Purpose: The purpose of this guideline is to minimize or eliminate employee exposure to communicable diseases.

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1 Infection Control Guideline / Best Practice GUIDELINE NUMBER: ICG-0025 EFFECTIVE DATE: 1 MARCH 97 Purpose: The purpose of this guideline is to minimize or eliminate employee exposure to communicable diseases. Objective: To educate emergency response personnel to the dangers they face from communicable diseases, and the precautions the Columbia Fire Department has adopted to provide a means to minimize, but not eliminate, health risks and to prevent infection from occurring in the patient, emergency personnel, and their families. Scope: This guideline applies to all identified personnel who have a potential for occupational exposure to bloodborne, airborne, or other infectious materials. Responsibility: It is the responsibility of all identified employees to comply with this policy. It is the responsibility of all Captains, Shift Commanders, and any personnel who act in the position of an officer to strictly enforce this guideline. The employee must learn the basics of infection control, including modes of disease transmission, and exposure risks. Guideline: The following employee positions are felt to be at risk of an exposure on a regular basis: 1. Shift Commander 2. Fire Captain 3. Fire Engineer/ Driver 4. Firefighter 110

2 The following employee positions are felt to be at little or no risk, to an exposure on a regular basis: 1. Fire Chief 2. Deputy Chief 3. Training ficer 4. Fire Marshal 5. Assistant Fire Marshal 6. Executive Secretary 5. Administrative Secretary UNIVERSAL PRECAUTIONS 1. All personnel will practice Body Substance Isolation (BSI), and all body fluids are to be considered infectious when performing treatment to any patients. (This will include treatment given to any Firefighting and EMS personnel.) SCENE MANAGEMENT 1. Emergency response personnel shall use the Incident Command System to manage the emergency scene effectively. This will include the following infection control measures: Proper use of PPE (gloves, masks, eye protection, etc.) for patient care vs. extrication. Proper packaging and disposal of contaminated equipment Proper resource and task management that limits potential exposure of personnel 2. Any personnel performing treatment on any patient shall wear and use any Personal Protective Equipment (PPE) necessary to protect themselves from any potential exposure to body fluids at the incident. 3. The employee may temporarily and briefly decline to use any Personal Protective Equipment (PPE) when in their professional judgment the use of such equipment in that specific instance would have prevented the delivery of health care or public safety services or poses an increased hazard to the safety of the employee and / or their co-workers. When the employee makes such a judgment call, the employer shall investigate and document the 111

3 circumstances of the incident to determine if changes should be instituted to prevent further occurrences. 4. Emergency response personnel must ensure that any personal cuts, abrasions, wounds, etc., are always properly dressed for their own protection and the patient s. Personnel who cannot control open lesions will not be permitted to provide patient care. 5. Disposable latex/rubber gloves will be donned before initiating any emergency care tasks. This will include any contact with the patient, including assessment, loading, and delivery. 6. If possible, disposable latex/rubber gloves will be changed after contact with a patient and before beginning care to another patient. 7. All personnel will remove disposable latex/rubber gloves before entering the apparatus to prevent contamination of the steering wheel, radio, seat, etc. 8. Personnel are required to use masks and protective eyewear, or face shields when there exists a possibility for exposure to contaminated body fluids from any of the following: mucous membranes, eyes, mouth, or nose where splashes or aerosols of material are likely to occur. Such personal protective equipment is mandatory when providing emergency care to a patient s airway. 9. Masks should be placed on a patient who is coughing or is suspected of having active tuberculosis or meningitis. All emergency personnel involved with patient care for such individuals should also don masks. 10. Personnel will use disposable gowns if needed to provide the next level of barrier protection to the abdomen and chest as soon as practical, when not wearing turnout coat and bunker pants. 11. Disposable latex/rubber gloves are to be worn over the gown sleeves. 12. Disposable latex/rubber gloves shall not be washed or decontaminated for re-use. 112

4 13. Disposable latex/rubber gloves will be replaced as soon as possible when contaminated or as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. 14. If a garment is penetrated by blood or other potentially infectious materials, the garment(s) shall be removed immediately or as soon as feasible. 15. When personnel have completed treatment of the patient and are in no danger of being contaminated by any substance, they will remove disposable gloves and wash their hands thoroughly. Personnel should scrub hands briskly for seconds with warm water and soap. When handwashing facilities are not available, personnel should use a waterless hand cleaner according to the manufacturer s directions. Emergency response personnel shall NEVER wash hands in food preparation areas following any emergency response activity. Such handwashing should occur only in restroom facilities. 16. All disposable latex/rubber gloves used on incident, when removed, are to be placed in the Bio-Hazard bucket located on apparatus. The bag is to be sealed and disposed of properly, either by giving the bag to EMS personnel and they will dispose of it, or the bag is to be brought back to the station and placed in the receptacle marked for such waste. Bio-Hazard bucket is to be emptied and contents disposed of as a part of first Friday apparatus maintenance. (If Bio-Hazards are present) AT NO TIME ARE DISPOSABLE latex/rubber GLOVES, NEW OR USED, TO BE PLACED IN THE FLOORBOARDS OR CAB OF ANY APPARATUS OR VEHICLE OR ON THE GROUND OF ANY EMERGENCY SCENE. THIS PRACTICE IS STRICTLY PROHIBITED. 17. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in areas where there is a reasonable likelihood of exposure. This area is to be determined by the Incident Commander. 18. Food and drink shall not be kept on countertops or benchtops where blood or other potentially infectious materials are present. 19. Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. 113

