Healthcare safety solutions newsletter

Transcription

1 Healthcare safety solutions newsletter 4th Quarter 2014 Inside this issue: This document focuses on: Ebola outbreak: Tips for protecting workers Hand hygiene in the healthcare setting The dangers of Hepatitis C EBOLA OUTBREAK: TIPS FOR PROTECTING WORKERS Clayton Shoup, CSP, CIH, Workers Compensation Line of Business Director While Ebola outbreaks are generally limited to Africa, the latest outbreak raises some important implications for travelers, the healthcare industry and travel related services due to the potential for disease spread. This article outlines some of the strategies that can be used to address this issue. Introduction Ebola virus disease (EVD) is a type of filovirus that causes a serious hemorrhagic fever that begins with a fever and nausea and can lead to multiple organ failure and death. Filoviruses belong to a virus family called Filoviridae and can cause severe hemorrhagic fever in humans and nonhuman primates. EVD first appeared in Africa in 1976 and has reoccurred in periodic outbreaks since that time. The current outbreak in Western Africa began in January 2014 and has surpassed the size of any previous outbreak. Currently the outbreak is focused in Liberia, Guinea, Sierra Leone and Nigeria. The spread to Nigeria occurred through the air travel of an infected person. According to the World Health Organization (WHO), the number of cases of EVD has risen steadily and as of the writing of this article, over 5300 cases have been documented. It has a very high mortality rate, with deaths occurring in over 2600 cases. It is for this reason that concern has been raised regarding this outbreak and the possible spread through humanitarian activities and global travel. This article provides background on the current assessment of the Ebola outbreak in Western Africa and provides guidance for businesses in managing the Ebola threat. As with any emerging disease outbreak, the information on Ebola is changing and current references should be monitored periodically for up to date information. A list of useful references is included at the end of this document. Discussion Ebola virus disease (EVD) is a member of the filovirus family and comprises five distinct species. Three of the five specifies have been associated with outbreaks in Africa while the other two species have not. The species associated with the current Western Africa outbreak, Zaire ebolavirus, has been associated with about half of the prior outbreaks. Thus far the cases have all occurred in Africa and no cases have been documented in the Western Hemisphere. Typical symptoms of EVD begin with a sudden onset of fever, weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash and impaired liver/kidney function and jaundice. In some cases massive organ failure occurs and internal/external bleeding is noted. There are no vaccines or confirmed treatments. Severely ill patients need intensive support including oral rehydration with electrolytes or intravenous fluids. Unlike the common cold or flu, EVD is not transmitted through casual contact such as being in the vicinity of an infected person as they cough. Direct contact of open wounds or mucous 1

2 The source of the virus and transmission to humans appears to be exposure to diseased animals including chimpanzees, gorillas, monkeys, forest antelope and porcupines. membranes with contaminated blood, other bodily fluids or organs is needed to transmit the virus. EVD can remain on surfaces, so surfaces contaminated with these fluids can also transmit the disease. The incubation period for EVD can range from 2 to 21 days. Some body fluids may retain the virus longer even in asymptomatic individuals. The source of the virus and transmission to humans appears to be exposure to diseased animals including chimpanzees, gorillas, monkeys, forest antelope and porcupines. The ultimate repository of the virus is likely to be fruit bats that are common in the tropical rain forests in these regions of Africa. Human to human transmission occurs through contact of open wounds and mucous membranes of bodily fluids from an infected person. Another important source of transmission has been in the healthcare setting where resources are strained and the use of standard precautions is not universally followed. Most incidences of EVD have been transmitted through contact with animals, close contact with care givers either in the home or healthcare setting or during burial proceedings. Public health and healthcare resources in this region of Africa are strained, resulting in limited public education of the Ebola threat and difficulties in enforcement of public health actions, such as limiting public gatherings and quarantines. In some areas, screening of passengers in airports prior to boarding of air flights has begun. Due to the threat of transmission, the US Centers for Disease Control (CDC) has issued a travel advisory urging individuals to avoid non-essential travel to this region. If travel for essential or humanitarian purposes is necessary, travelers should use caution and avoid live animals, practice good personal hygiene, particularly hand washing, and avoid contact with individuals who are ill. If caring for the ill, significant precautions as outlined below are necessary. Travelers are also advised to monitor their health and seek immediate medical attention if any symptoms, such as fever, nausea, etc. occur. Guidance Ebola is not transmitted through the air like the common cold, the flu or other common illnesses. Transmission occurs only through contact with raw milk, meat and other fluids from infected animals or contact with the bodily fluids (e.g., blood, saliva, etc.) of infected individuals. The following suggestions are based on information from the WHO and CDC as best practices for preparing for and addressing the Ebola threat. Healthcare setting: Information regarding the EVD threat and appropriate actions to be taken should be communicated to all staff that may have potential patient contact. In addition, as appropriate, staff should be retrained on skills for infection prevention and control. Frontline healthcare providers (particularly ER, intake and primary care workers) should be acutely aware of the symptoms of EVD and prepared to implement standard (or universal) precautions when warranted. Staff should inquire about travel or recent contact with travelers when evaluating patients. Standard (or universal) precautions should be followed for all patients presenting with fever, nausea, muscle pain, etc. even prior to detailed examination or laboratory testing. This includes both patients and staff using surgical type masks for droplet protection and practicing good personal hygiene (particularly hand washing). Once Ebola is suspected, the patient should be moved to an isolation type room and staff should follow contact precautions as outlined by the CDC guidance referenced at the end of this document. Exposure of staff and family members to patients with suspected or confirmed cases should be controlled. Laboratory samples from patients are an extreme biohazard risk and testing should be performed under maximum biological containment conditions. Cleaning personal should follow the CDC guidance in handling any soiled laundry or equipment/surfaces that may have contacted body fluids. Laundry and equipment should be cleaned following standard disinfection protocols or incinerated if heavily soiled. Deceased EDV patients should be handled with the same level of precautions as infected individuals and buried in body bags and sealed caskets as soon as practical. 2

