Module 9 Safety and Supportive Care in the Work Setting.

Module 9

Safety and Supportive Care in the Work Setting

Malawi PMTCT Training Package 2

Module Objectives

Describe how Universal Precautions can prevent healthcare workers (HCWs) from exposure to bloodborne pathogens.

Outline strategies for preventing HIV transmission in the healthcare setting.

Identify key steps in the decontamination, cleaning, disinfection and sterilization of equipment and materials.


Module Objectives (continued)

Discuss risk reduction in obstetric settings.

Describe the management of occupational exposure to HIV.

Outline the National PEP regimen. Identify personal strategies to manage

burnout.


Unit 1:

Universal Precautions


Unit 1 Objective

Describe how Universal Precautions can prevent healthcare workers (HCWs) from exposure to bloodborne pathogens.


Basic Concepts of HIV Infection Prevention

HIV and other bloodborne diseases may be transmitted in healthcare settings: From client to HCW From HCW to client From client to client

Primarily spread through blood HIV transmission to HCWs almost always

associated with needlestick injuries


Basic Concepts of HIV Infection Prevention

In practice, transmission occurs during: Intravenous injections Blood donations Dialysis Transfusions


Basic Concepts of HIV Infection Prevention (continued)

Client-to-client transmission prevented by disinfecting or sterilizing equipment/devices used to puncture skin

Transmission of infectious agents in healthcare setting prevented by: Wash hands with soap and water Adhere to Universal Precautions and safe

environmental practices Provide ongoing education for employees about

infection prevention



Definition Universal Precautions are simple set of

effective practices designed to protect HCWs and clients from infection with a range of pathogens, including bloodborne viruses such as HIV. These practices are used when caring for ALL clients regardless of diagnosis.


Creating Safe Work Environment

Not feasible or cost-effective to test all clients for all pathogens before providing care

Level of precautions employed should be based on nature of procedure involved, not on client’s actual or assumed HIV status


Managing the Work Environment

To reduce occupational risks: Assess risks in work setting Explore strategies for meeting resource needs Develop standards and protocols that address safety Attain and maintain appropriate staffing levels Ensure staff have appropriate workloads Orient new staff to infection prevention procedures Provide ongoing staff education and supervision Reduce staff stress, isolation, and burnout Acknowledge and address the needs of HIV-infected

HCWs



Ensure that Universal Precautions are implemented, monitored, and evaluated.

Provide protective clothing and equipment, including gloves, plastic aprons, gowns, goggles, and other protective devices.

Provide and use appropriate disinfectants to clean up spills involving blood or other body fluids.

Increase availability and accessibility of puncture-resistant sharps containers


Ongoing Education for Employees

Orient staff to infection prevention policies

Ensure workers routinely exposed to blood and body fluids receive preliminary and ongoing training

Require that supervisors observe and assess safety practices and remedy deficiencies


Unit 2

Handling and Decontamination of Equipment and Materials


Unit 2 Objectives

Outline strategies for preventing HIV transmission in the healthcare setting.

Identify key steps in the decontamination, cleaning disinfection and sterilization of equipment and materials.

Discuss risk reduction in obstetric settings.


Hand Washing

Hand washing with plain soap and water is one of the most effective methods for preventing transmission of bloodborne pathogens and limiting the spread of infection. Soap and water hand washing, using friction under

running water for a minimum of 15 seconds. Alcohol-based hand rubs for routine decontamination

or hand antisepsis for hands not visibly soiled.


Hand Hygiene Recommendations

Wash before:

Putting on gloves Examining a patient Performing any procedure that involves contact with blood or body

fluids Handling contaminated items Eating

Wash after:

Removing gloves Examining a patient Performing any procedure that involves contact with blood or body

fluids Handling contaminated or soiled items Making contact with body fluids, mucous membranes, non-intact

skin, or wound dressings Using a toilet


Personal Protective Equipment

Personal protective equipment safeguards clients and staff. Gloves Aprons or gowns Eyewear Footwear

When resources for purchasing protective equipment are limited, purchasing gloves should receive priority.


Gloves

Use separate pair of gloves for each client Protection with gloves recommended when:

Reasonable chance of hand contact with blood, other body fluids, mucous membranes

HCW has skin lesions on their hand. Sterile gloves are required for surgical procedures.

Gloves not required for routine care activities in which contact is limited to client’s intact skin.


