exposure can be reduced by following procedures to prevent exposure to splashes and aerosols and avoiding rubbing or touching the eyes, nose, or mouth. Blood-Borne Pathogen The term blood-borne pathogen (BBP) is applied to any infectious microorganism present in blood and other body ﬂuids and tissues. Such pathogens, which can be present in a patient’s body ﬂuids even if there are no symptoms of disease, are among the most signiﬁcant biohazards faced by healthcare workers. Although HBV, HCV, and HIV tend to receive the most attention, BBPs include other hepatitis viruses; cytomegalovirus (CMV); the microorganisms that cause syphilis, malaria, and relapsing fever; the agent that causes Creutzfeldt–Jakob disease; and more recently, WEST NILE virus. HBV and Hepatitis D Virus Hepatitis B (once called serum hepatitis) is caused by HBV, a potentially life-threatening blood-borne pathogen that targets the liver. (Hepatitis means “inﬂammation of the liver.”) It has been the most frequently occurring laboratory-associated infection and the major occupational hazard in the healthcare industry, although the rate of infection has dropped 84 UNIT I: THE HEALTHCARE SETTING substantially since the advent of HBV immunization programs in the 1980s. Anyone infected with HBV is at risk of also acquiring hepatitis D (delta) virus (HDV), which is a defective virus that can multiply only in the presence of HBV. HBV Vaccination The best defense against HBV infection is vaccination. Vaccination consists of a series of three equal intramuscular injections of vaccine: an initial dose, a second dose 1 month after the ﬁrst, and a third dose 6 months following the initial dose. The vaccine also protects against HDV since it can only be contracted concurrently with HBV infection. Success of immunization and proof of immunity can be determined 1 to 2 months after the last vaccination dose by a blood test that detects the presence of the hepatitis B surface antibody (anti-HBs) in the person’s serum. OSHA requires employers to offer the vaccine free to employees within 10 working days of being assigned to duties with potential BBP exposure. Employees who refuse the vaccination must sign and date a declination (statement of refusal) form, which is kept in their personnel ﬁle. The most commonly used hepatitis B vaccine does not contain live virus and poses no risk of transmitting HBV, which was a problem of earlier vaccines. HBV Exposure Hazards HBV can be present in blood and other body ﬂuids such as urine, semen, cerebrospinal ﬂuid (CSF), and saliva. It can survive up to a week in dried blood on work surfaces, equipment, telephones, and other objects. In a healthcare setting, it is primarily transmitted through needlesticks (a single needlestick can transmit HBV) and other sharps injuries and contact with contaminated equipment, objects, surfaces, aerosols, spills, and splashes. In nonmedical settings, it is transmitted primarily through sexual contact and sharing of dirty needles. Symptoms of HBV Infection HBV symptoms resemble ﬂu symptoms but generally last longer. They include fatigue; loss of appetite; mild fever; muscle, joint, and abdominal pain; nausea; and vomiting. Jaundice appears in about 25% of cases. About 50% of those infected show no symptoms. Some individuals become carriers who can pass the disease on to others. Carriers have an increased risk of developing cirrhosis of the liver and liver cancer. Infection is conﬁrmed by detection of hepatitis B surface antigen (HBsAg) in an individual’s serum. Hepatitis C Virus (HCV) Hepatitis C, caused by infection with HCV, has become the most widespread chronic bloodborne illness in the United States. The virus, discovered in 1988 by molecular cloning, was found to be the primary cause of non-A, non-B hepatitis. No vaccine is currently available. HCV Exposure Hazards HCV is found primarily in blood and serum, less frequently in saliva, and seldom in urine and semen. It can enter the body in the same manner as HBV. However, infection primarily occurs after large or multiple exposures. As in the case of HBV, sexual contact and needle sharing are the primary means of transmission in nonmedical settings. Symptoms of HCV Infection HCV symptoms are similar to those of HBV infection, although only 25% to 30% of infections even cause symptoms. As with HBV, chronic and carrier states exist that can lead to cirrhosis of the liver and liver cancer. In fact, HCV infection is a leading indication for liver transplantation. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 85 Human Immunodeﬁciency Virus (HIV) HIV attacks the body’s immune system, causing AIDS by leaving the body susceptible to opportunistic infections. Opportunistic infections are caused by organisms that would not ordinarily be pathogens to a normal healthy individual. HIV infection has a poor prognosis and is of great concern to healthcare workers. KEY POINT Although the incidence of work-related HIV infection is relatively low, CDC studies have shown that phlebotomy procedures were involved in approximately 50% of the HIV exposures that have occurred so far in healthcare settings. HIV Exposure Hazards HIV has been isolated from blood, semen, saliva, tears, urine, cerebrospinal ﬂuid, amniotic ﬂuid, breast milk, cervical secretions, and tissue of infected persons. The risk to healthcare workers, however, is primarily through exposure to blood. HIV can enter the body through all the same routes as the hepatitis viruses. Symptoms of HIV Infection The incubation phase of HIV infection is thought to range from a few weeks up to a year or more. Initial symptoms are mild to severe ﬂu-like symptoms. During this phase, the virus enters the T lymphocytes (T lymphs or helper T cells), triggering them to produce multiple copies of the virus. The virus then enters a seemingly inactive incubation phase while hiding in the T lymphs. Certain conditions reactivate the virus, which slowly destroys the T lymphs. Once the T lymph count is reduced to 200 or fewer per milliliter of blood, the patient is ofﬁcially diagnosed as having AIDS, the third and ﬁnal phase of infection. In this phase, the immune system deteriorates signiﬁcantly and opportunistic infections take hold. Two symptoms of AIDS are hairy leukoplakia, a white lesion