5 20. Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed. Shearing or breaking contaminated needles is prohibited. 21. Contaminated needles and other contaminated sharps shall not be recapped or re moved unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical procedure. Recapping or removing must then be done by mechanical means, or by a one handed technique. 22. Broken glassware that may be contaminated shall not be picked up by the hands. It shall be picked up by mechanical means. 23. The incident commander will ensure that personnel answer infection control questions consistently that arise from contact with the public. Citizen inquiries about the use of PPE will be answered as follows: "Our use of personal protective equipment is as much for the safety of the patient as it is ours. Wearing such equipment assures your safety, and ours, from any contaminants that may be present." 24. At no time will any assessment or information about a patient become public knowledge. All patient information is to be STRICTLY CONFIDENTIAL and failure to do so will warrant strict disciplinary measures. 25. All emergency personnel shall not make public, directly or indirectly, the identity of a victim or suspected victim of a communicable disease. Victims of a communicable disease and their families have a legal right to conduct their lives without fear of discrimination. 26. The refusal to take proper action and the rendering of service to any victim(s) of a communicable disease, when appropriate personal protective equipment is available, shall be subject to disciplinary measures along with civil and/or criminal prosecution. 114

6 POST RESPONSE 1. It is the responsibility of all personnel to ensure that their work area (stations, offices, etc.) be maintained in a clean and sanitary condition. 2. Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials. 3. All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials shall be inspected and decontaminated on a regularly scheduled basis and as soon as feasible upon visible contamination. 4. Clothing and turnout gear which have been contaminated with blood or other potentially infectious materials should be decontaminated as soon as possible after the incident. 5. Contaminated clothing, turnout gear, and laundry should be properly bagged at the location where it was used. The bag must be properly marked as biohazard with the appropriate symbol. 6. When personnel generate biohazard waste at an incident, it is their responsibility to dispose of that material properly marked biohazard bag, with the ultimate responsibility falling to the Incident Commander. 7. Each station will have a standard issue biohazard waste container for the storage of biohazard waste. A biohazard bag must be placed in the container prior to storage of biohazard waste. 8. When preparing a biohazard container for disposal, personnel will wear both disposable latex/rubber gloves and eye protection. Biohazard containers must be disposed in an approved manner. 9. At no time will biohazard waste be packaged solely in the biohazard bags for disposal. 10. Emergency personnel shall have with them at their duty station at least one additional uniform. This will insure that all emergency personnel shall be able 115

7 to change if their clothes they are wearing become soiled/contaminated with body fluids and/or blood. 11. Uniforms that are grossly soiled/ contaminated with blood shall be handled as little as possible with a minimum of agitation. 12. Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use. Contaminated laundry that presents a reasonable likelihood of soak-through or leakage shall be packaged so as to prevent any leakage. Conditions may dictate that the uniform be disposed of, this shall be a decision of the Fire Chief or the Deputy Chief. 13. Contaminated Firefighting gear shall be bagged and carried to the appropriate facility to be cleaned. 14. The personnel responsible for transporting any soiled or contaminated gear or clothing shall wear disposable latex/rubber gloves to prevent possible contamination. After removing the gloves, hands or skin surfaces shall be washed thoroughly and immediately after contact with potentially infectious materials. 15. No personal protective equipment shall be brought into any sleeping, living, or eating areas of the fire station. This shall include all SCBA (harness, mask, and bottles), helmets, turnout coats, bunker pants, Firefighting and extrication gloves, resuscitation equipment, or any equipment that could have been at risk of exposure from a hazardous substance. 16. Personal protective equipment shall not be cleaned in any restroom or food preparation areas, to prevent the possible spread of contaminates. They shall be cleaned in the recommended sinks and areas away from the sleeping and eating areas 17. Equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to putting it back in service and shall be decontaminated as necessary, unless it can be demonstrated that decontamination of such equipment or portions of such equipment is not feasible. 116

