Penn State Emergency Medical Services

Penn State EMS Standard Operating Procedures and Constitution

University Ambulance Service
Centre County Company 20
Procedures Manual

UNIVERSITY HEALTH SERVICES INFECTION CONTROL MANUAL

CONTENTS

BLOOD SPILL - CLEANING AND
DECONTAMINATION

BLOODBORNE PATHOGENS EXPOSURE CONTROL
PLAN

BLOODBORNE PATHOGEN EXPOSURE PROCEDURE

BODY SUBSTANCE ISOLATION

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BLOOD SPILL - CLEANING AND DECONTAMINATION

Purpose:

To reduce blood borne exposure by removing any blood spill.

Small Spills

1. Wear gloves.

2. Using paper towels soak up the spilled blood.

3. Dispose of contaminated waste in properly marked biohazard waste container.

4. Spray with DISPATCH; 1:10% bleach solution or any other approved disinfectant,
until the surface is thoroughly wet.  Keep the area moist for at least 5 min.

5. Allow surface to air dry completely.

6. Dispose of gloves in biohazard waste container.

7. Wash hands.

Large Spills

1. Obtain EZ Cleans self-contained spill cleaner found in UCC Procedure Room, in
laboratory and in General Medicine Treatment Room.

2. Wear gloves.

3. Follow directions on package.

4. Dispose of waste in properly labeled biohazard waste container.

5. Refer to Small Spills and follow steps 4 through 7.

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UNIVERSITY HEALTH SERVICES
BLOODBORNE PATHOGENS EXPOSURE CONTROL
PLAN

In accordance with the OSHA bloodborne pathogens standard 29 CFR 1910.1030, the
following exposure control plan has been developed.

Exposure Determination

University Health Services (UHS) recognizes that certain employees may incur
occupational exposure to blood or other potentially infectious materials. The
exposure determination is made without regard to the use of personnel protective
equipment (i.e., employees are considered to be exposed even if they wear personal
protective equipment). This is a list of all job classifications in which all employees
may be expected to incur such occupational exposure. At UHS the following job
classifications are in this category.

College Health Nurse - Auxiliary Units
College Health Nurse - Nurse Clinic
College Health Nurse - Head, Inpatient Services
College Health Nurse - Head, Outpatient Services
College Health Nurse - Injections
College Health Nurse - Outpatient, Inpatient, and Urgent Care Clinic
College Health Nurse - Women's Health
College Health Nurse - Occupational Health
Kitchen/Janitorial Worker
Nurse Practitioner
Nurse Manager
Physical Therapist
Physician
Physician Assistant
Primary Care Coordinator
Nursing Assistant
Medical Assistant
X-ray Technician
Pharmacy Technician
Medical Technologist

Implementation Schedule and Methodology

A. Compliance Methods

Universal precautions will be observed at this facility to prevent contact with blood
or other potentially infectious materials. All blood or other potentially infectious
materials will be considered infectious regardless of the perceived status of the
source individual. (See Body Substance Isolation Procedure)

Engineering and work practice controls will be utilized to eliminate or minimize
exposure to employees at UHS. Where occupational exposure remains after
institution of these controls, personal protective equipment shall also be utilized. At
UHS the following engineering controls will be utilized:

Handwashing facilities in all clinical areas

Puncture resistant, color coded, leak-proof sharps containers in all patient care areas
as is necessary

The above controls will be examined and maintained on a regular schedule.
Departmental supervisors will ensure that these controls are maintained in an
appropriate manner.

Adequate handwashing facilities are available to all employees. At UHS these
handwashing facilities are located in Nurses's station, Women's Health Lab area,
Treatment Room, Restrooms, Laboratory, X-ray, Physical Therapy, Physician's
offices, Urgent Care, Triage, Allergy/Immunization.

Hands are to be washed when necessary and in a manner according to UHS
Handwashing Procedure.

Contaminated needles will be handled according to UHS Body Substance Isolation
Section 4 "Needles and Sharps Instruments." At UHS needles are not to be recapped.