on the tongue, and Kaposi’s sarcoma, a cancer of the capillaries that produces bluish-red nodules on the skin. End stages of AIDS are characterized by deterioration of the nervous system leading to neurological symptoms and dementia. OSHA Standard for Blood-Borne Pathogens The OSHA Blood-borne Pathogens Standard was promulgated (put into force) when it was concluded that healthcare employees face a serious health risk from occupational exposure to blood and other body ﬂuids and tissues. Enforcement of the standard, which is mandated by federal law, is meant to reduce or not eliminate occupational exposure to BBPs. The standard requires implementation of engineering controls and work practice controls to prevent exposure incidents, availability and use of PPE, special training, medical surveillance, and the availability of vaccination against HBV for all at risk employees. KEY POINT Engineering controls are devices that isolate or remove a BBP hazard. Work practice controls are practices that change the way tasks are performed to reduce the likelihood of BBP exposure. The BBP standard was revised in 2001 to conform to the Needlestick Safety and Prevention Act passed by Congress and signed into law in November 2000. The act directed OSHA to revise the BBP standard in the following four key areas: Revision and updating of the exposure control plan Solicitation of employee input in selecting engineering and work practice controls Modiﬁcation of deﬁnitions relating to engineering controls New record-keeping requirements Exposure Control Plan To comply with the OSHA standard, employers must have a written exposure control plan. The plan must be reviewed and updated at least annually to document the evaluation and 86 UNIT I: THE HEALTHCARE SETTING BOX 3-6 KEY ELEMENTS OF AN EXPOSURE CONTROL PLAN 1. An exposure determination: A list of all job categories and tasks with potential BBP exposure 2. Methods of implementation and compliance including: A universal precautions statement requiring all employees to observe UP or the equivalent. Engineering controls, such as sharps disposal containers, self-sheathing needles, sharps with engineered sharps injury protections, and needleless systems that isolate or remove the BBP hazard. Work practice controls that reduce likelihood of exposure by altering the way tasks are performed. Examples include policies that require hand washing after glove removal and prohibit eating, drinking, smoking, or applying cosmetics in laboratory work areas. PPE or barrier protection devices such as gloves, gowns, lab coats, aprons, face shields, masks, and resuscitation mouthpieces that minimize the risk of BBP infection. Disposable PPE and laundry service for reusable PPE must be provided to the employee at no cost. Housekeeping schedule and methods that require decontamination of work surfaces at least once a day and after any contact with blood or other potentially infectious material with 1:10 bleach solution or other EPA-approved disinfectant. 3. Hepatitis B vaccine and postexposure follow-up procedures. 4. Communication of hazards to employees in the form of: Warning labels and signs attached to containers of potentially infectious material, including refrigerators and freezers where infectious material may be stored. Labels must be predominantly ﬂuorescent orange or orange–red, containing a biohazard symbol and the word “biohazard.” Red bags or containers may be substituted for labels. BBP training and information provided to employees at no cost and during working hours when ﬁrst assigned to tasks with risk of exposure. A copy of the BBP standard and an explanation of its contents readily available to employees. Provision for annual training within 1 year of initial training. 5. Record keeping requirements: Medical records: A requirement for the employer to maintain conﬁdential medical records on each employee with occupational exposure. Records must include the employee’s name, social security number, and HBV vaccination status. Training records: A requirement for the employer to maintain records of training sessions that include the content, the qualiﬁcations of persons conducting them, and the names and titles of persons attending. Sharps injury log: A requirement for the employer to keep a log of injuries from contaminated sharps. The log entry should include where and how the incident occurred, and the type and brand of device involved. Information recorded must protect employee conﬁdentiality. implementation of safer medical devices. Nonmanagerial employees with risk of exposure must be involved in the identiﬁcation, review, and selection of engineering and work practice controls and their participation must be documented. Key elements of an exposure control plan are shown in Box 3-6. BBP Exposure Routes Occupational exposure to blood-borne pathogens can occur if any of the following happens while a healthcare worker is performing his or her duties. The skin is pierced by a contaminated needle or sharp object. Blood or other body ﬂuid splashes into the eyes, nose, or mouth. Blood or other body ﬂuid comes in contact with a cut, scratch, or abrasion. A human bite breaks the skin. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS A 87 B Figure 3-10 Eyewash basin. A. Press the lever at the right side of the basin. B. The stream of water forces the caps from the nozzles. Lower your face and eyes into the stream and continue to wash the area until the eyes are clear. (Reprinted with permission from Kronenberger J. Lippincott Williams and Wilkins’ Comprehensive Medical Assisting, 3rd ed. Baltimore: Lippincott Williams & Wilkins; 2008.) Exposure Incident Procedure An exposure incident requires immediate attention for the most promising outcome in the event that the exposure involves a BBP. The immediate response by the employee in the event of an exposure incident includes the following: Needlestick or other sharps injury: Carefully remove shards of glass or other objects that may be embedded in the wound and wash the site with soap and water for a minimum of 30 seconds. KEY POINT There is currently no scientiﬁc evidence that squeezing the wound or cleaning with an antiseptic reduces the transmission of BBPs. Cleaning with bleach or other caustic agents is not