Dear HCPro Customer: Enclosed is your latest supplement to the OSHA Program Manual for Dental Facilities. This supplement is designed to keep your product up to date. If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail [email protected]. At HCPro, customer comments and suggestions are very important to us—let us know how we can serve you better. Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book. FILING INSTRUCTIONS Rev. 9/14 OPMFDF Supplement to OSHA Program Manual for Dental Facilities VISIT www.hcmarketplace.com for the latest compliance and training information. Remove Insert Reason for Change Title page Title page updated xvii through xix xvii through xix OSHA Program Manual Contents—updated Tab 7 Contents Tab 7 Contents updated 7-25 through 7-33 7-25 through 7-35 Tab 7: Infection Prevention and Control Plan—updated (Multidrug-Resistant Organisms (MDRO), CDC Classification of MDRO Threats, MDRO Prevention and Control, Colonization vs. Infection, MDRO Transmission, How Antibiotic Resistance Happens) September 2014 Revisions
Transcript
Dear HCPro Customer:
Enclosed is your latest supplement to the OSHA Program Manual for Dental Facilities. This supplement is designed to keepyour product up to date.
If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 ore-mail [email protected]. At HCPro, customer comments and suggestions are very important to us—let usknow how we can serve you better.
Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book.
FILING INSTRUCTIONS
Rev. 9/14 OPMFDF Supplement to OSHA Program Manual for Dental Facilities
VISIT www.hcmarketplace.com for the latest compliance and training information.
Remove Insert Reason for Change
Title page Title page updated
xvii through xix xvii through xix OSHA Program Manual Contents—updated
Tab 7 Contents Tab 7 Contents updated
7-25 through 7-33 7-25 through 7-35 Tab 7: Infection Prevention and Control Plan—updated
(Multidrug-Resistant Organisms (MDRO), CDC Classification of MDRO
Threats, MDRO Prevention and Control, Colonization vs. Infection,
MDRO Transmission, How Antibiotic Resistance Happens)
September 2014 Revisions
About the AuthorSheila Dunn, DA, MT (ASCP), holds a doctoral degree in clinical laboratory science from the Catholic
University of America in Washington, DC. She has helped thousands of outpatient medical facilities comply
with federal regulations such as CLIA and OSHA through her presentations at a nationwide seminar series.
She has written more than 150 articles about regulatory issues and healthcare delivery systems and serves
Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com
9/2014
xvii
Contents
TAB 7: Infection Prevention and Control A Quick Look At TB ...................................................................................... 7-1
TB Transmission .................................................................................................................. 71Risk Factors for Developing Active TB ................................................................................ 72
TB Exposure Control Plan Policy ............................................................... 7-2Overview: How to Protect Staff from Contracting TB at Work ............................................. 73TB Risk Assessment ........................................................................................................... 74
TB Risk Assessment Results (Form 20) ..................................................................... 75Early Identification of Patients with Active TB ..................................................................... 76
Symptoms of TB .......................................................................................................... 76Handout: Cover Your Cough/Wash Your Hands .................................................................. 78Managing Patients with Suspected or Confirmed TB .......................................................... 79
TB Isolation Procedures for CoughInducing and AerosolGenerating Procedures .... 79Respiratory Protection for Dental Workers: N95 Respirators or Medical Powered Air Purifying Respirators (PAPRs) ................................................ 79
Employee TB Skin Testing (TST) ........................................................................................ 710Baseline Employee TST: The TwoStep Tuberculin Skin Test ..................................... 711
TwoStep TST Interpretation ............................................................................... 711Interpretating the TST ......................................................................................... 711False Positive/False Negative TB Tests .............................................................. 712Workers Who Have Had BCG Vaccination ......................................................... 712
Periodic Retesting of Employees ................................................................................ 712Recording TST Results ............................................................................................... 712TST Record (Form 21) ................................................................................................ 713TB Skin Test Declination (Form 22) ............................................................................ 714
Evaluation & Management of Healthcare Employees Exposed to TB ................................ 715Employees with Symptoms of TB ............................................................................... 715Employees Who Have Been Exposed to a Known TB Patient ................................... 715Positive Employee Skin Tests and Skin Test Conversions .......................................... 715TB Exposure Log (Form 23) ........................................................................................ 716Decontaminating Patient Care Area and Equipment ................................................... 717
Employee Training ............................................................................................................... 717
Pandemic Influenza and Other Infectious Diseases ................................. 7-18PrePandemic Planning ....................................................................................................... 718Once A Pandemic Is Announced ......................................................................................... 721OSHA Enforcement for Pandemics ..................................................................................... 723
Identifying Very High and High Exposure Risks .......................................................... 723Dealing with N95 Respirator Shortages ..................................................................... 724Prioritize Your Facility’s Use of N95 Respirators ........................................................ 724Documentation ............................................................................................................ 725
Multidrug-Resistant Organisms (MDRO) ................................................... 7-26CDC Classification of MDRO Threats ................................................................................ 726MDRO Prevention and Control ............................................................................................ 728Colonization vs. Infection .................................................................................................... 728