3 Employees or visitors who have traveled to the Western Africa should monitor themselves for symptoms for 21 days. Humanitarian Efforts: Due to the size of the current outbreak and the strained public health and healthcare resources within the region, many humanitarian organizations are sending volunteers to the area to assist. These volunteers should follow the same precautions during patient care and support services as those listed earlier for the healthcare setting, while also following many of the general business advice discussed below. Travel Related Setting: Some countries in Western Africa have instituted screening at airports and border crossings watching for individuals with high fever and other illness. Individuals (e.g., passengers or crew members) who have been exposed to Ebola should not travel on commercial airplanes until they have been monitored for symptoms for 21 days and been cleared by a physician. Based on CDC guidance, crew members on a flight where a passenger or crew member becomes ill with fever, jaundice or bleeding should separate the sick person as much as possible from others. Provide a surgical mask to prevent droplet spread. Use impermeable gloves during direct contact of blood, other bodily fluids or items contaminated with blood (e.g., syringes). Crew members should practice good personal hygiene (particularly hand washing). Airlines may wish to provide universal precaution kits for crews. The captain of an aircraft bound for the United States is required to report onboard ill travelers to the CDC prior to arrival, in addition to following company procedures for in-flight medical consultation or obtaining medical assistance. Additional guidance from the CDC is provided in the reference at the end of this document. General Business Setting: Given the U.S. CDC s travel advisory, businesses should seriously consider postponing business related travel to the areas of Western Africa where the Ebola outbreak is occurring. That being said, exposure to Ebola in the general business setting appears to be less than that in the healthcare industry. Employees or visitors who have traveled to the Western Africa should monitor themselves for symptoms for 21 days. If these employees or visitors develop symptoms, they should not come to work and seek medical attention immediately. Prior to visiting the healthcare facility, they should call ahead of time and make the facility aware of the potential of Ebola exposure so that isolation precautions can be taken upon arrival. If travel to affected areas is necessary, the WHO and CDC suggest: o Individuals planning to work/meet in a healthcare setting should carefully follow standard precautions and infection control. Travelers should avoid contact with animals (alive or dead) and assure that any milk consumed is pasteurized and meat is cooked thoroughly. Also, facilities that prepare meats (such as slaughter houses) should be avoided. Avoid close, unprotected contact with sick people. Ensure good personal hygiene (particularly thorough hand washing). Employees traveling to Western Africa should consult with their physician regarding appropriate vaccinations and other inoculations before the trip. If employees traveling in Western Africa note symptoms, they should seek medical care locally before returning home. This helps minimize the chances of disease spread while traveling. If possible, they should use healthcare facilities with a good track record of infection control/ treatment. Travel protection services, if engaged prior to travel, may assist in identifying appropriate medical providers and in providing other assistance to the traveler. Should an employee or visitor become ill while on premises, prompt medical attention should be provided and cleaning staff should use EPA suggested disinfectants and cleaning methods. 3