recommended. Mucous membrane exposure: Flush the site (i.e., eyes, nose, or mouth) with water or sterile saline for a minimum of 10 minutes. Use an eyewash station (Fig. 3-10) if available to adequately ﬂush a splash to the eyes. Remove contact lenses as soon as possible and disinfect them before reuse or discard. Report the incident to the immediate supervisor. Report directly to a licensed healthcare provider for a medical evaluation, treatment if required, and counseling (see Box 3-7 for key elements of a postexposure medical evaluation.) KEY POINT Free conﬁdential medical evaluation following an exposure incident is required by OSHA regulations. If postexposure treatment is recommended, it should be started as soon as possible. BOX 3-7 KEY ELEMENTS OF A POSTEXPOSURE MEDICAL EVALUATION The employee’s blood is tested for HIV in an accredited laboratory. The source patient’s blood is tested for HIV and HBV, with the patient’s permission. If the source patient refuses testing, is HBV-positive, or is in a high-risk category, the employee may be given immune globulin or an HBV vaccination. If the source patient is HIV-positive, the employee is counseled and tested for HIV infection immediately and at periodic intervals, normally 6 weeks, 12 weeks, 6 months, and 1 year after exposure. The employee may be given azidothymidine (AZT) or other HIV therapy. The exposed employee is counseled to be alert for acute retroviral syndrome (acute viral symptoms) within 12 weeks of exposure. 88 UNIT I: THE HEALTHCARE SETTING Surface Decontamination OSHA requires surfaces in specimen collection and processing areas to be decontaminated by cleaning them with a 1:10 bleach solution or other disinfectant approved by the Environmental Protection Agency (EPA). Bleach solutions should be prepared daily. Cleaning must take place at the end of each shift or whenever a surface is visibly contaminated. Gloves should be worn when cleaning. Cleanup of Body Fluid Spills Special EPA-approved chemical solutions and kits are available for cleanup of blood and other body ﬂuid spills and for disinfecting surfaces. Gloves must be worn during the cleaning process. Cleanup procedures, which vary slightly depending upon the type and size of spill (see Procedure 3-2, below), should concentrate on absorbing the material without spreading it over a wider area than the original spill. Disposable cleanup materials must be discarded in a biohazard waste container. Reusable cleanup materials should be properly disinfected after use. Biohazard Waste Disposal Nonreusable items contaminated with blood or body ﬂuids are biohazardous waste and must be disposed of in special containers or bags marked with a biohazard symbol. Filled biohazard waste containers require special handling prior to decontamination and disposal. OSHA, EPA, and state and local agencies regulate biohazard waste disposal. ELECTRICAL SAFETY Fire and electrical shock are potential hazards associated with the use of electrical equipment. Knowledge of the proper use, maintenance, and servicing of electrical equipment such as centrifuges can minimize hazards associated with their use. Box 3-8 contains guidelines for electrical safety. PROCEDURE 3-2 Cleanup Procedures for Blood and Other Body Fluid Spills Type of Spill Cleanup Procedure Small spill (a few drops) Carefully absorb spill with a paper towel or similar material Discard material in biohazard waste container Clean area with appropriate disinfectant Large spill Use a special clay or chlorine-based powder to absorb or gel (thicken) the liquid Scoop or sweep up absorbed or thickened material Discard material in a biohazard waste container Wipe spill area with appropriate disinfectant Dried spills Moisten spill with disinfectant (avoid scraping, which could disperse infectious organisms into the air) Absorb spill with paper towels or similar material Discard material in biohazard waste container Clean area with appropriate disinfectant Spills involving broken glass Wear heavy-duty utility gloves (Never handle broken glass with your hands) Scoop or sweep up material Discard in biohazard sharps container Clean area with appropriate disinfectant CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS BOX 3-8 89 ELECTRICAL SAFETY Avoid the use of extension cords. Do not attempt to make repairs to equipment if you are not trained to do so. Do not handle electrical equipment with wet hands or when standing on a wet ﬂoor. Do not overload electrical circuits. Do not touch electrical equipment in patient rooms, especially when in the process of drawing blood. An electrical shock could pass through the phlebotomist and the needle and shock the patient. Inspect cords and plugs for breaks and fraying. Make cetain all electrical cords have three-prong plugs and that the third prong (grounding prong) is functional. Know the location of the circuit breaker box. Unplug and do not use equipment that is malfunctioning. Unplug equipment that has had liquid spilled in it. Do not plug in again until the spill has been cleaned up and you are certain the wiring is dry. Unplug equipment when you are servicing it, including when you are replacing a light bulb. Actions to Take if Electrical Shock Occurs Shut off the source of electricity. If the source of electricity cannot be shut off, use nonconducting material (e.g., hand inside a glass beaker) to remove the source of electricity from the victim. Call for medical assistance. Start cardiopulmonary resuscitation if indicated. Keep the victim warm. Fire Safety All employees of any institution should be aware of procedures to follow in case of ﬁre. They should know where ﬁre extinguishers are located and how to use them. They should know where the ﬁre blankets (Fig. 3-11) are kept and how to use them or heavy toweling to smother clothing ﬁres. They should know the location of emergency exits and be familiar with evacuation routes. Fire spreads rapidly and it is important for employees to know the basics of what to do and also what not to do if a ﬁre occurs so they can react quickly and appropriately. Box 3-9 lists dos and don’ts to follow if a ﬁre occurs. Figure 3-11 Fire blanket storage box. 90 UNIT I: THE HEALTHCARE SETTING BOX 3-9 FIRE SAFETY DOS AND DON’TS Do pull the nearest ﬁre alarm. Do call the ﬁre