Pertussis and Worker Vaccination ............................................................. 7-32Healthcare Worker Vaccination Recommendations 2011 ......................... 7-33Supplement: How Antibiotic Resistance Happens ................................... 7-35Supplement: Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care ......................................................... S1–S10Supplement: Guidelines for Infection Control in Dental Healthcare Settings ...................................................................................... 1–66
TAB 8: Master Record FormsGeneral Equipment and Facility Records
Safety Report .......................................................................................................................Form 1Autoclave Log .......................................................................................................................Form 2Eyewash Station Weekly Check Log ....................................................................................Form 2AAnnual OSHA Safety Program (Exposure Control Plan) Review .........................................Form 3Weekly Facility Review Checklist .........................................................................................Form 4AMonthly Facility Review Checklist ........................................................................................Form 4BAnnual Facility Review Checklist ..........................................................................................Form 5Fire Drill Evaluation Form.....................................................................................................Form 5AEmployee Fire Drill Participation Signup Sheet ..................................................................Form 5BHousekeeping Schedule ......................................................................................................Form 6Healthcare Facility Slip, Trip, and Fall Hazard Checklist ......................................................Form 6A
Bloodborne Pathogens RecordsBloodborne Pathogens Exposure Determination List #1......................................................Form 7Bloodborne Pathogens Exposure Determination List #2......................................................Form 8Bloodborne Pathogens PPE Compliance Checklist .............................................................Form 8AFailure to Use PPE ...............................................................................................................Form 8A1Safety Needle/Syringe Evaluation Form ..............................................................................Form 9Sharps Disposal Container Locations ..................................................................................Form 9ABloodborne Pathogens Compliance Checklist: ECP, Training, and Records..................... ..Form 9BSharps Evaluation Results Form ..........................................................................................Form 10Exposure Prevention Checklist ............................................................................................Form 10A
Bloodborne Pathogens Employee Medical RecordsIncident Report/Sharps Injury Log ........................................................................................Form 11Sharps Injury Log .................................................................................................................Form 11AHBV Vaccination Declination Form ......................................................................................Form 12HBV Employee Vaccination Form ........................................................................................Form 13Post Exposure Checklist ......................................................................................................Form 14
xix
Contents
Post Exposure Medical Evaluation Declination Form...........................................................Form 15Source Patient Testing Consent Form ..................................................................................Form 16
Hazard Communication Records Hazardous Substances List ..................................................................................................Form 17
Training RecordsNew Employee OSHA Orientation Checklist ........................................................................Form 18Annual Employee Training Record .......................................................................................Form 19Respiratory Protection Training Record ...............................................................................Form 19AQualitative Respirator Fit Test Report ..................................................................................Form 19B
TB / Infection Control RecordsTB Risk Assessment Results Form ......................................................................................Form 20TST Record ..........................................................................................................................Form 21TB Skin Test Declination ......................................................................................................Form 22 TB Exposure Log ..................................................................................................................Form 23Influenza Vaccine Log ..........................................................................................................Form 24Influenza Vaccine Declination Form (Seasonal and H1N1) ................................................Form 25AChecklist for Infection Prevention for Outpatient Settings ......................................................Form 25BList of Infection Prevention Contact Persons and Roles/Responsibilities ................................Form 25C
Bloodborne Pathogens Standard .........................................................................................91Amended Bloodborne Pathogens Standard (Sharps Safety) ...............................................913Hazard Communication Standard ........................................................................................914Exit Routes, Emergency Action Plans, and Fire Prevention Plans.......................................929Ionizing Radiation .................................................................................................................934Other OSHA Standards for Dental Facilities ........................................................................942
Additional OSHA ResourcesSuggested Work Restriction for Employees ........................................................................943
Key ContactsOSHA Consultative Services State Directory .......................................................................947Directory of States with Approved OSHA Plans ...................................................................950
Acronyms used in the OSHA Program Manual .......................................... 9-52
TAB 7: INFECTION PREVENTION AND CONTROL
Contents
A Quick Look At TB ......................................................................................... 7-1TB Transmission .................................................................................................................... 7-1Risk Factors for Developing Active TB .................................................................................. 7-2