Contaminated reusable sharps are handled according to UHS Body Substance
Isolation Section 4 "Needles and Sharps Instruments."

Work Area Restrictions

In work areas where there is a reasonable likelihood of exposure to blood or other
potentially infectious materials, employees are not to eat, drink, apply cosmetics or
lip balm, smoke or handle contact lenses. Food and beverages are not to be kept in
refrigerators, freezers, shelves, cabinets or on counter tops or bench tops where
blood or other potentially infectious materials are present.

Mouth pipetting/suctioning of blood or other potentially infectious materials is
prohibited.

All procedures will be conducted in a manner which will minimize splashing,
spraying, splattering, and generation of droplets of blood or other potentially
infectious materials.

Specimens

Specimens will be handled according to UHS Body Substance Isolation Section 5
"Patient Specimens."

Contaminated Equipment

Equipment which has become contaminated with blood or other potentially
infectious materials shall be examined prior to servicing or shipping and shall be
decontaminated as necessary unless the decontamination of the equipment is not
feasible.

Personal Protective Equipment

All personal protective equipment used at UHS will be provided without cost to
employees. Personal protective equipment shall be chosen and used according to
Body Substance Isolation Section Z "Personal Protective Equipment."

Cleaning and Decontamination

UHS shall be cleaned according to schedule of cleaning in Housekeeping
Department.

All contaminated work surfaces soiled with blood or body fluids shall be cleaned
and decontaminated according to UHS Body Substance Isolation Section 10
"Cleaning Spills of Blood and Body Fluids."

Regulated Waste Disposal

Regulated wastes shall be disposed of according to "Waste Management Policy."

Laundry

Laundry at UHS will be handled and cleaned according to UHS Body Substance
Isolation Section 12 "Laundry."

Hepatitis B. Vaccine

All employees who have been identified at risk of exposure to blood or other
potentially infectious materials shall be offered Hepatitis B. Vaccine according to
UHS Hepatitis B vaccination policy.

Post-exposure Evaluation and Follow-Up

When an employee incurs an exposure incident the procedure for Exposure to
Bloodborne Pathogens Procedure will be followed.

Training

Training for all employees will be conducted prior to initial assignment to tasks
where occupational exposure may occur, and annually thereafter. Training will be
conducted in the following manner.

Training for employees will include an explanation of the following:

1) The OSHA standard for bloodborne pathogens
2) Epidemiology and symptomatology of bloodborne disease
3) Modes of transmission of bloodborne pathogens
4) This Exposure Control plan
5) Procedures which might cause exposure to blood or other potentially infectious
materials at UHS
6) Control methods which will be used at UHS to control exposure to blood and
other potentially infectious materials
7) Personal protective equipment available at this facility
8) Post-exposure follow-up
9) Signs and labels used at this facility 
10) Hepatitis B. Vaccine program at this facility

Compliance with these standards is the responsibility of each department head by
direct observation and by the infection control nurse's unannounced "walk
throughs."

Noncompliance of these standards will be documented on CRIQs forms and
reported to the appropriate supervisor.

Follow-up counseling and educational training will be conducted by the supervisor.

Records

Medical Records, Training Records and records of exposure and post-exposure
follow-up will be kept in a confidential manner by the Infection Control Nurse.

All provisions by this standard shall be implemented by June 4, 1992.

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BLOODBORNE PATHOGEN EXPOSURE PROCEDURE

Specimen containers and needles should be handled with the utmost care. If an
incident should occur where an employee is contaminated by blood, body fluids or a
dirty needlestick, the following procedure should be.followed:

1. Immediately wash the site with Betadine scrub solution and running water. If the
exposure is in the eyes, irrigate with a minimum of 500 cc. sterile normal saline to
each eye. If exposure is to skin, flush with large amounts of water.

2. Employee reports incident to supervisor who will notify the infection control
nurse or the UCC physician after hours.

3. Complete UHS Incident Report and CRIQS form and forward to Risk
Management Coordinator.

4. Physician will evaluate and treat injury. At this time the physician will certify that
a significant exposure has occurred. Documentation of exposure and treatment
recommendations will be done on treatment record by physician. Infection Control
Nurse will complete (code) lab slips and superbill.