8 18. Each station will allocate a specific area for cleaning contaminated equipment: a. The area must be used only for the cleaning of personal protective equipment. b. The area must contain double stainless steel sinks with drain boards and splash panels if necessary. Such sinks should include: Hot and cold water faucets Sprayer attachments Faucets that do not require the user to grasp grasp with their hands to turn on or off The area must have drying rack shelving constructed of non-porous material and located over the cleaning sinks for the air drying of equipment, if space is available. All drainage from the shelving shall go into the sink or directly into the sanitary sewer system This area shall be away from the fire station kitchen, living, sleeping, or personal hygiene areas. This area must be conspicuously marked to prevent contamination of other fire station areas, and to help prevent possible contamination of the public. 19. If cleaning is only needed to a piece of equipment, personnel should use soap and water, combined with scrubbing action to clean it. This scrubbing action is the key to the physical removal of dirt and debris. 20. If disinfecting is required to a piece of equipment, personnel should clean the item with soap and water, then apply a disinfecting solution. Such solutions as bleach and water at a 1:10 dilution ratio is acceptable to reduce the number of disease producing organisms. After 24 hours this solution must be changed and re-mixed to be effective. 21. If high-level disinfecting is required, personnel should use a commercial chemical liquid for the sterilization of equipment. This liquid will be used as per the manufacturer s instructions. 22. If disinfecting is required, personnel shall don latex/rubber gloves and safety glasses before proceeding. 117

9 TRAINING 1. All personnel who are felt to be at risk for an exposure on a reasonable basis shall participate in a training program on occupational exposure and bloodborne pathogens. This is to occur at the time of initial assignment to tasks where occupational exposure may take place, and at least annually thereafter within (1) year of previous training. 2. Additional training shall be provided when changes are made in tasks or procedures that will affect personnel s occupational exposure and may be limited to the changes made. 3. All training material must be in content and vocabulary appropriate to the educational level, literacy, and language of the personnel using it. 4. The infection control training program shall include: a. An accessible copy of OSHA s standard on occupational exposure. b. A general explanation of the modes of transmission and symptoms of bloodborne diseases. c. An explanation of the Columbia Fire Department s infection control plan and means by which personnel can obtain a copy. d. An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials. e. An explanation of use and limitations of methods that will prevent or reduce exposure- including appropriate engineering controls, work practices, and personal protective equipment. f. Information on the types, proper use, location removal, handling, decontamination, and disposal of personal protective equipment. g. Information on Hepatitis B vaccine; including its effects, method of administration, benefits of being vaccinated, and that the vaccine is offered free of charge. h. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be available. i. Information on the post-exposure evaluation and the follow-up that the Columbia Fire Department is required to provide for the employee following an exposure incident. 118

10 j. An explanation of "bio-hazard" signs and labels and any other related labels or signs. k. An opportunity for interactive questions and answers with the person conducting the training. 5. The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace. 6. The Columbia Fire Department shall assure that personnel have demonstrated a proficiency in the subject matter before they are allowed to participate in work activities involving infectious materials. 7. Training records shall include: Date of the training session. Content or summary of the session. Names and qualifications of the persons conducting the training. Names and job titles of all persons attending the training. 8. Training records shall be kept and maintained for 3 years from the date on which the training occurred. EVALUATION 1. Engineering and work practice controls shall be examined and maintained or replaced on a regular schedule (annually) to ensure their effectiveness. This shall include examination of ALL exposures to date, reasons for the exposures, and the infection control procedure guideline. These shall be weighed against one another and a determination will be made by the committee designated by and including the infection control officer for any changes. Changes are to be presented to the Fire Chief / Deputy Fire Chief for approval before implemented. PRE-ENTRY HEALTH ASSESSMENT 1. It is the recommendation of this plan that any personnel who are involved in the Columbia Fire Department who are involved in emergency response will participate in a pre-employment physical based on the recommendations set up in NFPA

11 This shall include but not be limited to: A complete medical history and physical examination. Vision and hearing tests Blood and urine tests ( to test for proper bodily functions only, and not possible substance abuse ). Heart and lung tests TB tests 2. The physician performing the physical should be given a copy of NFPA 1582 before the examination and the physical should follow the recommendations in the standard. 3. It is also the recommendation of this guideline that all personnel who are involved in emergency response receive annual physicals. 4. All results of personnel physical examinations are to be filed with the Columbia Fire Department and kept with the personnel s permanent records. The results of any personnel s medical record shall remain STRICTLY CONFIDENTIAL. 5. Hepatitis B vaccinations shall be offered to all personnel who enter service with the Columbia Fire Department at no charge to the personnel. The vaccination will include a series of 3 shots given by a healthcare professional designated by the city, and the department will set up the vaccination at a reasonable time and place. 6. It is the recommendation of this guideline that all personnel who have had all shots in the Hepatitis B vaccination series, be tested for antibodies to reveal if the personnel is immune. If booster dose(s) is needed it shall be made available at no charge to the employee. 7. Personnel have the right to decline the Hepatitis B vaccination and may do so if he/she desires. The personnel who decline the Hepatitis B vaccination shall sign a form stating their decision to decline and this form will be attached to their record. If those same personnel decide to accept the vaccination, the Columbia Fire Department shall make available the Hepatitis B vaccination at that time. 8. If a routine booster dose(s) of Hepatitis B vaccine is recommended by the United States Public Health Service at a future date, such dose(s) shall be made available at no charge to the employee. 120