Tips for Effective Glove Use

Wear correct size gloves Use water-soluble hand lotions and moisturizers Avoid oil-based hand lotions or creams Do not wear rings Keep fingernails short Store gloves where they are protected from

extreme temperatures


Personal Protective Equipment

Aprons or gowns Aprons provide protective waterproof barrier. Gown should be worn to protect skin and prevent soiling

of clothingEyewear Eyewear protects eyes from accidental splashesFootwear Gum boots or leather shoes provide protection to the

feet from injury by sharps or heavy items that accidentally fall

Avoid wearing sandals, thongs, or shoes made of soft materials


Strategies for Resource-Constrained Settings

Universal Precaution measures are difficult to practise when supplies are low and protective equipment not available

Use resources cost-effectively by prioritising the purchase and use of supplies

Reduce occupational exposure to HIV by reducing contact with blood


Equipment & Materials

Handling and disposal of sharps Most HIV transmission to HCWs is the

result of skin puncture with contaminated needles or sharps

Injuries more likely when sharps are recapped, cleaned, or inappropriately discarded.


Equipment & Materials

Recommendations for use of sterile injection equipment

Use new, quality-controlled disposable syringes & needles

Avoid recapping of needles If recapping necessary, use single-handed scoop technique.

Collect used syringes and needles at point of use in puncture/leak-proof sharps container

Destroy or burn used needles and syringes so people cannot access them

Wear gloves Handle all laboratory specimens with care Use holders for all blades


Careful Handling of Sharps

Always point sharp end away from yourself and others.

Pass scalpels and other sharps with the sharp end pointing away from other person.

Whenever possible, place sharp on flat surface (a tray) to pass to other person.

Pick up sharps one at a time and never pass handfuls of sharp instruments or needles.


Single-handed Recap Method

Step 1:

Scoop up the cap

Step 2:

Push cap firmly down


Sharps Containers

Using sharps disposal containers helps prevent injuries from disposable sharps

Sharps containers should be fitted with a cover, and should be puncture-proof, leak-proof, and tamper-proof

If safety boxes unavailable, many available objects can substitute as sharps containers: Tin with a lid Thick plastic bottle Heavy plastic box Heavy cardboard box


Safe Use of Sharps Containers

All sharps containers should be clearly marked “SHARPS”

Place sharps containers away from high-traffic areas and as close as possible to where the sharps will be used.

Attach containers to walls or other surfaces if possible.

Never reuse sharps containers for other purposes.

Seal and close containers when ¾ full.


Decontamination, Cleaning, High Level Disinfection, & Sterilization

Method used to decontaminate equipment or supplies should be based on:

Risk of infection associated Decontamination process the object can tolerateRoutine procedures: Use heavy gloves Dismantle all equipment before cleaning Wear additional protective clothing such as

aprons, gowns, goggles, and masks when at risk for being splashed with body fluid


Decontamination of Equipment & Materials

DefinitionDecontamination is a process that makes

inanimate objects safer to be handled by staff before cleaning

Soak contaminated items for 10 minutes in 0.5% chlorine solution

Larger surfaces should be decontaminated by wiping with disinfectant (e.g., 0.5% chlorine solution or 1–2% phenol).

Decontamination should be done at point of use immediately after the procedure.


How to Prepare 0.5% Chlorine Solution

•Brand of Bleach, % chlorine

•To obtain a 0.5% chlorine solution

Household bleach, 5% chorine

1 part household bleach to 9 parts water

Jik, 3.5% chlorine 1 part Jik bleach to 6 parts water

Powder bleach, 35% chlorine

14.2 grams of dry powder to 1 litre of water


DefinitionCleaning is a process that physically removes all

visible dust, soil, blood or other body fluids from inanimate objects as well as removing sufficient numbers of microorganisms to reduce risks for those who touch the skin or handle the object

Consists of washing with soap or detergent and water, rinsing with clean water and drying

If tap water contaminated, use water that has been boiled for 10 minutes and filtered to remove particulate matter

OR use chlorinated water


Cleaning of Equipment

Any instrument or equipment that comes into contact with intact skin should be cleaned before use

Any instrument or equipment should be thoroughly cleaned & rinsed before further processing

Use personal protective equipment during cleaning

Can be performed in department, unit, and ward or in a central sterilization department/area.


Definition

High-level disinfection (HLD) is a process that eliminates nearly all microorganisms, except some bacterial endospores, from inanimate objects by boiling, steaming, or using chemical disinfectants.


Any instrument or equipment that comes into contact with non-sterile tissue should be high-level disinfected or sterilized before it is used.

Decontaminate, clean instruments and equipment prior to HLD.

