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standard workplace precautions-waste management
1. NACO HCP - ORIENTATION
PROGRAMME FOR DOCTORS
Venue : Government Thiruvarur Medical College
and Hospital, Thiruvarur
Date : 26-12-2013 & 27-12-2013
Resource Persons :
Dr. Asika Beham, M.D., H.O.D. - Microbiology, GTMCH, Thiruvarur
Dr. T.S. Santhi, M.D., H.O.D. – Medicine, GTMCH, Thiruvarur
Dr. A. Annamalai Vadivoo, M.B.B.S., F.H.M., ART Medical Officer, Thiruvarur
3. Session Objectives
By the end of the session participants will be able to:
Learn the importance of Standard Workplace Precautions
Enumerate the illnesses transmissible occupationally
Discuss the Standard Operating Procedures involved in
Bio-medical Waste Management
Evaluate a health care worker sustaining an injury and
prescribe the appropriate PEP
Emphasise the needed follow up procedures after PEP
Standard Workplace Precaution & PEP 2
4. Standard Workplace Precautions
Universal Precautions were introduced in Health
Care Settings as early as in 1985
In 1996, the terminology was modified into
Standard Workplace Precautions
Definition: A set of precautions to protect Health
Care Workers (HCW) from occupational exposure
to blood borne pathogens
Standard Workplace Precaution & PEP 3
5. Story Time
A nurse gets a needle stick while giving an
injection to an HIV-positive patient. Her glove
was punctured. She applies first aid to clean
her injury. She panics and calls the doctor…
What precautions if any, did the nurse follow while doing
the procedure?
What was the first step taken by the nurse after the injury?
How can you relate to this incident from your work?
Standard Workplace Precaution & PEP 4
6. Relative Risk of Seroconversion
with Percutaneous Injury
Standard Workplace Precaution & PEP
Source: CDC. MMWR 2001;50(RR11): 1-42
5
7. Who are at risk?
Nursing staff and students
Laboratory staff
Emergency care provider
Interns & medical students
Laboratory staff
Labour & delivery room staff
Physicians
Dentists
Cleaning staff & mortuary staff & waste handler
Surgeon & OT staff
Standard Workplace Precaution & PEP 6
8. Exposure to body fluid
Considered “at risk”
Exposure to body fluid
Considered “not at risk”
Blood Tear
Semen Sweat
Vaginal Secretion Urine/Faeces
CSF Saliva
Synovial,Pleural,
Pericardial, Peritoneal fluid
Sputum
Amniotic fluid Vomitus
Any body fluid contaminated with “visible blood”
Shall be considered “atrisk”
Potentially Infectious Body Fluid
Standard Workplace Precaution & PEP 7
9. Environmental Transmission
What is the risk for environmental
transmission of HIV?
No environmental transmission reported
HIV inactivated quickly outside the body
HIV does not multiply outside the body
Infectivity is lost quickly after fluid dries
Standard Workplace Precaution & PEP 8
10. Infectious Wastes Specifically Are
Blood and blood products in
a free flowing, unabsorbed
state, Body organs
Contaminated sharps
Isolation Wastes
Laboratory wastes
Unfixed pathological tissues
Standard Workplace Precaution & PEP 9
11. Hand Hygiene
Hands are the most common mode
of pathogen transmission
Hand washing is an extremely
important step in overall infection
control
Hand washing significantly removes
the bacterial flora and HIV from the
skin surface
Hand washing protects you and
your patients from the pathogen
transmission
Standard Workplace Precaution & PEP 10
12. Standard Workplace Precaution & PEP
When should you wash your hands?
Before, during, and after preparing food
Before eating food
Before and after caring for someone who is sick
Before and after treating a cut or wound
After using the toilet
After changing diapers or cleaning up a child who has
used the toilet
After blowing your nose, coughing, or sneezing
After touching an animal, animal feed, or animal waste
After touching garbage
11
13. What is the right way to wash your
hands?
Wet your hands with clean running water
(warm or cold) and apply soap
Rub your hands together to make a lather
and scrub them well; be sure to scrub the
backs of your hands, between your fingers
and under your nails
Continue rubbing your hands for at least
20 seconds. Need a timer? Hum the
"Happy Birthday" or “Twinkle , Twinkle”
song from beginning to end twice
Rinse your hands well under running water.
Dry your hands using a clean towel or air
dry.