department. Do attempt to extinguish a small ﬁre. Do close all doors and windows if leaving the area. Do smother a clothing ﬁre with a ﬁre blanket or have the person roll on the ﬂoor in an attempt to smother the ﬁre. Do crawl to the nearest exit if there is heavy smoke present. Don’t panic. Don’t run. Don’t use elevators. Fire Components Test your classes of ﬁre knowledge and express your creativity with color. Do WORKBOOK Matching Exercise 3-3. Four components, present at the same time, are necessary for ﬁre to occur. Three of the components, fuel (combustible material), heat to raise the temperature of the material until it ignites or catches ﬁre, and oxygen to maintain combustion or burning have traditionally been referred to as the ﬁre triangle. The fourth component, the chemical reaction that produces ﬁre, actually creates a ﬁre tetrahedron (Fig. 3-12), the latest way of looking at the chemistry of ﬁre. Basic ﬁre safety involves keeping the components apart to prevent ﬁre or removing one or more of the components when there is a ﬁre to extinguish it. Fire extinguishers put out ﬁres by removing one or more components. There are different types of ﬁre extinguishers, depending on the class of ﬁre involved. Classes of Fire Five classes of ﬁre are now recognized by the National Fire Protection Association (NFPA). Classiﬁcation is based on the fuel source of the ﬁre. The ﬁve classes are as follows: Fire Tetrahedron Heat Oxygen Fuel Chemical Reaction Figure 3-12 Fire tetrahedron. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 91 Class A ﬁres occur with ordinary combustible materials, such as wood, papers, or clothing, and require water or water-based solutions to cool or quench the ﬁre to extinguish it. Class B ﬁres occur with ﬂammable liquids and vapors, such as paint, oil, grease, or gasoline, and require blocking the source of oxygen or smothering the fuel to extinguish. Class C ﬁres occur with electrical equipment and require nonconducting agents to extinguish. Class D ﬁres occur with combustible or reactive metals, such as sodium, potassium, magnesium, and lithium, and require dry powder agents or sand to extinguish (they are the most difﬁcult ﬁres to control and frequently lead to explosions). Class K ﬁres occur with high-temperature cooking oils, grease, or fats and require agents that prevent splashing and cool the ﬁre as well as smother it. Memory Jogger The following will help you remember each ﬁre classiﬁcation. Class A ﬁres occur with ordinary combustible materials; emphasize the “a” when saying the word “ordinary.” Class B ﬁres occur with ﬂammable liquids; emphasize the “b” when saying the word “ﬂammable.” Class C ﬁres are electrical ﬁres; emphasize the “c” when saying the word “electrical.” Class D ﬁres: These occur with combustible or reactive metals, so keep in mind that when you say the word “metal” quickly, it sounds like “medal,” which has a “d” in it, and medals are commonly made of metal. Class K ﬁres: Keep in mind that they occur with cooking oils or fats in kitchens, which begins with a “k.” Fire Extinguishers There is a ﬁre extinguisher class (Fig. 3-13) that corresponds to each class of ﬁre except class D. Class D ﬁres present unique problems and are best left to ﬁreﬁghting personnel to extinguish. Using the wrong type of ﬁre extinguisher on a ﬁre can be dangerous. Consequently, some ﬁre extinguishers are multipurpose to eliminate the confusion of having several different types of extinguishers. Multipurpose extinguishers are the type most frequently used in healthcare institutions. Common ﬁre extinguisher classes and how they typically work are as follows: Class A extinguishers use soda and acid or water to cool the ﬁre. Class B extinguishers use foam, dry chemical, or carbon dioxide to smother the ﬁre. Class C extinguishers use dry chemical, carbon dioxide, Halon, or other nonconducting agents to smother the ﬁre. Class ABC (multipurpose) extinguishers use dry chemical reagents to smother the ﬁre. They can be used on class A, B, and C ﬁres. Class K extinguishers use a potassium-based alkaline liquid speciﬁcally formulated to ﬁght high-temperature grease, oil, or fat ﬁres by cooling and smothering them without splashing. Some class K extinguishers can also be used on class A, B, and C ﬁres. Memory Jogger The NFPA code word for the order of action in the event of ﬁre is RACE, where the letters stand for the following: R Rescue individuals in danger. A Alarm: activate the ﬁre alarm. C Conﬁne the ﬁre by closing all doors and windows. E Extinguish the ﬁre with the nearest suitable ﬁre extinguisher. 92 UNIT I: THE HEALTHCARE SETTING CLASS & SYMBOL A INTENDED USE Fires involving ordinary combustible materials such as cloth, wood, rubber, paper, and many plastics. Ordinary Combustibles B Fires involving flammable liquids and vapors, such as grease, gasoline, oil, and oil-based paints. Flammable Liquids C ICON TYPE OF EXTINGUISHER A AB ABC Water Foam Dry chemical AB ABC BC Foam Fires involving electrical equipment such as appliances, tools, or other equipment that is plugged into an electricity source. Electrical Equipment Dry Dry chemical chemical PULL PIN AIM NOZZLE BC ABC BC Carbon Dry Dry dioxide chemical chemical Fires involving combustible, reactive, or flammable metals. D D SQUEEZE TRIGGER Combustible Metals K OPERATION Dry powder Fires involving high temperature cooking oils, grease or fat such as vegetable oils, animal oils, or fats typically found in commercial kitchens. K Cooking Oils Potassium-based alkaline liquid SWEEP NOZZLE Figure 3-13 Classes of ﬁre extinguishers. (Symbols reprinted with permission from NFPA 10, Portable Fire Extinguishers, Copyright © 2007, Nationl Fire Protection Association. This reprinted material is not the complete and ofﬁcial position of the NFPA on the referenced subject, which is represented only by the standard in its entirety.) RADIATION SAFETY The principles involved in radiation exposure are distance, shielding, and time. This means that the amount of radiation you are exposed to depends upon how far you are from the source of radioactivity, what protection you have from it, and how long you are exposed to it. Exposure time is important because radiation effects are cumulative. KEY POINT Those working in areas where there