TB Exposure Control Plan Policy .................................................................. 7-2Overview: How to Protect Staff from Contracting TB at Work ............................................... 7-3TB Risk Assessment .............................................................................................................. 7-4
TB Risk Assessment Results (Form 20) ........................................................................ 7-5Early Identification of Patients with Active TB ........................................................................ 7-6
Symptoms of TB ............................................................................................................ 7-6Handout: Cover Your Cough/Wash Your Hands .................................................................... 7-8Managing Patients with Suspected or Confirmed TB ............................................................ 7-9
TB Isolation Procedures for Cough-Inducing and Aerosol-Generating Procedures ....... 7-9Respiratory Protection for Dental Workers: N-95 Respirators or Medical Powered Air Purifying Respirators (PAPRs) ................................................... 7-9
Employee TB Skin Testing (TST) ........................................................................................... 7-10Baseline Employee TST: The Two-Step Tuberculin Skin Test ....................................... 7-11
Two-Step TST Interpretation .................................................................................. 7-11Interpretating the TST ............................................................................................ 7-11False Positive/False Negative TB Tests ................................................................. 7-12Workers Who Have Had BCG Vaccination ............................................................ 7-12
Periodic Retesting of Employees ................................................................................... 7-12Recording TST Results .................................................................................................. 7-12TST Record (Form 21) ................................................................................................... 7-13TB Skin Test Declination (Form 22) ............................................................................... 7-14
Evaluation & Management of Healthcare Employees Exposed to TB ................................... 7-15Employees with Symptoms of TB .................................................................................. 7-15Employees Who Have Been Exposed to a Known TB Patient ...................................... 7-15Positive Employee Skin Tests and Skin Test Conversions ............................................ 7-15TB Exposure Log (Form 23) .......................................................................................... 7-16Decontaminating Patient Care Area and Equipment ..................................................... 7-17
Employee Training ................................................................................................................. 7-17
Page
Pandemic Influenza and Other Infectious Diseases .................................... 7-18Pre-Pandemic Planning ......................................................................................................... 7-18Once A Pandemic Is Announced ........................................................................................... 7-21OSHA Enforcement for Pandemics ....................................................................................... 7-23
Identifying Very High and High Exposure Risks ............................................................. 7-23Dealing with N-95 Respirator Shortages ........................................................................ 7-24Prioritize Your Facility’s Use of N-95 Respirators .......................................................... 7-24Documentation ............................................................................................................... 7-25
Pertussis and Worker Vaccination ................................................................ 7-32Healthcare Worker Vaccination Recommendations 2011 ............................ 7-33Supplement: How Antibiotic Resistance Happens ...................................... 7-35Supplement: Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care ............................................................ S1–S10Supplement: Guidelines for Infection Control in Dental Healthcare Settings ......................................................................................... 1–66
Contents
7-25
OSHA Program Manual for Dental Facilities
Prioritization of Respiratory Protection During Respirator Shortages for Healthcare Personnel Not Participating in Aerosol-Generating Procedures(Numbers 1–4 indicate relative priorities for respiratory protection, with 1 being the highest priority and 4 being the lowest priority) Exposure Scenario Not Vaccinatedb Vaccinatedc
Personnel Without Risk Factors for Influenza-Related Complicationsd
Routine care—frequent close exposuree 2 4Routine care—infrequent close exposuref 3 4
Personnel With Risk Factors for Influenza-Related Complicationsg
Routine care—frequent close exposure 1 3Routine care—infrequent close exposure 2 4a. This table is provided as an example of prioritization that considers intensity and duration of exposure, personal health
risk factors for complications of infection, and vaccination status. Advance planning is critical to efficient implementation of prioritized use during supply shortages.
b. Not vaccinated: not vaccinated or less than 14 days after vaccination. Consider including those with immunosuppressive conditions or treatment with immunosuppressive therapies anticipated to impair vaccine response in this group.
c. Vaccinated: 14 or more days after vaccination.d. See section on “Healthcare Personnel at Higher Risk for Complications of Influenza” for list of personal risk factors for
influenza-related complications; also see: www.cdc.gov/h1n1flu/recommendations.htm.e. Personnel frequently in close contact with patients with suspected or confirmed 2009 H1N1 influenza. For the purposes of this
document, close contact is defined as working within 6 ft. of the patient or entering into a small enclosed airspace shared with the patient (e.g., average patient room). This generally includes personnel working in settings where cases of suspected or confirmed 2009 H1N1 influenza are routinely seen (e.g., emergency departments and primary care in environments such as clinics in outpatient settings, employee healthcare facilities, and correctional facilities).
f. Personnel infrequently in close contact with patients with suspected or confirmed 2009 H1N1 influenza. This generally includes personnel working in settings where cases of suspected or confirmed 2009 H1N1 influenza are not routinely seen and/or having job duties not involving close contact.
g. Gathering of personal information for the purposes of pandemic planning and response must be done in a fashion that is compliant with all applicable rules and regulations, including the Americans with Disabilities Act (ADA). A short technical assistance document is available at the following Web address: www.eeoc.gov/facts/pandemic_flu.html. Consider offering alternative work environments as an accommodation for employees at highest risk for complications of influenza during periods of increased influenza activity or if influenza severity increases.
