Universal precations for health care workers


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Lecture for medical students, , doctors or ant health care workers. It gives details how a medico can protect one self while caring for patients. Without discrimination.

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  • The SC and EC are used to estimate the risk of transmission from the occupational exposure and help determine the type of PEP regimen
  • The initial step - not shown here - is to determine the status of the exposed person. If this person is seronegative (and the exposure was not simply cutaneous) then:
    Determine the status of the source patient
    If the source patient’s status is unknown or the patient is unwilling to get tested, assess the background risk of the patient. In general, hospitalized patients in Ethiopia are high risk (>3% background prevalence)
    If the source patient is positive or comes from a high risk background, PEP is indicated
  • If the patient needs PEP, then the next step (Step 2) is to determine the HIV status of the source patient or (SC). If the HIV positive patient is asymptomatic and their CD4 count is preserved, the source code (SC) = 1. In the case of advanced disease, primary infection, or a low CD4 count/high viral load, the SC = 2. In some cases you may not know the HIV status or the source and in this case the HIV SC is unknown.
    This code will help determine the most appropriate PEP regimen, as shown later.
  • The combination of EC and SC guides the recommendation for 2 or 3 drug PEP regimens.
    The important thing to consider is the fact that you have only one chance to give PEP. It is better to err on the side of treatment with 3 versus 2 drugs if there is doubt. However, it is equally important protect scarce resources when PEP is not warranted.
  • Universal precations for health care workers