Standard Workplace Precaution & PEP
Image Courtesy GHTM/I-TECH,
Tambaram, Chennai
12
16. Hand Hygiene and Gloves
Gloves are not the substitute for
Hand Washing
Always wash hands before/after
removing gloves, after handling all
materials known or suspected to be
contaminated
Good hand washing: 20 seconds
with running water, soap & friction
Gloves need to be removed between
patients
Dispose of single-use items correctly
after use
Standard Workplace Precaution & PEP 15
17. What is the alternate way?
Washing hands with soap and water is the best way
to reduce the number of germs on them
If soap and water are not available, use an alcohol-
based hand sanitiser, contains at least 60% alcohol
Alcohol-based hand sanitisers can quickly reduce
the number of germs on hands in some situations,
but sanitizers do not eliminate all types of germs
Apply the product to the palm of one hand
Rub your hands together
Rub the product over all surfaces of your hands and
fingers until your hands are dry
Hand sanitisers may not be as effective when hands
are visibly dirty
Standard Workplace Precaution & PEP 16
18. Personal Protective Equipments (PPE)
Used in Healthcare Settings
Gloves: Protect hands
Gowns/aprons: Protect skin
and/or clothing
Masks and respirators: Protect
mouth/nose
Respirators: Protect respiratory tract
from airborne infectious agents
Goggles: Protect eyes
Face shields: Protect face, mouth,
nose and eyes
Standard Workplace Precaution & PEP 17
19. Standard Workplace Precaution & PEP
Factors Influencing PPE Selection
Type of exposure anticipated
Splash / spray versus touch
Category of isolation precautions
Durability and appropriateness for the task
Fit to the user
18
20. One or two pair
Single use or reusable
Hand Protection: Gloves
Minimise the risk of acquiring
infections from patients
Prevent microbial flora from
being transmitted from health
care providers to patients
Glove material – vinyl, latex,
nitrile
Sterile or non-sterile
Gloves are not the substitutes
for Hand washing
Standard Workplace Precaution & PEP 19
21. Gloves
Should be available in a variety
of sizes and types
May causes hand fatigue,
if gloves don’t fit correctly
Glove integrity may be
compromised
Injury is more likely to occur
due to an ill fitting glove
Standard Workplace Precaution & PEP 20
22. Example of Gloves that are too TIGHT
Pulls too tightly across the palm;
Will cause fatigue at thumb joint
Will cause fatigue as fingers try to flex
Standard Workplace Precaution & PEP 21
23. Example of Gloves that are too LOOSE
Gloves that are too large pose a danger as excess glove material can
catch on something and tear
Tactile sensitivity during procedures is greatly reduced as well
Standard Workplace Precaution & PEP 22
24. Do’s and Don’ts of Glove Use
Work from “clean to dirty”
Limit opportunities for “touch contamination” - protect
yourself, others and the environment
Don’t touch your face or adjust PPE with contaminated
gloves; Don’t touch environmental surfaces except as
necessary during patient care
Change gloves
During use if torn and when heavily soiled (even during use
on the same patient); After use on each patient
Discard in appropriate receptacle
Never wash or reuse disposable gloves
Standard Workplace Precaution & PEP 23
25. Gowns or Aprons
Purpose of use
Material:
Natural or man-made
Reusable or disposable
Resistance to fluid penetration
Clean or sterile
Standard Workplace Precaution & PEP 24
26. Standard Workplace Precaution & PEP
Face Protection
Masks – protect nose and mouth
Place over nose, mouth and chin. Fit
flexible nose piece over nose bridge.
Secure on head with ties or elastic
and adjust to fit
Should fully cover nose and mouth
and prevent fluid penetration
Goggles – protect eyes
Should fit snuggly over and around
eyes
Personal glasses not a substitute for
goggles
25
30. Definition
Bio-medical waste means any waste which is
generated during the diagnosis, treatment (or)
immunization of human beings (or) animals or in
research activities pertaining thereto or in the
production (or) testing of biological.
Standard Workplace Precaution & PEP 29
31. Standard Workplace Precaution & PEP
Health care waste facts….