Source: Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel
DocumentationAs always with OSHA, documentation is a key component to compliance. Be sure you can produce the following:An up-to-date pandemic planConsideration of the hierarchy of controls “Good faith” proof of your effort to provide respiratory protection that is at least as
effective as N-95 respirators If you are prioritizing respirators because of shortages, make sure the plan shows
consideration for: { Vaccination status of workers { Type of procedure (routine care vs. aerosol generating) { Frequency of close exposure (within 6 ft.) { Risk factor of complications (pregnant workers) { Documentation of respirator shortage/evidence of attempt to buy
7-26
OSHA Program Manual for Dental Facilities
Pandemic Resources
1. Enforcement Procedures for High to Very High Occupational Exposure Risk to 2009 H1N1 Influenza, OSHA (www.osha.gov/OshDoc/Directive_pdf/CPL_02_02-075.pdf)
2. Centers for Disease Prevention and Control, CDC (www.flu.gov)3. OSHA Pandemic Influenza Web page (www.osha.gov/dsg/topics/pandemicflu)4. CDC: Middle East Respiratory Syndrome (MERS) (www.cdc.gov/CORONAVIRUS/MERS)
Multidrug-Resistant Organisms (MDRO)Multidrug-resistant organisms (MDRO) are bacteria that have become resistant to certain antibiotics, which means these antibiotics can no longer be used to control or kill the bacteria. Widespread penicillin resistance was first identified in the early 1950s in Staphylococcus aureus, a common bacteria that causes sores, boils, and cellulitis. By the 1980s, more than half of the S. aureus infections in hospitals were resistant to methicillin. Methicillin-resistant S. aureus (MRSA) has long been associated with healthcare-acquired infections (HAI) but is now commonly acquired outside the healthcare setting. The widespread use of antibiotics over time has led to the development of many other MDROs.
In April 2013, the Centers for Disease Control and Prevention (CDC) released a report on Antibiotic Resistance Threats in the United States. The stated purpose of the report was to highlight the seriousness of the threat that antibiotic-resistant organisms pose to high-risk groups, including those with chronic illnesses. CDC estimates that more than 2 million people are sickened by MDRO infections every year resulting in at least 23,000 deaths. CDC states that the estimates are low because it is difficult to determine when someone’s death is primarily caused by infection with antibiotic-resistant bacteria or when other co-existing illnesses may have contributed to or caused death. Even when alternative treatments exist, the data has shown that patients with resistant infections are much more likely to die, and survivors have significantly longer hospital stays, delayed recovery and long-term effects.(see www.cdc.gov/drugresistance/threat-report-2013/pdf.)
CDC Categories of MDRO ThreatsThe CDC has prioritized the MDRO threats into one of three categories: urgent, serious, and concerning. Criteria used to categorize the threats include clinical and economic impact, incidence (rate of infection), 10-year projection on incidence, transmissibility, availability of antibiotics, and barriers to prevention. Bacteria in the CDCs urgent category include:
Clostridium difficile
Although C. difficile is not currently resistant to antibiotics used to treat it, it was included in the CDC assessment because of its unique connection with antibiotic use and the high illness and death rate. CDC estimates that there are at least 250,000 illness and 14,000 deaths from C. difficile annually.
7-27
OSHA Program Manual for Dental Facilities
Carbapenem-resistant Enterobacteriaceae (CRE)
CDC indicates that gram-negative bacteria are particularly worrisome because they are becoming resistant to nearly all drugs that would be considered for treatment. The most serious gram-negative infections are healthcare-associated, and the most common pathogens are Enterobacteriaceae, such as Klebsiella, Pseudomonas aeruginosa, and Acinetobacter. Treating infections with these organisms is identified as an increasing challenge for healthcare because the few remaining effective antibiotics are more toxic, less effective, and often more expensive.
There are 12 bacteria considered to be serious threats. This list includes:
Methicillin-resistant Staphylococcus aureus (MRSA) causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can cause sepsis and death. “Staph” bacteria, including MRSA infections can be very serious and are one of the most common causes of healthcare associated infections. CDC estimates there were more than 80,000 invasive (serious) MRSA infections and 11,000 related deaths in 2011. It is unknown how many lesser infections occur each year.
Staph is commonly found on the skin and nasal mucous membranes of healthy people. It may also be found in chronic sores such as those caused by psoriasis or eczema.