    1. 1. Are we at risk of HIV? Dr Madhu Oswal SAMVAD HIV HELPLINE Muktaa Charitable Foundation
    2. 2. Procedures we perform in the clinic set-up - General Examination of patients PV exam, P/A exam, oral cavity - Giving IM injection - Giving IV injection - Drawing blood for lab investigation • Minor Procedures – Catheterization, pap smear, IUD insertion, ascitis fluid tapping, etc. • Minor Surgeries – Suturing, I& D, removing corn,lipoma, taking biopsy, etc.
    3. 3. Procedures we perform in the Hospital set-up • - All as above, plus (all that we do in clinic) Ryles tube insertion Plural tapping CSF tapping Suction Intubation • In operation Theatres - Invasive procedures - Vaginal delivery
    4. 4. Duties your assistant/Nurses/Aaya/mama perform • Handling bio-medical waste • Cleaning soiled surfaces • Washing soiled linen – clothes, bed sheets, etc. • Handling vomitus, urine, stools, suction material • Handling lab specimen – sputum, blood, urine, etc. • Cleaning toilets, bathrooms, urinals, bed pan, suction jar, etc.
    5. 5. What Extra-precautions should we take when we deal with HIV +ve patients? NONE
    6. 6. Universal precautions UP means-EVERYONE, EVERYWHERE,ALWAYS, UP applies to – blood, semen, vaginal secretons, cerebro-spinal fluid, ascitic fluid, pericardial fluid & amniotic fluid UP does not apply to urine, stools, saliva, tears, sputum, vomitus – if not blood stained or contaminated with blood
    7. 7. How much is the risk? • HBV • HCV • HIV - 4% 1.8% 0.4% HIV is an very fragile virus. Then why ‘phobia’ about HIV?
    8. 8. Estimated Pathogen-Specific Seroconversion Rate Per Exposure for Occupational Needlestick Injury 5 . AETC http://depts.washington.edu/hivaids
    9. 9. Type of Exposure Involved in Transmission of HIV to Health Care Workers AETC http://depts.washington.edu/hivaids 6
    10. 10. Risk Factors for HIV Transmission with Occupational Exposure to HIV-Infected Blood Odds Ratio Confidence Interval Deep Injury 15 6.0-41 Visibly Bloody Device 6.2 2.2-21 Device Used in Artery or Vein 4.3 1.7-12 Terminally Ill Source Patient 5.6 2.0-16 0.19 0.06-0.52 Risk Factor Use of Zidovudine for PEP P<0.01 for all associations 8
    11. 11. UNIVERSAL PRECAUTIONS4 components • • • • Hand Hygiene Barriers Care of sharps and needles Sterilization and disinfection
    12. 12. Hand Washing Before- Examining patient Removal of glove Before wearing glove AfterExamining a patient Contact potentially contaminated body secretions/excretions, instruments routine surgical scrub After removing glove Too simple to be important but Most Important
    13. 13. Gloves, apron, goggles, etc • For protection of HCW from infection from the patient. • For protection of patient from infection from HCW or other source. • Be judicious in use of gloves. • Utility gloves, sterile gloves, non-sterile gloves.
    14. 14. Handling needles and sharps - Disposable needles - Do not RECAP – 80% Do not BEND Do not BREAK Cut the needle in a puncture resistant container - Use hands- free technique while passing ‘sharp’ instruments.
    15. 15. Things/Instruments we need to reuse or dispose off safely • Decontamination • Disinfection – removing and reducing some agents of infection • Sterilization – Killing all organisms including spores
    16. 16. Dis-infection - Cleaning with soap and water - Heat – boiling for a minute kills all organism. For spores – 20 - Chemical - Sodium Hypochlorle 1% - Glutaarlderyde 2%(Sterylium) - Ethyl alcohol – 70% (Hospital spirit) - Chlorhexidine – 3%(Savlon) -Iodine tinc-3% -Iodophores 7.5-10%(Betadine)
    17. 17. Sterilization Dry Heat – (Incirinators) – destroy soiled dressings, biomedical, waste, equipments Autoclave – For equipment which can tolerate heat – clothes, dressing, instruments, apparatus, etc. Ethylene oxide- Respirator, HL machine Gamma radiation – Suture material, catheters, gloves, etc.
    18. 18. What to do if one gets a pinprick/exposure? Do not Panic!!! - Do not squeeze the wound or suck. - Allow the wound to bleed freely. - Wash the puncture site with soap & water - Confirm the serostatus of the source case If negative – do nothing If positive – know your sero-status at baseline - Assess the risk(with the help of an HIV expert) - Seek for PEP, if necessary with 6 hrs, not later than 72 hrs
    19. 19. Decision-making Tools for PEP • Source code (SC) – Risk assessment of the source patient – SC 1, SC 2, SC Unknown • Exposure code (EC) – Risk assessment of exposure type – EC 1, EC 2, EC 3
    20. 20. Step 1: Does This person Need HIV PEP? Source patient HIV - HIV + Unknown / Unwilling to get tested* High background risk No PEP PEP Low background risk No PEP *CDC recom: usually PEP unnecessary; consider use if source patient is high risk
    21. 21. Step 2: Determine HIV Status Code of Source (HIV SC) HIV Negative HIV Positive Asymptomatic/high CD4 = HIV SC 1 No PEP Advanced disease, primary infection or low CD4 =HIV SC 2 HIV Status Unknown or Source Unknown = HIV SC Unknown
    22. 22. Step 4: Determine PEP Regimen (2) Exposure Type Source Infection Status HIV+ Class 1 HIV+ Class 2 Less Severe Basic (2 Drugs) Expanded (3 Drugs) More Severe Expanded (3 Drugs) Expanded (3 Drugs) • Less Severe: Solid needle, superficial injury • More Severe: Large-bore hollow needle, deep punture, visible blood on device, or needle used in patient's artery or vein • HIV Class 1: Asymptomatic or HIV RNA less than 1500 copies/ml • HIV Class 2: Symptomatic HIV infection, AIDS, acute seroconversion, or known high HIV RNA 28
    23. 23. Step 4: Determine PEP Regimen HIV SC EC PEP Recommendation 1 1 PEP may not be warranted 2 1 Consider basic regimen 1 2 Recommend basic regimen 2 2 Expanded regimen recommended 1 or 2 3 Expanded regimen recommended Unknown If EC is 2 or 3 and a risk exists, consider PEP basic regimen
    24. 24. HIV Post Exposure Prophylaxis • 2 drug regimen  Zidovudine plus lamivudine (combivir)  Stavudine plus Lamivudine  Tenofovir plus lamivudine • 3 drug regimen  LPV/r or Indinivr or Nelfinavir plus NRTI backbone  Efavirez plus NRTI backbone  Consider resistance potential of source patient  Don’t use NVP (hepatotoxicity) 29
    26. 26. THANKS
    27. 27. Contact Info Dr Madhu Oswal 9890044477 madhu.oswal@mcf.org.in