may be high levels of radioactivity are required to wear a dosimeter badge, which records accumulated radiation exposure. Badge readings must be checked by the appropriate authority at regular intervals. A clearly posted radiation hazard symbol (Fig. 3-14) is required in areas where radioactive materials are used and on cabinet or refrigerator doors where radioactive materials are stored. In addition, radioactive reagents and specimens must be labeled with a radiation CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 93 Figure 3-14 The radiation hazard symbol. hazard symbol. A radiation hazard symbol on a patient’s door signiﬁes that a patient has been treated with radioactive isotopes. A phlebotomist may encounter radiation hazards when collecting specimens from patients who have been injected with radioactive dyes, when collecting specimens from patients in the radiology department or nuclear medicine, and when delivering specimens to radioimmunoassay sections of the laboratory. The phlebotomist should be aware of institutional radiation safety procedures. In addition, the phlebotomist should recognize the radiation hazard symbol and be cautious when entering areas displaying it. Because radiation is particularly hazardous to a fetus, pregnant employees should avoid areas displaying the radiation symbol, patients who have recently been injected with radioactive dyes, and specimens collected from patients while radioactive dye is still in their systems. CHEMICAL SAFETY A phlebotomist may come in contact with hazardous chemicals when using cleaning reagents, adding preservatives to 24-hour urine containers, or delivering specimens to the laboratory. Inappropriate use of chemicals can have dangerous consequences. For example, mixing bleach with other cleaning compounds can release dangerous gases. In addition, many chemicals are potent acids, such as the hydrochloric acid (HCl) used as a urine preservative, or alkalis, both of which can cause severe burns. Container labels provide important information regarding the contents and should always be read carefully before use. See Box 3-10 for general chemical safety rules. CAUTION: An important chemical safety rule to remember when dealing with acids and other liquids is never add water or other liquids to an acid, as it can cause an explosive type reaction. If a mixture containing both is to be made, always add the acid to the other liquid. BOX 3-10 GENERAL RULES FOR CHEMICAL SAFETY Always wear proper protective clothing—including lab coat, apron, gloves, and safety goggles—when working with chemicals. Always use proper chemical cleanup materials when cleaning up chemical spills. Never store chemicals above eye level. Never add water to acid. Never indiscriminately mix chemicals together. Never store chemicals in unlabeled containers. Never pour chemicals into dirty containers, especially containers previously used to store other chemicals. Never use chemicals in ways other than their intended use. 94 UNIT I: THE HEALTHCARE SETTING Memory Jogger Think of the letters “AAA” to remember the safety rule “always add acid”. OSHA Hazard Communication Standard OSHA developed the Hazard Communication (HazCom) Standard to protect employees who may be exposed to hazardous chemicals. According to the law, all chemicals must be evaluated for health hazards, and all chemicals found to be hazardous must be labeled as such and the information communicated to employees. KEY POINT The HazCom standard is known as “The Right to Know Law” because of the labeling requirement. HazCom Labeling Requirements Although labeling format may vary by company, all chemical manufacturers must comply with labeling requirements set by the Manufacturers Chemical Association. Labels for hazardous chemicals must contain: A statement of warning such as “danger” or “poison” A statement of the hazard (e.g., toxic, ﬂammable, combustible) Precautions to eliminate risk First aid measures in the event of a spill or other exposure Material Safety Data Sheets The OSHA HazCom standard requires manufacturers to supply material safety data sheets (MSDSs) for their products. An MSDS contains general information as well as precautionary and emergency information for the product. Every product with a hazardous warning on the label requires an MSDS to help ensure that it will be used safely and as intended. KEY POINT Employers are required to obtain an MSDS for every hazardous chemical present in the workplace and to make all MSDS readily accessible to employees. Department of Transportation Labeling System Hazardous materials may have additional labels of precaution, including a Department of Transportation (DOT) symbol incorporating a United Nations hazard classiﬁcation number and symbol (Table 3-3). The DOT labeling system uses a diamond-shaped warning sign (Fig. 3-15) Hazard class symbol Colored background Hazard class designation or four-digit identification number United Nations hazard class number Figure 3-15 Example of DOT hazardous materials labels (ﬂammable, poison, corrosive, etc.). (From Jones SA, Weigel A, White RD, et al., eds. Advanced Emergency Care for Paramedic Practice. Philadelphia: J. B. Lippincott; 1992.) CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS TABLE 3-3 United Nations Hazard Classiﬁcation Numbers and Symbols United Nations Hazard Class Symbol Background Color Examples Bursting ball Orange Fireworks Ammunition Dynamite Flame Flammable Red Cylinder Nonﬂammable Green Flammable: Butane Propane Nonﬂammable: Ammonia Chlorine Flame Red Brake ﬂuid Camphor oil Glycol ethers Gasoline Flammable solids or substances Flame Flammable Solid Red and white vertical stripes Lithium Magnesium Phosphorus Titanium Substances that release, ﬂammable gases when in contact with water Slashed W Water-Reactive Materials Red and white vertical stripes with blue top quadrant Circle with ﬂame Yellow Ammonium nitrate Benzoyl peroxide Calcium chlorite Skull with crossbones White Chemical made Pesticides Cyanide AIDS specimens Propeller Yellow over white Cobalt 14 Plutonium Radioactive waste Uranium 235 Test tube over hand Test tube over metal White over black Caustic potash Caustic soda Hydrochloric acid Sulfuric acid ORM-A ORM-B ORM-C ORM-D ORM-E White ORM-A: dry ice ORM-B: quick lime ORM-C: sawdust ORM-D: hair spray ORM-E: hazardous waste Class 1 Explosives Class 2 Gases (compressed, liquiﬁed, or dissolved under pressure) Class 3 Flammable liquids Class 4 Class 5 Division 5.1: oxidizing substances Division 5.2: organic peroxides Class 6 Poisonous and infectious substances Class 7 Radioactive materials Class 8 Corrosives Class 9 Miscellaneous dangerous substances referred to as other regulated material (ORM) 95 96 UNIT I: THE HEALTHCARE SETTING FLAMMABILITY SIGNAL–RED HEALTH SIGNAL–BLUE REACTIVITY SIGNAL–YELLOW RADIOACTIVE, WATER REACTIVE, OR OTHER SPECIFIC HAZARD Identification of Health Hazard Color Code: BLUE Identification of Flammability Color Code: RED Type of possible injury SIGNAL 4 3 Materials that on short exposure could cause serious temporary or residual injury even though prompt medical treatment was given. 