it means all waste generated from hospital
85% non-hazardous wastes
10% infectious wastes
5% non-infectious but hazardous
Persons at risk:
Medical doctors, nurses, health care, auxiliary and
hospital maintenance personnel
Workers in support service – lab, imaging services,
laundries and transportation
Workers in waste disposal facilities – hospital workers
Patients in health care institutions
Visitors to health care institutions
30
32. Standard Workplace Precaution & PEP
Operationalisation of Waste Disposal
Key Strategies
Segregation of
Waste
Collection and
Storage
Transportation
Treatment
and
Disposal
31
33. Standard Workplace Precaution & PEP
Operationalisation of Waste Disposal
Strategies in the institutions
Generation of waste
Source segregation in color coded bags
Collection from all the hospital facilities
Onsite treatment (where ever necessary)
Storage in the designated storage room
Weighing
Transportation by private / govt. agency
32
34. Types of Bio-Medical
Hazardous Waste
Infectious
All Body Fluids
Anatomical parts and lab specimens
Sharps
Toxic
Chemicals and pharmaceuticals
Genotoxic waste
Radioactive
Genotoxic waste
Standard Workplace Precaution & PEP 33
35. Waste
Category
No
WasteCategoryType
Treatmentand
DisposalOptions
1 Human Anatomical Waste Incineration / deep burial
2 Animal Waste Incineration/deep burial
3
Microbiology and
Biotechnological Waste
Autoclaving / microwaving /
incineration
4 Waste Sharps
Incineration / destructionand
Disposal in secured landfills
5
Discarded Medicines &
Cytotoxic drugs
Incineration / destruction and
Disposal in secured landfills
Categories of waste
Standard Workplace Precaution & PEP
Courtesy: Tamilnadu Health System Project
34
36. Waste
Category
No
WasteCategoryType
Treatmentand
DisposalOptions
6 Soiled wastes Incineration / deepburial
7 Solid wastes
Disinfection/auto/
Microwaving and
mutilation/shredding
8 Liquid wastes
Disinfection and discharge
Into drains
9 Incineration ash Disposal municipal landfill
10 Chemical waste
Disinfection and discharge
Into drains
Categories of waste
Standard Workplace Precaution & PEP
Courtesy: Tamilnadu Health System Project
35
37. Colour
coding for
bags/bins
Waste category Type
Container
Type Treatmentat
Hospital
Final
Disposal
Blue
15L
25L
50L
Waste sharps
Broken glass,
Ampoules, vials & sutures
Plastic bag
1%sodium
hypochlorite
solution
autoclaving/
microwaving
and
mutilation/
shredding
Broken needles,
needles,blades,scalpels,
lancet,etc
Puncture proof
Container (twin
Bin system)
Red(big)
50L
Solid waste
Disposable wast eitems like
tubing’s,catheters,intra
Venous sets, plastic saline
bottles, pouche setc.,
Plastic bag
1%sodium
hypochlorite
solution
autoclaving/
microwaving
and
mutilation/
shredding
Red(small)
15L
25L
Microbiology and
Biotechnology waste
6.Soiled waste
Blood and body fluid
Contaminated items
Plastic bag NIL
Incineration/
Deep burial
Colour Coding
Standard Workplace Precaution & PEP 36
39. different categories of waste
• Personnel should use
protective gear while
handling the waste
Image Courtesy GHTM, Tambaram, Chennai
Follow the colour codes,
as advised by the respective
state governments
Segregation of Waste
• Make available colour-coded
bins and bags in patient care
areas
• Segregation should take
place at source
• Follow colour-codes for
Standard Workplace Precaution & PEP 38
40. Safety Precautions
for Waste Management
Training and education of waste handlers and
drivers
Strict protocols on sharps handling and disposal
Written protocols/colourful posters as reminders
for the health care staff
Limit access to only trained persons with personal
protective gear
Eliminate steps that require unnecessary handling
hazardous wastes
Standard Workplace Precaution & PEP 39
41. Commonly used disinfectants
in the laboratory
Technicians should know the procedures
to prepare the following disinfectants:
Ethyl alcohol (70%)
Glutarldehyde (2%)
Sodium hypochlorite solution (1%, 10%)
Polyvidone Iodine (PVI) 10%
Standard Workplace Precaution & PEP 40
42. 43
Recommended strength of the
Sodium hypochlorite solution
Spills [10%]
Surface contamination
1% (smooth surface)
10% (porous surface)
Liquid infectious waste
(with large amount of organic matter) [10%]
Sharp container for sharps [1%]
41
43. Management of spills
Put absorbent material down on spillage area
Flood with 10% sodium hypochlorite solution
upon & around the spill and leave for 30 minutes
Place the absorbent material in the biohazard
bag meant for infectious waste
Reapply the disinfectant solution to all exposed
surfaces
Thorough wash of the area with soap and water
Standard Workplace Precaution & PEP 42
44. No to Recapping of Needles
Standard Workplace Precaution & PEP 43
46. Splashes to the EYE
• Demonstrate how to do it
• Flush the eye for 5 minutes with clean water
(for microorganisms)
• Flush at least for 15 minutes (for chemicals)
Standard Workplace Precaution & PEP 45
47. •
•
•
•
Standard Workplace Precaution & PEP
Handling & Disposal of
HIV positive dead body
Avoid direct contact with blood and body fluids.