HLD is not a sterilization process. HLD by:

Boiling or steaming instruments and other items for 20 minutes. Soaking the instruments and other items for 20 minutes in 2–

4% glutaraldehyde solution, 8% formaldehyde solution, or 0.1% chlorine solution and rinse with sterile or HLD water

High-Level Disinfection (HLD)


Sterilization is a process that eliminates all microorganisms (bacteria, viruses, fungi and parasites) including bacterial endospores from inanimate objects by high-pressure steam (autoclave), dry heat (oven), chemical sterilants or radiation.

Definition


Sterilization

All instruments and equipment should be decontaminated, cleaned, and dried prior to sterilization.

Any instrument or equipment used to enter sterile tissue or the vascular system of a client, should be sterilized before it is used.

Microwaves ovens, pressure cookers, dishwashers, ultraviolet cabinets, ultrasonic cleaners, and similar devices do not sterilize and should not be used for this purpose.


If using steam sterilization: Observe recommended temperature,

pressure and holding time. For most autoclaves (unless otherwise recommended by the manufacturer): Temperature should be 121C (250F) Pressure should be 106 kPa (15 lbs/in2) Time should be 20 minutes for unwrapped

items, 30 minutes for wrapped items

Sterilization (continued)



If using dry heat sterilization: Unless otherwise recommended by the manufacturer,

recommended temperature and times are as follows: Sterilize at 170C (340F) for 1 hour (total cycle time—placing

instruments in oven, heating to 170C, timing for 1 hour, and then cooling—is from 2–2.5 hours), OR

Sterilize at 160C (320F) for 2 hours (total cycle time is from 3–3.5 hours).

All packed and wrapped instruments and equipment should be stored in a manner that ensures sterility is maintained.


If using chemical sterilization: Some high-level disinfectants will kill endospores after

prolonged (10–24 hour) exposure. Common disinfectants used for chemical sterilization

include glutaraldehydes and formaldehyde. Sterilize by soaking at least 10 hours in 2–4%

glutaraldehyde solution or at least 24 hours in 8% formaldehyde.

Both glutaraldehydes and formaldehyde require special handling and leave a residue on treated instruments; therefore, rinse with sterile water afterwards



Use gloves Collect linen in bags or fold with the

soiled parts inside for transport (do not rinse or sort in the patient care area)

Soak in 0.5% chlorine solution for ten minutes

Wash in hot soapy water and air dry If the linen is to be used in theatre, it

should be sterilized.

Handling of Soiled Linen


Potential for exposure to HIV-contaminated blood and body fluids is highest during labour and delivery.

Wash hands Cover broken skin or open wounds with

watertight dressings Wear gloves Wear a waterproof plastic apron during delivery Cover the cord with gloved hand or gauze

before cutting

Reducing Risk of Occupational Exposure in the Obstetric Setting


Reducing Risk of Occupational Exposure in the Obstetric Setting (continued)

Wear eye shield during episiotomy and suturing Use needle holders when suturing Pass all sharp instruments on a tray, rather than hand-to-

hand When episiotomy is necessary, use appropriate-sized

needle (21 gauge, 4 cm, curved) and needle holder If blood splashes on skin, immediately wash the area

with soap and water. If splashed in the eye, wash the eye with water only. If blood splashes on floor, wash with chlorine solution Dispose of solid waste according to local procedures


Promoting a Safe Work Environment Resource List:

Group Discussion

Exercise 9.1


Reducing HIV transmission Risk in MCH Settings:

Case Study

Exercise 9.2


Managing Occupational Exposure to HIV

Unit 3


Describe the management of occupational exposure to HIV.

Outline the National PEP regimen.

Unit 3 Objectives


Occupational risk of becoming HIV-infected due to needle-stick is low (less than 1%)

Risk of exposure from needle-sticks and contact with blood and body fluids exists in settings where: Safe needle procedures and Universal Infection

Prevention Precautions are not followed Waste management protocols are inadequate or not

consistently implemented Protective gear is in short supply Rates of HIV infection in the client population are

high

Managing Occupational Exposure to HIV Infection


Promotes retention of staff who are concerned about the risk of exposure to HIV

Increases staff willingness to work with HIV-infected people

Reduces the occurrence of occupationally-acquired HIV infection in HCWs

A comprehensive PEP protocol outlines the methods for preventing occupational exposure to HIV and other bloodborne pathogens.

Benefits of Making PEP Available for HCWs:


“PEP” refers to treatment (using ARV drugs) of the HCW who has experienced an occupational exposure.

ARV therapy started immediately after exposure to HIV may prevent HIV infection, although not 100% effective.

Treatment should be initiated within 1-2 hours of exposure, but PEP can be started up to 72 hours after exposure.

HIV exposure is classified as either low risk or high risk.