Drug Resistant Streptococcus pneumonia
Streptococcus pneumonia is the leading cause of bacterial pneumonia and meningitis in the U.S. It can also cause bloodstream, ear, and sinus infections. It is estimated that pneumococcal disease causes 4 million disease episodes and 22,000 deaths annually. Pneumococcal ear infections (otitis media) are the most common type of pneumococcal disease among children, causing 1.5 million infections that often result in antibiotic use. It is estimated that the hospitalization costs associated with pneumococcal disease are greater than $96 million each year. Pneumococcal vaccines introduced in 2010 protect against infections with the most resistant strains. This has led to a decrease in the number of infections with resistant strains. If this trend continues, this threat might be reclassified to “concerning.” Drug-resistant tuberculosis
Infections with multidrug-resistant and extensively drug-resistant tuberculosis (MDR and XDR TB) are increasing threats outside of the U.S. In the U.S., infections are uncommon because of prevention and protection programs. Healthcare workers are educated about risks and TB skin testing is a routine part of healthcare hiring practices. If the infection rates of MDR and XDR TB increase within the U.S., this antibiotic-resistant threat will change to urgent as TB is readily transmitted via respiratory secretions and treatment options are limited.
Bacteria in the concerning threats include:Vancomycin-resistant Staphylococcus aureus (VRSA)Erythromycin-resistant Group A StreptococcusClindamycin-resistant Group B Streptococcus
7-28
OSHA Program Manual for Dental Facilities
Although there are multiple effective treatment options at this time, these organisms cause severe illness and require monitoring. In some cases, rapid outbreak response might be required.
MDRO Prevention and ControlIn general, healthy people are at low risk of becoming infected with MDROs. The risk of infection is increased if you have:
An existing severe illness.A hospital or nursing home admission in the previous year, with at least one underlying
chronic illness such as diabetes, chronic kidney disease, skin lesions, or HIV.Previous prolonged use of antibiotics.Previous MDRO infection or colonization.A suppressed immune system or are elderly.Frequent procedures, such as hemodialysis.
Colonization vs. Infection
Colonization refers to the presence of microorganisms with growth and multiplication, but without tissue invasion or damage. In the case of MRSA, the body site most commonly colonized is the anterior nares (nose). Other body sites often colonized with MRSA include open wounds, the respiratory tract, perineum, upper extremities, umbilicus (in infants), urinary tract, and axilla (armpits). MRSA colonization can serve as a reservoir for the spread of these microorganisms to others and can lead to infection in the host. Colonized patients are also known as asymptomatic carriers.
Infection is the entry and multiplication of microorganisms in the tissues of the host, leading to local or systemic signs and symptoms of infection.
MDRO Transmission
MDRO infections can occur anywhere on/in the body:SkinBloodstreamUrinary tractWoundsSurgical site
Several factors make for easy MDRO transmission. NIOSH has identified these factors as the five Cs:Crowding.Frequent skin-to-skin Contact.Compromised skin (i.e., cuts or abrasions).Contaminated items or surfaces. Lack of Cleanliness.
7-29
OSHA Program Manual for Dental Facilities
Patients who already have an MDRO infection or who carry the bacteria on their bodies but do not have symptoms (i.e., are colonized) are the most common sources of transmission.
Effective efforts to eliminate MDRO transmission are guided by four main tenets: Using proper precautions when treating MDRO patients in the facility.Decreasing the probability of harboring MDROs in the environment.Taking appropriate actions if employees are infected with MDROs.Eliminating the overuse of antibiotics.
Patient Precautions
Flag records of MDRO-positive patients. Treat patients formerly infected with MDRO as potentially contagious, unless three or more surveillance cultures indicate otherwise.
When possible, schedule a patient who is known to have MDRO as the last appointment of the day. If the patient cannot be scheduled at the end of the day, add 15 minutes onto the appointment time to allow for adequate decontamination following the patient visit.
Provide staff members with education and training in patient precautions that aid in the prevention of MDRO transmission. Perform staff training during initial workplace orientation and also during periodic educational updates for dental personnel. Refer to specific organizational experience with resistant bacteria and prevention strategies whenever applicable.
Hand HygieneThe main mode of transmission for most MDROs is via hands (especially healthcare workers’ hands), which may become contaminated by contact with: Colonized or infected patients. Colonized or infected body sites of the personnel themselves, or devices, items, or
environmental surfaces contaminated with body fluids containing MDROs.
Handwashing is the first and best step to stopping the spread of MDROs. Staff members will:Wash hands using soap and water or alcohol-based hand sanitizers. It is important to
note that the spores of C. difficile are not killed by alcohol-based hand sanitizers. Soap and water is always required for potential contact with C. difficile.
Wash and dry hands thoroughly before and after contact with every patient.Wash and dry hands thoroughly after handling any potentially contaminated equipment.Wash and dry hands thoroughly after removing gloves.Wash and dry hands before touching items such as keyboards, instrument controls, exam
tables, and positioners for x-rays or MRIs to avoid cross-contamination.
The leadership and healthcare providers should be accountable for implementing a culture that supports and promotes appropriate hand hygiene practices.
7-30
OSHA Program Manual for Dental Facilities
Contact PrecautionsMDRO-infected patients can be cared for safely. Contact precautions are necessary to prevent cross-contamination to other patients and dental workers:Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated
items. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of MDROs (e.g., non-intact skin, fecal material, wound drainage, and mucous membranes). Because environmental surfaces may be contaminated, don gloves before or upon entry to a patient area. Remove gloves before leaving the patient area and wash hands immediately. Dry hands completely. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s environment to avoid transfer of microorganisms to other patients and environments.