5. If known, source patient should be contacted by Infection Control Nurse or Nurse
Manager and consent obtained for Hbsag and RPR. HIV testing of source will be
done according to UHS HIV Testing Procedure.

6. Exposed individual will be tested for RPR and HBV infectivity; HIV testing will be
done according to UHS HIV Testing Procedure.

7. Follow-up will be initiated, including HBIG and/or HBV vaccine per attached
úguidelines.

8. Lab tests will be ordered by predetermined code number to ensure confidentiality.

9. If the source patient is seropositive for RPR, HBV and/or HIV or the source is
unknown the exposed employee should be retested according to the Follow-up
(F/U) visit schedule:

a) F/U visit #1 (at 6 weeks post exposure): HIV 
b) F/U visit #2 (at 12 weeks post exposure): HIV/RPR 
c) F/U visit #3 (at 6 months post exposure): HIV 
d) Appropriate HBV screening should be done according to attached guidelines.

10. An "Employer' s Report of Occupational Injury or Disease" report form should
be obtained from the Risk Management Coordinator, completed and returned.

11. Superbill for charges incurred is submitted to checkout clerk. Charges include
laboratory charges and fees for health education counseling.
University Health Services

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BODY SUBSTANCE ISOLATION

Purpose:

The purpose of this policy is to outline a system of infection precautions 	to
reduce the transmission of infectious agents. including HBV and HIV, 	between
patients, from health care workers to patients and from patients
	to health care workers.

Policy

1. Handwashing - see UHS Handwashing Procedure

2. Personal Protective Equipment

A. Gloves

	1. Gloves should be worn for all direct contact with moist body substances,
non-intact skin, and mucous membranes of all patients. They should also be worn
to handle items contaminated with moist body substances. Gloves should be worn
for performing percutaneous vascular access procedures, for example, inserting an
intravascular catheter for parenteral therapy.

	2. Sterile gloves should be used for all procedures involving normally sterile
areas of the body. Clean examination gloves may be used for contact with mucous
membranes and moist body substances. Gloves should be changed after contact with
each patient, whenever torn or when a needle stick or other injury occurs. Gloves
may need to be changed when moving from contact with a contaminated site
(infected wound) to contact with a clean site (intravenous insertion site).

	3. Sterile and clean examination gloves are not washed, disinfected or reused.

	4. General purpose utility gloves, such as rubber household gloves, may be
used for housekeeping chores involving potential contact with body fluids or gross
microbial contamination. They may be decontaminated and reused but should be
discarded if they show signs of deterioration such as cracking, peeling, discoloration
or if they have punctures or tears.

B. Masks and Protective Eye wear

	1. Masks and protective eyewear (goggles) reduce the incidence of body fluid
contamination of mucous membranes of the mouth, eyes and nose.

	2. Masks and goggles should be worn when there is a possibility of splashing,
splattering or generating droplets of body fluids.

	3. Masks are single use and disposable. Goggles may be reusable. If reused,
goggles should be cleaned with the hospital approved germicide or a 1:10 bleach
solution between uses.

C. Gowns

	1. Gowns or aprons are worn to reduce the possibility of body fluid
contamination of exposed skin and soiling of clothing.

	2. Gowns or aprons should be worn during procedures that are likely to cause
splattering or splashing of body fluids.

 3. Needles and sharp instruments

	A. Used needles and sharp instruments are handled carefully to avoid injury.

	B. Used needles are not recapped, bent, broken, or other wise manipulated by
hand. Used needles and other disposable sharp items are disposed of in puncture
resistant containers as close to the point of use as practical. Puncture resistant sharps
needle boxes are mounted in patient rooms, treatment room, doctor's offices, UCC,
and Allergy/Immunization Clinic.

	C. Reusable sharps, needles, tweezers, etc., are handled carefully and
cleaned/disinfected or sterilized appropriately.

4. Patient Specimens

	A. All patient specimens are placed in leak proof containers or fluid
impervious bags for transport within the health center.