Wear protective gear- gloves, apron. Disinfect with
1% sodium hypochlorite all needle puncture holes,
wound drainage and dress with impermeable
dressings.
Plug all orifices with swabs soaked in 1% sodium
hypochlorite solution. Wash and disinfect the body
with 1% sodium hypochlorite solution.
Do not embalm the body. Cover the body with
robust plastic sheet (150 um thick) and cover it
tightly with tapes or zipper.
46
48. • It should be disinfected with sodium hypochlorite
before washing. Hands should be washed
thoroughly after removing gloves and protective
clothing.
Standard Workplace Precaution & PEP
Handling & Disposal of
HIV positive dead body
• Clean the outside plastic sheet with 0.1% sodium
hypochlorite if soiled. Soiled linen should be bagged
and sent to laundry.
47
50. Management of Exposure site
Do not panic
Skin
Wash wound & surrounding with soap and water
Rinse well
Do not squeeze
Do not use Antiseptic or Skin washes
Standard Workplace Precaution & PEP 49
51. Management of Exposure site
• Splash of Blood / Other Potentially Infected Material
– Unbroken skin
• Wash area immediately
• Do not use antiseptic
– Eye
• Eye irrigation with water
• If using contact lens leave them in place while irrigating
Remove once eye is cleaned remove them & clean
– Mouth
• Spit fluid immediately
• Rinse mouth thoroughly with water / saline repeatedly
• Do not use soap or disinfectant
Standard Workplace Precaution & PEP 50
52. Category Definition
Mild
Exposure
•Mucous Membrane / non intact skin with small volume
(e.g. Superficial wound with a low calibre needle
•Contact with eyes or mucous membrane
•Subcutaneous injections following small-bore needles)
Moderate
Exposure
•Mucous Membrane / non intact skin with large volume
•Percutaneous superficial exposure with a solid needle
(e.g.Cut or needle stick injury penetrating glove)
Severe
Exposure
•Percutaneous with large volume
•An accidental injury with high calibre needle (e.g.18G) with
Visibly contaminated blood
•A deep wound
•Transmission of significant volume of blood
•Anaccidental needle stick injury with previously used IV
needle/ IV cannula
Categories of Exposure
Standard Workplace Precaution & PEP 51
53. Sourceof
HIV
DefinitionofRiskinSource
HIV Negative
Source is not HIV infected; but consider HBV & HCV
Testing in all injury cases
Low Risk HIV Positive and clinically Asymptomatic
High Risk HIV Positive and clinically Symptomatic
Unknown
•Status of the patient unknown;
•Neither patient nor his/her blood available for
testing
•The risk assessment will be based only up on the
Exposure (HIV Prevalence in the geographical area
Should be considered)
HIV status of source of Exposure
Standard Workplace Precaution & PEP 52
54. Mucous Membrane or Skin
integrity compromised
Volume
No PEP
required
Intact Skin
No PEP required
Less severe-
solid needle,
Superficial scratch
EC 2
Small volume-
few drops /
short duration
EC1
Large volume-
major splash /
long duration
EC 2
No
What Type of exposure has occurred?
More severe-
hollow bore,
deep injury
EC 3
Percutaneous exposure
Severity
Yes
HIV Exposure code
Is the Source material is blood, bloody fluid or Other Potentially Infected
Material (OPIM) or an instrument contaminated with one of these substances?