4 Healthcare facilities should be proactive in staff education and patient treatment. Conclusion The current Ebola outbreak is limited to Western Africa and has generally been associated with contact with diseased individuals from close contact by caregivers either at home or in the healthcare setting. Standard precautions should be used universally to minimize potential disease spread by sick individuals. Healthcare facilities should be proactive in staff education and patient treatment. Other businesses should seriously consider delaying business travel to Western Africa, but if necessary, educate employees on ways to protect themselves. As with any emerging disease outbreak, the information on this Ebola outbreak is changing and current references should be monitored periodically for up to date information. References World Health Organization: disease/ebola/en/ U.S. Centers for Disease Control: vhf/ebola/index.html CDC Ebola Guidance for Airlines: quarantine/air/managing-sick-travelers/ebolaguidance-airlines.html CDC Guidance for Management of Ebola Patients in Hospitals: CDC Guidance for Environmental Infection Control in Hospitals for Ebola Virus: gov/vhf/ebola/hcp/environmental-infectioncontrol-in-hospitals.html HAND HYGIENE IN THE HEALTHCARE SETTING Elizabeth Moreland, CSP, CHSP, ARM Casualty Healthcare Segment Leader Proper hand hygiene is one of the best ways to keep from getting sick and prevent germs from being spread to others. For hospitals, nursing homes and other healthcare facilities, hand hygiene is particularly important to control disease transmission. Introduction Hand hygiene refers to hand washing, antiseptic hand wash/hand rubs, or surgical hand antiseptics. According to the Centers for Disease Control and Prevention (CDC), appropriate hand washing results in a reduced incidence of both nosocomial (acquired in a healthcare facility) and community infections. Healthcare workers report that various factors contribute to poor compliance with hand hygiene. These include: Working in units with high patient demands, such as ICUs and Emergency Rooms Believing that wearing gloves eliminates the need to wash ones hands Complaints of hand dryness or irritation due to repeated hand washing Inconvenient location of sinks Lack of soap or towels Usage of unapproved soaps and/or lotions It is important that employers educate employees on the importance of hand hygiene and proper hand washing techniques, along with providing the essential products (soaps, towels, sinks, alcohol-based products) to insure good hand hygiene is practiced. General hand hygiene tips It is best to wash your hands with soap and running water. Use alcohol based hand rubs when soap and water are not available. These hand rubs, rinses, or gels can significantly reduce the number of germs on the skin and are fast acting. 4

5 Antimicrobial soap mechanically removes, kills or inhibits microbial flora. Hand washing Tips The components of good hand washing include using an adequate amount of soap, rubbing hands together to create friction, and rinsing under running water. The action of drying the hands also helps to remove most of the transient bacteria present. Prompt and thorough hand washing between patients and after contact with blood and other body fluids is an important component of infection control and body substance isolation procedures. Repeated use of HOT (vs. warm) water to wash hands may increase the risk of dermatitis. To help protect exposure to infectious materials, hands should be washed before and after: Work Eating Smoking Using Personal Protective Equipment (i.e. gloves) Each patient contact Putting in contact lenses Applying makeup In addition, hands should be washed after: Handling uncooked foods, particularly raw meat, poultry or fish Changing diapers or cleaning up a child who has gone to the bathroom After using the bathroom (*) Handling garbage Handling animal or animal waste Blowing your nose, coughing, or sneezing The Occupational Safety and Health Administration (OSHA) standard for Bloodborne Pathogens hand washing requirements include: Employers must ensure employees who come in contact with blood or other potentially infectious materials wash their hands and other skin with soap and water or flush mucous membranes with water as soon as feasible after contact. Employers must provide readily accessible hand washing facilities and insure employees wash their hands immediately or as soon as feasible after removal of gloves. When hand washing is not feasible, the employer may provide either an appropriate antiseptic hand cleaner in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleaners or towelettes are used, hands should be washed with soap and running water as soon as feasible. (*) Studies show that up to 30% of individuals do not regularly wash their hands after using the restroom. By not washing their hands, people may be spreading germs (present in our bodies and in the restroom environment) onto every surface they touch. For example, Hepatitis A is commonly spread through poor restroom practices, as are many food borne outbreaks. It is also good practice to use a disposable towel to open a restroom door for exiting after hand washing. PROPER HAND HYGIENE TECHNIQUES Hand washing with plain or antimicrobial soap and water Plain soap mechanically removes transient bacteria from the skin, but does not kill bacteria released by the shedding of dead skin cells. Antimicrobial soap mechanically removes, kills or inhibits microbial flora. There are varying levels of activity among antimicrobial soap products. Place hands together under water (preferably warm) Apply soap (according to the manufacturers directions) and rub your hands together for at least seconds. Wash all surfaces well, including wrists, palms, backs of hands, fingers, thumbs and under the fingernails. Clean dirt from under your fingernails. Rinse the soap from your hands. Use towel to turn off the faucet. Dry your hands completely with a clean towel if possible. If towels are not available, it is okay to air dry your hands. Pat your skin rather than rub, to avoid chapping and cracking. If you use a disposable towel, throw it in the trash. 5