12 POST EXPOSURE 1. If emergency response personnel have been exposed to blood or any potentially infectious substance, that person shall notify his/her supervisor as soon as feasible. That supervisor will then notify the designated Infection Control ficer of the exposure. The exposed personnel shall complete an exposure form as soon as feasible. ALL exposures shall be documented. 2. Upon notification of an exposure, the Infection Control ficer shall document the exposure in that personnel s medical record and document it separately for department records, no matter how minor the exposure. The severity of the exposure will be based upon the exposure chart contained within this document. Also at this time the Infection Control ficer shall initiate an investigation of the exposure incident to be completed as soon as feasible and coordinate any follow-up activities and inform the exposed personnel of any required followup treatment. 3. The exposed personnel will, within 48 hours of a verified exposure, and the severity is determined to need treatment, that personnel shall be examined by a physician designated by the City of Columbia. At this time, if the exposed personnel consent, blood shall be collected as soon as feasible. If the personnel consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If within 90 days of the exposure incident, the personnel elect to have the baseline sample tested, such testing shall be done as soon as feasible. 4. If emergency personnel have a verified exposure he/she can request that the source patient be tested for Hepatitis B and HIV and the attending physician can test the source individual and the results documented if the request is granted. 5. When the source individual is already known to be infected with HBV or HIV, testing for the source individual s known HBV or HIV status need not be repeated. 6. Results of the source individual s testing shall be made available to the exposed personnel. This shall be done face-to-face by the Infection Control ficer and should not go through the ranks to keep the information confidential. Though 121

13 the results of the source individual test are known, at no time should any further information about the patient be disclosed. 7. If the exposure is in conjunction with an injury, such as a laceration or a puncture (needle stick), according to most physicians it should be handled as following: The physician, or qualified healthcare professional, shall draw blood from the exposed personnel. The blood will be tested for HBV and HIV. A medical history shall be obtained form the exposed personnel. The wound shall be cleaned and treated. A tetanus shot, or any additional treatment will be given if the physician feels that it is needed. Blood work will then be drawn at 3 months, 6 months, and 12 months and tested for HBV and HIV. 8. If emergency personnel have an occupational exposure to an airborne pathogen from a known or suspected source it should be handled as follows: The supervisor should be notified and personnel should fill out the proper exposure form. 9. Notify the Infection Control ficer at the receiving hospital to find out whether the patient is at risk for the airborne virus. Determination will be based on: 1. Interview with the patient 2. Interview of the patient s physician. 3. Review of the patient s chart 10. If it is determined that personnel were exposed to an at-risk patient diagnosed or presumed to have Tuberculosis, then a TB smear and a culture be taken from the patient and checked to see whether airborne pathogens exist. The cultures should be checked as to their drug resistance. The supervisor should be notified and personnel should fill out the proper exposure form. 122

14 11. Notify the Infection Control ficer at the receiving hospital to find out whether the patient is at risk for the airborne virus. Determination will be based on: 1. Interview with the patient 2. Interview of the patient s physician. 3. Review of the patient s chart 12. If it is determined that personnel were exposed to an at-risk patient diagnosed or presumed to have Tuberculosis, then a TB smear and a culture be taken from the patient and checked to see whether airborne pathogens exist. The cultures should be checked as to their drug resistance. 13. Personnel exposed to patients confirmed to have Infectious Tuberculosis should be treated as follows: a. Once verification and documentation have been made the personnel shall be examined by a healthcare professional within 48 hours. b. If the personnel has not had a skin test within the last 3 months, then a skin will be administered as soon as possible. A skin test shall be administered 12 weeks post exposure if the initial test is negative. Chest x-rays and preventative therapy will be administered based on the recommendation of the treating physician and on current TB guidelines. If the 2 nd skin test and patient culture results are negative, no further action is required. 123

15 14. Personnel exposed to patients confirmed to have other airborne pathogens (meningitis, chickenpox, measles, etc.) will be prescribed treatment per the recommendation of the treating physician. 15. All exposures that require treatment shall be treated as an on-the -job injury and the proper forms to deal with them shall also be filled out. Authentication: Donald R. Martin, Fire Chief February 2000 Steven E. Cross, Deputy Fire Chief February 2000 Review/Revision Dates: February 2000; November 2000; 124

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