Standard Workplace Precaution & PEP 53
55. HIV negative
No PEP required
Status/Source unknown
HIV SC unknown
HIV positive
Low titer exposure
Asymptomatic,
high CD4
High titer exposure
Advanced disease,
low CD4
HIV SC1 HIV SC2
HIV Source code
HIV status of exposure source
Standard Workplace Precaution & PEP 54
56. EC HIVSC PEPrecommendation
1 1 May not be warranted
1 2 Consider basic regimen (Twodrugs)
2 1 Recommend basic regimen(Twodrugs)
2 2 Recommend expanded regimen(Threedrugs)
3 1or2 Recommend expanded regimen(Threedrugs)
2/3 Unknown
Consider basic regimen if HIV prevalence is
High in the given population
Determining PEP recommendation
Standard Workplace Precaution & PEP 55
57. Effectiveness of PEP depends on…
• Efficacy of PEP is best, if administered within
two hours of exposure
• PEP needs to be given within 72 hours of exposure
• Do not delay the first dose of PEP while waiting for
result of HIV testing of source or injured HCP
• Informed consent must be obtained before testing
a source as per National guidelines
• Negative result (in source) doesn’t exclude HIV infection
• Base line rapid HIV testing of HCW before PEP
• Positive HIV result in HCW helps in stopping the PEP
and referral to ART centre for evaluation for ART
Standard Workplace Precaution & PEP 56
58. Assessment of Exposed Person
Confidential counselling and assessment by
experienced physician
Assess for pre-existing HIV infection
Importance of HIV testing & post-test counselling
Psychological support
Documentation of injury and HIV testing in PEP
Register
Standard Workplace Precaution & PEP 57
59. Counselling for PEP
• Duration of PEP (4 weeks)
• Importance of drug adherence
• What is known about the efficacy of PEP
• Common side effects, likely to be experienced
• Prevention practices at the time of PEP
(Barrier protection / contraception)
• Provider should correct misconceptions during
all times of counselling sessions
Standard Workplace Precaution & PEP 58
60. PEP Prescription
• Decide PEP regimens
– Basic regimen
– Expanded regimen
: 2 drug combination
: 3 drug combination
• Decision of starting PEP based on Exposure type
and HIV status of source
• If source person is on ART drugs expert should be
consulted after starting 2 drugs
Standard Workplace Precaution & PEP 59
61. Regimen Drugs
Basic
Regimen
(Twodrugs)
Zidovudine+ Lamivudine (if Hb is >9 G%)
Tenofovir+ Lamivudine(if Hb is <9 G%)
Expanded
Regimen
(Three
drugs)
Zidovudine/Tenofovir+ Lamivudine+
Ritonavir boosted Atazanavir
If Protease Inhibitor is not available, EFV600mg
May be considered as an option (third drug) in the
Expanded PEP. Monitored for CNS side effects
(nightmares,insomnia)
PEP Prescription
Standard Workplace Precaution & PEP 60
62. PercentofHCWs
Tolerability of HIV PEP
in Health Care Workers
Incidence of Common Side Effects
Zidovudine +
Lamivudine
Source: Wang SA. Infect Control Hosp Epidemiol 2000;231:780-5
61
63. For Expert reference / consultation
• Delay in reporting exposure more than 72 hours
• Unknown source
– Local epidemiology & severity of exposure
• Known or suspected pregnancy; Do not delay PEP
• Breast feeding issues
• Source person on ART or possibility of drug resistance
• Major toxicity of PEP regimen
• Non tolerance or Non adherence
• Any doubt or complicated case like psychological
problems
Standard Workplace Precaution & PEP 62
64. Timing InpersonstakingStandardPEP
Weeks2&4 Complete Blood Count (For AZT patients)
Weeks6 HIV-Ab
Weeks12
(Month3)
HIV-Ab
Weeks24
(Month6)
HIV-Ab
Laboratory follow-up
Standard Workplace Precaution & PEP 63
65. Prevention
• Primary prevention:
– Avoid unprotected exposure to blood &
Other Potentially Infected Material (OPIM)
• Use Personal Protective Equipments (PPE)
Consistently
• Universal precautions must be followed for
all patients at all times
Standard Workplace Precaution & PEP 64
66. Consider all blood samples infectious
Standard Workplace Precautions
Prevention is the key step!
universal precaution needle destroyer
Always Always protective protective gearuse use gear Consider all blood samples infectious
Follow Universal Precaution
Standard Workplace Precaution & PEP
Handling ofof Sharps Use Needle DestroyerSafe handling sharps
65
67. Story Time
A nurse gets a needle stick while giving an
injection to an HIV-positive patient. Her glove
was punctured. She applies first aid to clean
her injury. She panics and calls the doctor…
– What precautions if any, did the nurse follow while doing
the procedure?
– What was the first step taken by the nurse after the injury?
– How can you relate to this incident from your work?
Standard Workplace Precaution & PEP 66
68. Key Points
• Consider all patients / samples as potentially
infectious
• Implement Standard Workplace Precaution plan
• Use barriers to prevent blood / body fluid contact
• Prevent percutaneous injuries
• Document and Report injury or exposure
• Implement PEP Plan and sensitise all the Health Care
Workers (HCW)
• Promote hepatitis B vaccination
• Hands that Heal should never harm…!
Standard Workplace Precaution & PEP 67