6 To control the spread of communicable and nosocomial infection, hospitals, nursing homes and other healthcare facilities should enforce strong hand hygiene procedures to all employees who provide products, services, or patient care to residents or patients. Hand hygiene with alcohol based products (hand rubs, rinses, gels) Antiseptic hand rubs kill or inhibit microbial flora, but do not remove soil. For this reason, alcohol products should not be used in lieu of soap and water when visible dirt is present. Apply product (with amount applied according to manufacturers directions) to palm of one hand. Rub hands together. Cover all surfaces of hands and fingers. Rub until hands are dry. It is not necessary, or recommended, to routinely WASH hands after application of alcohol-based products. While antimicrobial-impregnated wipes are considered equivalent to hand washing, they should not be a substitute for alcohol hand rubs or antimicrobial soap. Surgical hand antisepsis with antimicrobial soap or alcohol-based hand rubs The purpose of this procedure, which is performed prior to surgical procedures and before donning sterile gloves, is to eliminate transient microorganisms and reduce resident hand flora. Remove rings, watches, bracelets before beginning a surgical hand scrub. Use a nail cleaner and running water to remove debris from under fingernails. When using antimicrobial soap on hands and forearms, scrub for at least 2-6 minutes or as recommended by the manufacturer or company policy/procedure. When using an alcohol-based surgical hand scrub product with persistent activity, prior to donning the sterile gloves, the employee should prewash hands and forearms with a non-antimicrobial soap by: Drying hands and forearms completely Applying the alcohol-based product as recommended (at least 120 seconds). Allowing the hands and forearms to dry completely. Tips regarding fingernails Because pathogenic organisms can survive under and around fingernails, it is important to pay attention to these areas while washing or using alcohol hand rubs for cleaning. Freshly applied nail polish does not increase the number of germs present, but chipped polish may harbor bacteria. Those persons with artificial nails may harbor even higher counts of bacteria than those who do not wear them. It is recommended that healthcare personnel in high-risk areas not wear artificial nails. Summary To control the spread of communicable and nosocomial infection, hospitals, nursing homes and other healthcare facilities should enforce strong hand hygiene procedures to all employees who provide products, services, or patient care to residents or patients. Hand hygiene training, enforcement of hand hygiene rules, and providing adequate and appropriate cleaning supplies are important steps to insure infection control in the healthcare environment. References Hand Hygiene for Healthcare Workers. Association for Professionals in Infection Control and Epidemiology. March Online. August An Ounce of Prevention Keeps the Germs Away. Center for Disease Control. Online. August Hand washing: Clean Hands Save Lives. Center for Disease Control. December Online. August