	B. Care should be taken when collecting and handling specimens to avoid
contamination of the outside of the container and the lab slip.

	C. Because all body fluids, substances and specimens from all patients are
hand]ed as infectious, there is no need for special labeling of specimens.

5. Patient Isolation

	A. Body substance isolation eliminates the need for most other categories of
isolation.

	B. Respiratory isolation procedures are maintained to prevent transmission
of air-borne infections, (see Infection Control Manual - Respiratory Isolation).
Private rooms are indicated for patients on Respiratory Isolation and for patients w
h poor hygiene.

6. Health Care Workers

	A. Health care Workers with exudative lesions or weeping dermatitis will be
evaluated by the Duty Physician. They should refrain from direct patient care
activities, from handling patient care equipment, and from handling patient
specimens until the condition is resolved.

	B. Health care workers should report all incidents of body fluids exposure to
their supervisor. Body fluids exposures such as needlestick injuries, splashes to the
mucous membranes of the eye, nose, or mouth and skin exposure involving large
amounts of body fluids or prolonged exposure must be reported. (See Blood w Body
Fluid Exposure policy.) It is especially important to report skin exposures if skin is
chapped, abraded, cracked, or afflicted with dermatitis or exudative lesions.

7. Precautions for Invasive Procedures

	A. Invasive procedures are those diagnostic or therapeutic procedures that
involve surgical entry into the tissues, body cavities or repair of traumatic injuries.
These procedures create a significant potential for exposure to blood and body fluids.

	B. Barriers to prevent skin and mucous membrane exposure to body fluids,
including masks, goggles, and gowns, should be used if this type of exposure is
anticipated.

	C. Sterile gloves should be worn for all invasive procedures.

	D. Gloves that are torn or punctured should be removed and a new glove
used as soon as possible.

8. Sterilization and Disinfection of Patient Care Equipment

	A. Non-disposable articles should be cleaned, rinsed, and dried before being
sent to Central Supply.

	B. Gloves should be worn for all cleaning and decontamination procedures.
Goggles should be worn if splashing is anticipated.

	C. Instruments and other non-disposable medical devices that enter normally
sterile tissue should be sterilized before reuse. When sterilization is not feasible, the
equipment should receive high level disinfection with a 20 minute soak of
appropriate cold sterilization solution.

	D. Instruments that touch intact mucous membranes may be sterilized or
receive high level disinfection.

	E. Medical devices or instruments that require disinfection or sterilization are
thoroughly cleaned before processing.

9. Housekeeping

	A. In patient care areas horizontal surfaces, such as bedside tables and floors
are cleaned on a regular basis; when soiling or spills occur; and when a patient is
discharged. work surfaces must be cleaned and decontaminated upon completion of
a procedure.

	B. Other surfaces such 25 w alls and curtains are cleaned when visibly soiled.

	C. A hospital grade disinfectant/detergent registered w the EPA is used to
clean environmental surfaces. It is used according to the manufacturer's
instructions.

	D. Reusable trash receptacles that hold contaminated items shall be inspected
and decontaminated on a regular basis.

10. Cleaning Spills of Bodily Fluids

Body fluid spills are cleaned with an EPA-registered hospital disinfectant with a
label claim for viricidal activity against the HIV virus. A 1:10 solution of household
bleach may be used for decontamination of body fluid spills.

11. Laboratory

	A. Guidelines for handling blood specimens:

	1. Ali blood, i.e., serum, plasma, or while blood should be handled as
potentially infections.

	B. The following precautions are recommended by the CDC.

	1. Promptly place used needles in puncture-resistant containers. Do not break
needle or reinsert into the original sheath.

	2. Use mechanical pipettors to manipulate all liquids - mouth pipetting IS
prohibited.

	3. Wear lab coats, gowns, or uniforms while handling potentially infectious
material and discard these appropriately before leaving the lab.

	4.  Wear glasses to avoid contact with blood, specimens containing blood,
blood-soiled items, body fluids, excretions and secretions and the surface or objects
exposed to these substances.