Wear a surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.
Wear a gown to protect skin and prevent soiling of clothes during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions or cause soiling of clothing. Examples are if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. Don the gown upon entry to the patient area and remove it before leaving.
Disinfect reusable patient care equipment according to the manufacturer’s directions or discard single-use items that are soiled with blood, body fluids, secretions, or excretions. An appropriate disinfectant is a 1:10 solution of ordinary household bleach, made up fresh daily, or an equivalent EPA-approved commercial product. Consider using disposable patient care items (e.g., blood pressure cuffs and tourniquets) for a known MDRO patient.
Handle, transport, and process used linen soiled with blood, body fluids, secretions, or excretions in a biohazardous labeled container.
Use care when giving injections or placing IVs. Ensure that the site is covered immediately and blood from the puncture wound does not contact the pads or table. Clean and decontaminate any soiled areas immediately.
Have patients change into clean or disposable garments prior to their examination.
Note: Suspect and confirmed cases of tuberculosis require airborne precautions regardless of whether the TB is multidrug resistant.
Environmental Cleaning
By decreasing the probability of harboring MDRO, in the environment, the risk of transmitting MDROs is reduced.
Clean rooms and equipment with an EPA-approved hospital-level disinfectant; follow the manufacturer’s instructions. Focus on obviously soiled surfaces and frequently touched surfaces. There is no need to routinely clean and disinfect walls, window drapes, and other vertical surfaces unless visibly soiled. Discard solutions used for cleaning and disinfection after use.
7-31
OSHA Program Manual for Dental Facilities
Environmental cleaning procedures should include the following:Visually inspect all exam tables, exam chairs, pads, etc., between patients. If body fluids
are noted, disinfect immediately.Clean all surfaces of exam tables, exam chairs, pads, etc., with an appropriate
disinfectant at least daily.Once per month, inspect exam tables, exam chairs, and pads to check for fraying or tearing. If
present, replace or repair since torn surfaces are not easily cleaned and disinfected. Enclose any pillows used in waterproof coverings. Decontaminate covers daily (or
immediately, if body fluids are noted). If a patient has an open wound or history of MDROs, completely clean and disinfect the
exam table, exam chair, and any pads, etc., before the next patient.Periodically clean the upholstered furniture and furnishings in patient waiting areas. Keep the environment as clean and dry as possible. Clean and dry all equipment after use.
Infected Employees
Workers in all healthcare settings, clinical and nonclinical, may be colonized or infected similarly to individuals from communities where MDROs are present. For example, community-acquired MRSA (CA-MRSA) is becoming increasingly prevalent. It should not be assumed that a healthcare worker with MRSA has been infected from the workplace.
Unless advised by a healthcare provider, workers should not be routinely excluded from going to work, according to the CDC. Employees will keep areas of the skin affected by MRSA covered. A worker with wound drainage (i.e., pus) will cover the area with clean, dry bandages and follow his or her healthcare provider’s instructions on proper care of the wound. Since pus from infected wounds can contain MRSA, keeping the infection covered will help prevent the spread of MRSA to others.
Work exclusions should be reserved for: Employees with wound drainage that cannot be reliably contained by a dressing or other
barrier method or workers who cannot maintain good hygiene practices.Employees with active infections who participate in activities in which skin-to-skin contact
with affected skin areas is likely to occur.Employees that work in sterile areas or participate in invasive procedures.Employees that are febrile or show other symptoms of MDRO infection.
Culturing to establish colonization is generally not indicated. No work restrictions are necessary for colonized personnel unless they have been epidemiologically implicated in Staphylococcus aureus transmission within the facility.
If there is evidence linking a healthcare staff member to ongoing transmission of any MDRO, obtain the proper cultures from the individual for evaluation. In the case of MRSA, use one sterile swab moistened with sterile saline. Gently swirl the swab in each anterior nare (i.e., the opening of each nostril) for two to three seconds. The same swab can be used for both nares.
7-32
OSHA Program Manual for Dental Facilities
Place the swab in a transport system and label prior to shipping to a qualified laboratory for identification and susceptibility testing. The laboratory should be instructed to screen the specimen for MRSA only.
Treatment of a MRSA carrier state among dental workers appears to have no effect on the spread of MRSA. Therefore, routine decolonization of staff members is not recommended.
MDRO Resources
1. Antibiotic Resistance Threats in the United States, 2013, CDC2. CDC Campaign to Prevent Antimicrobial Resistance in HealthCare Settings3. OSHA Hospital eTool—MRSA. www.osha.gov/SLTC/etools/hospital/hazards/mro/mrsa/
mrsa.html.4. CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings 2007. www.cdc.gov/ncidod/dhqp/gl_isolation.html.5. CDC: Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroguideline2006.pdf.6. NIOSH: “MRSA and the Workplace.” www.cdc.gov/niosh/topics/mrsa.