2 1 0 Susceptibility of materials to burning SIGNAL Materials that on very short exposure could cause death or major residual injury even though prompt medical treatment was given. Materials that on intense or continued exposure could cause temporary incapacitation or possible residual injury unless prompt medical treatment is given. Materials that on exposure would cause irritation but only minor residual injury even if no treatment is given. Materials that on exposure under fire conditions would offer no hazard beyond that of ordinary combustible material. Identification of Reactivity (Stability) Color Code: YELLOW 4 3 2 1 Susceptibility to release of energy SIGNAL Materials that will rapidly or completely vaporize at atmospheric pressure and normal ambient temperature, or that are readily dispersed in air and that will burn readily. Liquids and solids that can be ignited under almost all ambient temperature conditions. Materials that must be moderately heated or exposed to relatively high ambient temperatures before ignition can occur. Materials that must be preheated before ignition can occur. 4 3 2 1 Materials that will not burn. 0 0 Materials that in themselves are readily capable of detonation or of explosive decomposition or reaction at normal temperatures and pressures. Materials that in themselves are capable of detonation or explosive reaction but require a strong initiating source or that must be heated under confinement before initiation or that react explosively with water. Materials that in themselves are normally unstable and readily undergo violent chemical change but do not detonate. Also, materials that may react violently with water or that may form potentially explosive mixtures with water. Materials that in themselves are normally stable, but that can become unstable at elevated temperatures and pressures or that may react with water with some release of energy, but not violently. Materials that in themselves are normally stable, even under fire exposure conditions, and that are not reactive with water. Figure 3-16 National Fire Protection Association 704 marking system example and explanation. containing the United Nations hazard class number, the hazard class designation or four-digit identiﬁcation number, and a symbol representing the hazard. National Fire Protection Association Labeling System Another hazardous material rating system (Fig. 3-16) was developed by the NFPA to label areas where hazardous chemicals and other materials are stored, thus alerting ﬁreﬁghters in the event of a ﬁre. This system uses a diamond-shaped symbol divided into four quadrants. Health hazards are indicated in a blue diamond on the left, the level of ﬁre hazard is indicated in the upper CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 97 Figure 3-17 Combination safety shower and eye wash. quadrant in a red diamond, stability or reactivity hazards are indicated in a yellow diamond on the right, and other speciﬁc hazards are indicated in a white quadrant on the bottom. Safety Showers and Eyewash Stations The phlebotomist should know the location of and be instructed in the use of safety showers and eyewash stations (Fig. 3-17) in the event of a chemical spill or splash to the eyes or other body parts. The affected parts should be ﬂushed with water for a minimum of 15 minutes, followed by a visit to the emergency room for evaluation. Chemical Spill Procedures Chemical spills require cleanup using special kits (Fig. 3-18) containing absorbent and neutralizer materials. The type of materials used depends upon the type of chemical spilled. An indicator in the cleanup materials detects when the materials have been neutralized and are safe for disposal. The EPA regulates chemical disposal. Figure 3-18 Spill cleanup kit. 98 UNIT I: THE HEALTHCARE SETTING First Aid The ability to recognize and react quickly and skillfully to emergency situations may mean the difference between life and death for a victim. Do you know the meaning of the elements that make up the word hemorrhage? Test yourself with WORKBOOK Skills Drill 3-2. EXTERNAL HEMORRHAGE According to current American Red Cross guidelines, hemorrhage (abnormal or profuse bleeding) from an obvious wound can be effectively controlled by ﬁrmly applying direct pressure to the wound until bleeding stops or EMS rescuers arrive. Pressure should be applied using cloth or gauze, with additional material added if bleeding continues. It is acceptable to use an elastic bandage to hold the compress in place as long as pressure is applied to the bandage. Standard precautions should be followed. CAUTION: The original compress should not be removed when adding additional ones because removal can disrupt the clotting process. Previous guidelines added elevating the affected part above the level of the heart and, if efforts to control bleeding were ineffective, use of arterial pressure points. Although not included now, these actions are not considered improper or harmful. Using a tourniquet to control bleeding can be harmful and is not recommended. A tourniquet should be used only as a last resort to save a life after all other means to control bleeding are unsuccessful, as may occur with an avulsion (a tearing away or amputation of a body part) or a severely mangled or crushed body part. SHOCK A state of shock results when there is insufﬁcient return of blood ﬂow to the heart, resulting in an inadequate supply of oxygen to all organs and tissues of the body. Numerous conditions including hemorrhage, heart attack, trauma, and drug reactions can lead to some degree of shock. Because shock can be a life-threatening situation, it is important that the symptoms be recognized and dealt with immediately. Common Symptoms of Shock Common symptoms of shock include: Pale, cold, clammy skin Rapid, weak pulse Increased, shallow breathing rate Expressionless face and staring eyes First Aid for Shock When providing ﬁrst aid to a victim of shock, be sure to do the following: 1. Maintain an open airway for the victim. 