	5. Follow procedures that will minimize formation of droplets and aerosols
during the manipulation of infectious material.

	6. Note that it is advisable to use biological safety cabinets or other
containment devices for procedures with a high potential for creating aerosol or
infectious droplets.

	7. Decontaminate lab work surfaces, needle holders, tourniquets, etc., with a
disinfectant after completion of procedures or immediately following
contamination with infectious material. Use either BacDown disinfectant or 10%
Clorox solution.

	C. Decontaminate potentially contaminated material, preferably by
autoclaving, before disposal or reprocessing.

	1. All potentially contaminated material is placed in orange biohazard bag in
waste cans provided and then taken to the autoclave room to be autoclaved.

	D. Always wash your hands after completing laboratory activity, and remove
protective clothing before leaving.

12. Laundry

	A. All soiled linen is bagged at the location where it is used.

	B. Soiled linen is not rinsed in patient care areas. Linen soiled with body
fluids is placed and transported in bags that prevent leakage and labeled BODY
SUBSTANCE ISOLATION.

	C. Persons handling linen soiled with body fluids should wear gloves and
gowns to reduce the risk of skin contact and soiling of clothing.

	D. Linen should be washed with detergent and hot water (at least 160F, 71C)
for 25 minutes.

13. Infectious Waste Disposal

	A. Disposable articles such as paper or plastic waste bags, tongue depressors,
plastic utensils, paper plates and cups, paper towel, contaminated dressings, needles,
syringes and food from isolation units which have been contaminated with
infectious secretions or excretions, blood or body fluids are considered infectious
waste.

	B. Infectious waste will be placed in biohazard bags which will be closed
around the opening of the bag with a rubber band. These bags arc obtained from the
Facility Supervisor on a "Stores Requisition" form.

	C. Pressurized containers are absolutely not to be placed in biohazard bags as
they present a hazard if autoclaved or incinerated. They should not be allowed in
the isolation units.

	D. Liquids and soft soluble food waste are to be flushed down the toilet. They
are not to be put in the biohazard bags.

	E. The biohazard bags should be taken to Central Supply daily to be
autoclaved. They should be placed in the container next to the autoclave for
unprocessed bags. After decontamination, the bags are placed in a designated
container for shipment to Hershey by the CSR technician.

	F. M&O cleaning personnel should be advised to leave all biohazard bags in
the unit for disposition during the day.

	G. Contaminated syringes and needles will be placed in puncture resistant
containers marked "SHARPS - INFECTIOUS WASTE." They will be taken to
Central Supply for decontamination w hen the "FILL" level has been reached

	H. Any questionable items should be brought to the attention of the Infection
Control Committee.

	I. Biohazard waste will be decontaminated by autoclave in Central Supply
then picked up by designated University employees.

	J. Decontaminated biohazard waste will be disposed of according to The
Pennsylvania State University Infectious Waste Management Program.
HANDWASHING PROCEDURE

Handwashing is the single most effective way to prevent the spread of infection.

	1. Equipment and supplies needed:

		a. A good source of hot and cold running water. 
		b. Source of liquid hand soap. 
		c. Supply of clean paper towels or disposable wipes.

	2. Procedure:

		a. To prepare for washing your hands and forearms, remove jewelry
and roll your sleeves up, securing them so they do not fall down during the
washing process.

		b. Turn on water taps, cold first, then hot and test the water. The water
should be comfortably warm.

		c. Wet hands and forearms under the running water.

		d. Apply a generous amount of hand soap to the hands.

		e. Rub hands, front and back, up over wrists and in between fingers.
CDC recommends a minimum of 10 seconds.

		f. Rinse your hands front and back and up wrists and forearms
thoroughly under the running water to remove all soap residue.

		g. Using a clean paper towel turn off water.

		h. Discard paper towel into trash.

		i. Use fresh, clean paper towel(s) to dry hands. Frequent handwashing
will have a tendency to dry out your skin. The use of a good hand lotion after
washing will help prevent rough, dry skin or chapped hands.