Pertussis and Worker VaccinationReports of whooping cough (pertussis) were at an all-time high in the U.S. during 2010 and 2011, according to the CDC. The ongoing pertussis reports prompted the Advisory Committee on Immunization Practices (ACIP) to update the vaccination guidelines for healthcare workers in February 2011.
ACIP recommends a single dose of Tdap for healthcare personnel who have not previously received Tdap as an adult regardless of age and have direct patient contact. Tdap vaccination can protect healthcare personnel against pertussis and help prevent them from spreading it to their patient. Priority should be given to vaccinating those who have direct contact with babies under 12 months of age.
This change is included in the Healthcare Worker Vaccination Recommendations Revised 2011) table in Tab 12 of the OSHA Program Manual. Tdap can be administered regardless of interval since the previous Td dose.
NOTE from APIC Recommendations: Healthcare personnel include but are not limited to physicians and medical students, other primary care providers, nurses and nursing students, aides, respiratory therapies, radiology and laboratory technicians, dental professionals and students, social workers, chaplains, volunteers, dietary, clerical workers, and support staff.
ACIP also made amended post-exposure prophylaxis recommendations for healthcare personnel who have already received Tdap vaccine. Staff members who “are exposed and are expected to have contact with persons at high-risk of severe pertussis disease (e.g.,
7-33
OSHA Program Manual for Dental Facilities
hospitalized neonates and pregnant women) need to receive post-exposure prophylaxis,” according to ACIP. If a vaccinated staff member has been exposed but is not in contact with at-risk patients, the facility has the option of providing postexposure prophylaxis or monitoring the worker for 21 days after exposure and treating at the onset of signs and symptoms of pertussis.
The ACIP changes are recommendations only. There is no specific requirement under federal OSHA to provide the Tdap vaccination to potentially exposed workers, but OSHA could cite the employer under the General Duty Clause for failing to protect workers from hazards that were known to be present in the workplace. It is important to note that pregnant women should receive a Tdap during each pregnancy to provide material pertussis antibodies for the newborn. Even though the DTaP immunization series begins at 2 months of age, newborns are at high risk for pertussis until they are over 12 months and they have had three of the five DTaP immunizations. Family members of the newborn are also encouraged to be up to date with their Tdap Immunizations.
Employers should also check with their state health department for regulations specific to pertussis vaccination: www2a.cdc.gov/nip/StateVaccApp.
Healthcare Worker Vaccination Recommendations (Advisory Committee on Immunization Practices, Updated November 25, 2011)
Vaccine Recommendations in briefHepatitis B (HB) recombinant vaccine
Preexposure: Healthcare personnel (HCP)at risk for exposure to blood or body fluids; or postexposure as indicated. 2 doses 4 weeks apart; third dose 5 months after second; booster doses not necessary; all doses should be administered IM in the deltoid.
Hepatitis B immune globulin (HBIG)
Postexposure prophylaxis. 0.06 mL/kg IM as soon as possible after exposure, if indicated.
Influenza vaccine (TIV and LAIV)
All HCP. Annual vaccination with current seasonal vaccine. TIV is available in IM and ID formulations. LAIV is administered intranasally.
Measles live-virus vaccineVaccination should be recommended for all HCP who lack presumptive evidence of immunity;¶ vaccination should be considered for those born before 1957. 2 doses SC; ≥28 days apart.
Mumps live-virus vaccineVaccination should be recommended for all HCP who lack presumptive evidence of immunity.†† Vaccination should be considered for those born before 1957. 2 doses SC; ≥28 days apart
Rubella live-virus vaccineVaccination should be recommended for all HCP who lack presumptive evidence of immunity.§§. 1 dose SC; (However, due to the 2-dose requirements for measles and mumps vaccines, the use of MMR vaccine will result in most HCP receiving 2 doses of rubella-containing vaccine.)
Tetanus and diphtheria (toxoids) and acellular pertussis (Tdap)
All HCP, regardless of age. 1 dose IM as soon as feasible if Tdap not already received and regardless of interval from last Td. After receipt of Tdap, receive Td for routine booster every 10 years.
All HCP who do not have evidence of immunity defined as: written documentation of vaccination with 2 doses of varicella vaccine: laboratory evidence of immunity††† or laboratory confirmation of disease; diagnosis or verification of a history of varicella disease by a health-care provider,§§§ or diagnosis or verification of a history of herpes zoster by a health-care provider. 2 doses SC 4--8 weeks apart if aged ≥13 years.