2. Call for assistance. 3. Keep the victim lying down with the head lower than the rest of the body. 4. Attempt to control bleeding or other cause of shock if known. 5. Keep the victim warm until help arrives. CAUTION: Never give ﬂuids if the patient is unconscious or semiconscious or has injuries likely to require surgery and anesthesia. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 99 CARDIOPULMONARY RESUSCITATION AND EMERGENCY CARDIOVASCULAR CARE Most healthcare institutions require their personnel to be certiﬁed in cardiopulmonary resuscitation (CPR). Consequently, most phlebotomy programs require it as a prerequisite or corequisite or include it as part of the course. The American Heart Association recommends the 6- to 8-hour Basic Life Support (BLS) Healthcare Provider Course for those in healthcare professions. The course includes instruction in how to perform CPR on victims of all ages, use of an automated external deﬁbrillator (AED), and how to remove a foreign-body airway obstruction. Certiﬁcation is good for 2 years. American Heart Association CPR and ECC Guidelines The latest (2010) American Heart Association (AHA) guidelines for CPR and Emergency Cardiovascular Care (ECC) aim to simplify lay rescuer training, and stress the need for early chest compressions for victims of sudden cardiac arrest. Untrained bystanders are now encouraged to provide Hands-Only™ (compressions only) CPR. Trained lay rescuers, if able, still provide compressions and ventilations; however, the latest guidelines call for them to start chest compressions before opening the airway or initiating rescue breathing. Consequently, the previous ABCs (airway, breathing, compressions) of CPR taught in BLS courses have been replaced with CAB (compressions, airway, breathing), except for CPR on newborns. The guidelines also place increased emphasis on high-quality CPR that includes: A compression rate of at least 100 per minute (formerly it was approximately 100 per minute An adult compression depth of at least 5 cm (2 inches) An infant and child compression depth of one third of the anterior-posterior diameter of the chest; approximately 4 cm (1.5 inches) for infants and 5 cm (2 inches) for children Allowing complete chest recoil between compressions Minimizing interruptions in chest compressions (trying to limit them to less than 10 seconds) Avoiding excessive ventilation (BLS single rescuer compression-to-ventilation ratio stays at 30:2) AHA ECC Adult Chain of Survival The AHA ECC adult chain of survival is a ﬁve-step course of action used to aid victims of sudden cardiac arrest that can optimize their chance of survival and recovery. The links in the chain are: 1. Immediate recognition of cardiac arrest and activation of the emergency response system. 2. Early CPR with an emphasis on chest compressions 3. Rapid deﬁbrillation 4. Effective advanced life support 5. Integrated post-cardiac arrest care Personal Wellness “The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.” Thomas Edison Today, many people are striving for personal wellness. A century ago, such a goal was unknown, and people counted themselves lucky just to survive. For example, a person born in 1890 could expect to live only 40 years. Infectious disease took the lives of many, and environmental conditions contributed to the spread of disease. Today, our most serious health threats are chronic illnesses such as heart disease or cancer—diseases that we have the power to prevent. Personal wellness requires a holistic approach, or one that meets the physical, emotional, social, spiritual, and economic needs. It is something almost everyone can have, but achieving it requires knowledge, self-awareness, motivation, and effort. 100 UNIT I: THE HEALTHCARE SETTING PERSONAL HYGIENE Personal wellness starts with good personal hygiene. It is important to shower or bathe and use deodorant on a regular basis. Teeth should be brushed and mouthwash used more than once a day if possible. Hair should be clean and neatly combed. Fingernails should be clean, short, and neatly trimmed. Good personal hygiene communicates a strongly favorable impression about an individual. A fresh, clean appearance without heavily scented lotions or colognes portrays health and instills conﬁdence in employees and their patients and employers as well. KEY POINT Phlebotomists should pay special attention to personal hygiene not only for optimal health, but also because their job involves close patient contact. PROPER NUTRITION “Let thy food be thy medicine, and thy medicine be thy food.” Hippocrates, the father of medicine, 500 B.C. Nutrition has been deﬁned as the “act or process of nourishing.” In other words, a food is nutritious if it supplies the nutrients the body needs “to promote growth and repair and maintain vital processes.” The basic purpose of nutrition is to keep us alive, but more importantly, good nutrition provides what the body needs for energy and day-to-day functioning. Physical health depends on eating well. In this fast-paced world, few of us receive the nutrition we need. Even though what we eat is described as the good American diet, in reality, what we eat is not always nutritious. Our food is often so highly processed and chemically altered that it no longer promotes healthy bodies. The American Institute for Cancer Research (AICR) recently published a recommended diet to reduce the risk of cancer. They suggested that a person choose a predominantly plant-based diet rich in a variety of vegetables, fruits, legumes, and minimally processed starchy staple foods. A healthy diet contains the widest possible variety of natural foods. It provides a good balance of