7 THE DANGERS OF HEPATITIS C Terrie Bryan, MS, ARM, HEM Baby Boomers are five times more likely to have Hepatitis C than other adult Americans. Introduction If you re a Baby Boomer (those born between 1945 through 1965) expect another blood test to be added to your next physical. The Centers for Disease Control and Prevention (CDC) estimates that 1 in 30 Baby Boomers has been infected with Hepatitis C and most have no clue. Hepatitis C can go undetected without symptoms, but slowly causes serious liver diseases, including liver cancer. It is also the leading cause of liver transplants in the U.S. In August 2012 the CDC made a recommendation that all Baby Boomers have a one-time screening for the Hepatitis C Virus (HCV). This move could help identify 800,000 more Americans with Hepatitis C. and is part of the CDC s No More Hepatitis campaign. Three-quarters of all Hepatitis C infections and three-quarters of Hepatitis C deaths occur in Baby Boomers, says CDC Director Thomas R. Frieden, MD, MPH. Baby Boomers are five times more likely to have Hepatitis C than other adult Americans. Frieden says the expanded testing, along with appropriate care and treatment, could save more than 120,000 lives. At risk populations include: History of blood transfusions or other blood products, or organ transplant before widespread adoption of screening measures Long-term dialysis treatment Exposure to HCV such as through a health care setting Infection with HIV, the AIDS virus Children born to mothers with HCV Tattooing or piercing with non-sterile instruments Injection drug use, even if only used one time The increase in heroin use has also led to an increase in the number of persons infected with Hepatitis C virus. Today HCV infection is the most common chronic bloodborne infection in the United States; approximately 3.2 million persons are chronically infected. Chronic HCV infection develops in 70% 85% of HCV-infected persons; 60% 70% of chronically infected persons have evidence of active liver disease. The majority of infected persons might not be aware of their infection because they are not clinically ill. However, infected persons serve as a source of transmission to others and are at risk for chronic liver disease or other HCV-related chronic diseases decades after infection. Of every 100 persons infected with HCV, approximately may go on to develop chronic infection may go on to develop chronic liver disease 5 20 may go on to develop cirrhosis over a period of years 1 5 may die from the consequences of chronic infection (liver cancer or cirrhosis) Prevention The sooner you know, the more you can protect your liver and your life, Frieden says. If the test is positive, people can lower their risk of liver cancer and cirrhosis by: Avoiding certain medications that affect the liver Avoiding alcohol Getting vaccinated against Hepatitis A and B New therapies can cure up to 75% of infections but many have side effects and are only effective if the infection is detected in the early stages, before damage to the liver and other organs has occurred. Healthcare worker risk In healthcare settings, exposures occur through needlesticks or cuts from other sharp instruments contaminated with an infected person s blood or through contact of the eye, nose, mouth, or nonintact skin with an infected person s blood. Risk of infection may vary with factors such as the pathogen involved, the type of exposure, the amount of blood involved in the exposure and the amount of virus in the patient s blood at the time of exposure. According to the CDC, the average risk for infection after a puncture (needlestick or cut) exposure to HCV-infected blood is approximately 1.8%. That may sound like a very small risk but there is no vaccine against HCV and the disease can go undetected for many years. This is why it is critical to report any and all possible exposures and be vigilant about follow up testing. 7

8 Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. Prevention is the key with HCV. Many needlesticks and other cuts can be prevented by using safer techniques and disposing of used needles in appropriate sharps disposal container. Safer techniques include eliminating the poor practice of recapping needles and using medical devices with safety features designed to prevent injuries. Sharps disposal containers should be within arm s reach of where the needles or other sharps are being used, should have large and should have wide openings. Many injuries occur when a clinician is trying to use a sharps container that is full or nearly full. By forcing just one more needle into the container other needles or sharps sticking up out of the opening can puncture the skin. Best Practice would be to close and seal the sharps container when it is about ¾ full and replace it with a new container. Using appropriate barriers such as gloves, eye and face protection, or gowns when contact with blood is expected can prevent many exposures to the eyes, nose, mouth or skin. Post-exposure follow Up Healthcare organizations should make available to their workers a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place HCWs at risk for acquiring any bloodborne infection, including HCV. Employers also are required to establish exposure-control plans, including postexposure follow-up for their employees, and to comply with incident reporting requirements mandated by the Occupational Safety and Health Administration (OSHA). Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. A clinician should be made available to review the incident report and determine the need for follow up testing and treatment. HCV-antibody testing should be performed for at least 6 months post-exposure, with the first testing conducted between 0-6 weeks after the exposure, then at 3 months and again at 6 months. If the employee does test positive for the HCV-antibody, treatment should begin as soon as possible to prevent advancement of the disease. Resources: Hepatitis Information Line: HEPCDC PEPline (the National Clinicians Postexposure Prophylaxis Hotline) is a 24-hour, 7-day-a-week consultation service for clinicians managing occupational exposures or References: CDC Post-Exposure Guidelines: Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Post-exposure Prophylaxis: rr5011a1.htm The Zurich Services Corporation 1400 American Lane, Schaumburg, Illinois The Zurich Services Corporation Risk Engineering (10/14) The information in this publication was compiled by The Zurich Services Corporation from sources believed to be reliable. We do not guarantee the accuracy of this information or any results and further assume no liability in connection with this publication, including any information, methods or safety suggestions contained herein. Moreover, The Zurich Services Corporation reminds you that this publication cannot be assumed to contain every acceptable safety and compliance procedure or that additional procedures might not be appropriate under the circumstances. The subject matter of this publication is not tied to any specific insurance product nor will adopting these procedures insure coverage under any insurance policy The Zurich Services Corporation