Varicella-zoster immune globulin
Persons without evidence of immunity who have contraindications for varicella vaccination and who are at risk for severe disease and complications¶¶¶ known or likely to be susceptible who have direct, nontransient exposure to an infectious hospital staff worker or patient. 125U/10 kg IM (minimum dose: 125U; maximum dose: 625U) 125U/10 kg IM (minimum dose: 125U; maximum dose: 625U)
Abbreviations: IM = intramuscular; HBV = hepatitis B virus; HBsAg = hepatitis B surface antigen; SC = subcutaneous; HIV = human immunodeficiency virus; MMR = measles, mumps, rubella vaccine; TB = tuberculosis; HAV = hepatitis A virus; IgA = immune globulin A; ID = intradermal; TIV = trivalent inactivated split-virus vaccines; LAIV = live attenuated influenza vaccine;
* Persons who provide health care to patients or work in institutions that provide patient care (e. g., physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, hospital volunteers, and administrative and support staff in health-care institutions). Source: U.S. Department of Health and Human Services. Definition of health-care personnel (HCP). Available at http://www.hhs.gov/ask/initiatives/vacctoolkit/definition.htmlExternal Web Site Icon.
† Health-care personnel and public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids include acupuncturists, dentists, dental hygienists, emer- gency medical technicians, first responders, laboratory tech-nologists/technicians, nurses, nurse practitioners, phlebotomists, physicians, physician assistants, and students entering these professions. Source: CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. Part II: immunization of adults. MMWR 2006;55 (No. RR-16).
§ The package insert should be consulted to weigh the risks and benefits of giving HBIG to persons with IgA deficiency, or to persons who have had an anaphylactic reaction to an IgG containing biologic product.
¶ Written documentation of vaccination with 2 doses of live measles or MMR vaccine administered ≥28 days apart, or laboratory evidence of measles immunity, or laboratory confirmation of measles disease, or birth before 1957.
** Persons immunocompromised because of immune deficiency diseases, HIV infection (who should primarily not receive BCG, OPV, and yellow fever vaccines), leukemia, lymphoma or general-ized malignancy or immunosuppressed as a result of therapy with corticosteroids, alkylating drugs, antimetabolites, or radiation.
†† Written documentation of vaccination with 2 doses of live mumps or MMR vaccine administered ≥28 days apart, or laboratory evidence of mumps immunity, or laboratory confirmation of mumps disease, or birth before 1957.
§§ Written documentation of vaccination with 1 dose of live rubella or MMR vaccine, or laboratory evidence of immunity, or laboratory confirmation of rubella infection or disease, or birth before 1957, except women of childbearing potential who could become pregnant; though pregnancy in this age group would be exceedingly rare.
¶¶ Source: CDC. Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR 2001;50:1117.
*** Source: CDC. Update on adult immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1991:40 (No. RR-12).
††† Commercial assays can be used to assess disease--induced immunity, but they often lack sensitivity to detect vaccine-induced immunity (i.e., they might yield false-negative results).
§§§ Verification of history or diagnosis of typical disease can be provided by any health-care provider (e.g., school or occupational clinic nurse, nurse practitioner, physician assistant, or physician). For persons reporting a history of, or reporting with, atypical or mild cases, assessment by a physician or their designee is recommended, and one of the following should be sought: 1) an epidemiologic link to a typical varicella case or to a laboratory--confirmed case or 2) evidence of laboratory confirmation if it was performed at the time of acute disease. When such documentation is lacking, persons should not be considered as having a valid history of disease because other diseases might mimic mild atypical varicella.
¶¶¶ For example, immunocompromised patients or pregnant women.
7-35
OSHA Program Manual for Dental Facilities
Simply using antibiotics creates resistance. These drugs should only be used to treat infections.
Fertilizer or water containing animal feces and drug-resistant bacteria is used on food crops.
Animals get antibiotics and develop resistant bacteria in their guts.
George gets antibiotics and develops resistant bacteria in his gut.
Drug-resistant bacteria in the animal feces can remain on crops and be eaten. These bacteria can remain in the human gut.
Drug-resistant bacteria can remain on meat from animals. When not handled or cooked properly, the bacteria can spread to humans.
Healthcare Facility
Resistant bacteria spread to other patients from surfaces within the healthcare facility.
Resistant germs spread directly to other patients or indirectly on unclean hands of healthcare providers.
George stays at home and in the general community. Spreads resistant bacteria. George gets care at a
hospital, nursing home or other inpatient care facility.
Vegetable Farm
Patientsgo home.
How Antibiotic Resistance Happens
Examples of How Antibiotic Resistance Spreads
4.Some bacteria give
their drug-resistance to other bacteria, causing
more problems.
3.The drug-resistant
bacteria are now allowed to grow and take over.
1. Lots of germs.
A few are drug resistant.
2. Antibiotics kill
bacteria causing the illness, as well as good bacteria protecting the body from
infection.
CS239559
Source: The Centers for Disease Control and Prevention 2013 annual report.