carbohydrates, fat, protein, vitamins, minerals, and ﬁber. KEY POINT In general, the amount of food energy (calories) supplied by diet should not exceed the amount of energy expended, so that weight remains relatively constant over time. REST AND EXERCISE Personal wellness requires a nutritious diet, exercise, and getting the right amount of rest (Fig. 3-19). Healthcare workers often complain of fatigue (physical or mental exhaustion). Fatigue brought on by physical causes is typically relieved by sleep. Lack of rest and sleep can lead to medical Figure 3-19 Wellness through proper nutrition, exercise, and rest. CHAPTER 3: INFECTION CONTROL, SAFETY, FIRST AID, AND PERSONAL WELLNESS 101 problems. The typical frantic pace in healthcare facilities today makes it especially important to get the required hours of sleep and to take breaks during the day to rest, refresh, and stay ﬁt. It is even more inportant in this new decade because there seem to be very few moments of peace, quiet, and relaxation even when one is not at work. Studies show that being physically ﬁt increases the chance of staying healthy and living longer. The most accurate measurements of ﬁtness consist of three components—strength (the ability to carry, lift, push, or pull a heavy load), ﬂexibility (the ability to bend, stretch, and twist), and endurance (the ability to maintain effort for an extended period of time). No single measurement of performance classiﬁes a person as ﬁt or unﬁt. If a person becomes breathless after climbing a ﬂight of stairs or hurrying to catch a bus but is otherwise healthy, clearly he or she could beneﬁt from some form of conditioning or exercise. Exercise contributes to improved quality of life on a day-to-day basis. It strengthens the immune system, increases energy, and reduces stress by releasing substances called endorphins, which create a peaceful state. People who exercise tend to relax more completely, even when under stress. Regular physical activity also appears to reduce symptoms of depression and anxiety and to increase the ability to perform daily tasks. Walking is a form of exercise that can easily be incorporated into almost anyone’s life. KEY POINT If activity during work is low to moderate, AICR recommends that a person take an hour’s brisk walk or similar exercise daily because there has been convincing evidence that physical activity helps prevent colon cancer. Weight training is suggested as an excellent strength exercise. Studies have shown that using weights can build bone mass, even in the very elderly. For ﬂexibility, yoga and Pilates are two forms of exercise that emphasize bending, stretching, and twisting. In choosing an exercise activity, it is most important is to pick one that is enjoyable so that you will be more apt to do it routinely. View the Poor and Good Workplace Ergonomics for Phlebotomy and Proper Lifting Technique videos at http:// thepoint.lww.com/ McCall5e. BACK PROTECTION To lead an active and healthy life, you need a healthy back. The spine is designed to withstand everyday movement, including the demands of exercise. Improper lifting and poor posture habits, however, can cause weaknesses. It is estimated that back injuries account for approximately 20% of all workplace injuries and illnesses. Lower back pain is a costly health problem that affects both industry and society in general. Strategies to prevent back injuries include instruction concerning back mechanics and lifting techniques (Fig. 3-20), lumbar support, and exercise. Exercise promotes strong backs; it improves back support and directly beneﬁts the disks in the spinal column. Stress can make a person vulnerable to back problems because of muscle spasms. Keeping back muscles ﬂexible with exercise can alleviate this stress reaction. KEY POINT Healthcare workers are at risk for back injury because of activities they are required to do (e.g., lift and move patients) and because of the stressful environment often associated with healthcare today. Figure 3-20 Lifting techniques. 102 UNIT I: THE HEALTHCARE SETTING BOX 3-11 WAYS TO CONTROL STRESS Identify your problem and talk about it with a close friend, partner, or the person at the source of the problem. Learn to relax throughout the day—close your eyes, relax your body, and clear your mind. Exercise regularly—develop a consistent exercise routine that you can enjoy. Avoid making too many changes at once—plan for the future to avoid simultaneous major changes. Spend at least 15 minutes a day thoroughly planning the time you have. Set realistic goals—be practical about what you can accomplish. Avoid procrastination by tackling the most difﬁcult job ﬁrst. STRESS MANAGEMENT Stress is a condition or state that results when physical, chemical, or emotional factors cause mental or bodily tension. It challenges our ability to cope or adapt. Stress is sometimes useful, keeping us alert and increasing our energy when we need it. Persistent or excessive stress, on the other hand, can be harmful. Evidence suggests that “negative stress” (such as an emergency or an argument) has a damaging effect on personal wellness. Stressful situations are more likely to be damaging if they cannot be predicted or controlled. This fact is particularly apparent where job stress is concerned. Highly demanding jobs are much more stressful if an individual has no control over the workload, as is often the case in healthcare. Stress is more likely to have adverse effects on an individual if social support is lacking or there are personal or ﬁnancial concerns. Although the signs of stress may not be immediately apparent, different organs and systems throughout the body are being affected. The immune system may be weakened, and other symptoms such as hypertension, ulcers, migraines, and nervous breakdowns may eventually result. In the today’s hectic lifestyle and especially in the healthcare environment, it is necessary to manage stress to maintain personal wellness. Box 3-11 lists ways to deal with stress. STUDY AND REVIEW QUESTIONS Visit the EXAM REVIEW for more study questions. 1. Which of the following situations involves a nosocomial infection? a. A man has a bladder infection upon hospital admission. b. An employee contracts hepati

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