PEP: Low risk and High risk


High risk exposures: Percutaneous injuries with hollow needles and large volume of blood onto a mucosal surface from a source person who is known or highly likely to be HIV-positive

Low risk exposures: All other exposures, including percutaneous injuries with solid needles, exposures to fluids other than blood, and exposures to non-intact skin.

Exposure of blood or other fluids to intact skin is not a risk

Post-Exposure Prophylaxis (PEP): Low risk and High risk (continued)


First aid and other immediate measures: To reduce contact time with source person’s blood or

body fluid and decontaminate the site of the exposure Use soap and water to rinse any wound or skin site in

contact with infected blood or fluid. Rinse exposed mucous membranes thoroughly with

water. Irrigate generously any open wound with sterile saline

or disinfectant solution (2-5 minutes). Irrigate eyes with clear water, saline, or sterile eye

irrigants. Report exposure to the clinician on duty as soon as

possible.

After Occupational Exposure


Each health facility should keep a bottle of AZT+3TC (Duovir®) in designated unit for easy/secure access.

HCW should immediately report the exposure to senior staff

3-day supply of AZT+3TC given to HCW to begin PEP regimen as soon as possible after the exposure.

HCWs must be counselled about ARV side effects

Operational Considerations


National PEP ProtocolThe source client If HIV-positive, then PEP is indicated. If HIV-negative discontinue PEP If HIV-negative and possibly in the “window period”,

seek specialist advice. The HCW Encouraged to undergo HIV testing and counselling

immediately or within 72 hours of exposure. If HCW is HIV-positive, then PEP is not necessary HCW who tests HIV-negative should receive follow-up

HIV testing at 3 and 6 months. If negative at 6 months, counsel as if negative as a result of the exposure


PEP Regimen

Drug Zidovudine (AZT) 300mg/Lamivudine (3TC) 150mg (Duovir) Dose Frequency Duration One tablet

Twice a day (BD)

30 days

Duovir should be available at every health facility and at central medical stores. In some cases, lopinavir/ritonavir can be added to the Duovir therapy: specialist advice is necessary.


Monitoring and management of PEP toxicity If PEP used, HCWs should be monitored for

drug toxicity by laboratory testing at baseline and 2 weeks

May experience adverse symptoms including nausea, malaise, headache, and anorexia.

Pregnant workers or women of childbearing age who may be pregnant may receive PEP.

PMTCT services should support workers while they take PEP and help manage side effects.

Guidelines for Providing PEP


PEP Case Study:

Small-Group Discussion

Exercise 9.3


Supportive Care for the Carer

Unit 4


Identify personal strategies to manage burnout.

Unit 4 Objective


Burnout Burnout syndrome stems from extended

exposure to intense job-related stress and strain. Emotional exhaustion: feelings of helplessness,

depression, anger, and impatience Depersonalisation: detachment from the job and an

increasingly cynical view of clients and co-workers Decreased productivity: due to real or perceived

sense that their efforts are not worthwhile and do not seem to have an impact

Care for the Carer


Signs and Symptoms of Burnout

Behavioural Frequent changes in mood Eating too much or too little Drinking alcohol and/or smoking

too much Becoming “accident prone” Cognitive Unable to make decisions Forgetful, poor concentration Sensitive to criticism

Physical High blood pressure Palpitations, trembling Dry mouth, sweating Stomach upset Occupational Taking more days off Arguing with co-workers Working more hours but getting

less done Having low energy, less motivated


Institutional or job-related risk factors for burnout Work overload, limited or no breaks Long working hours Poorly structured work assignment (worker not able to

use skills effectively) Inadequate leadership and support Lack of training and skill-building specific to your jobPersonal risk factors for burnout Unrealistic goals and job expectations Low self-esteem Anxiety Caring for clients with a fatal disease

Risk Factors for Burnout


Tips for Managing Burnout

Find or establish a support group of peers

Search out a mentor Read books or listen to

tapes Take a course to learn

about a subject relevant to your work

Take structured breaks during work hours

Make time for yourself and your family

Exercise, eat properly, and get enough rest

Link with social groups, social functions or services that can provide support

Where possible, delegate some work-related responsibilities to colleagues


Burnout in the PMTCT Service:

Large Group Discussion

Exercise 9.4


Creating a safe work environment involves practising: Universal Precautions Management of the work environment Ongoing education of employees in all

aspects of infection prevention

Module 9: Key Points


Universal Precautions apply to all clients, regardless of diagnosis. Key components include: Hand washing Use of personal protective equipment Decontamination of equipment Safe handling and disposal of sharps Safe disposal of infectious waste materials Safe environmental practices

Module 9: Key Points (continued)


Decontaminated, cleaning, high-level disinfection, and/or sterilized of all instruments used in invasive procedures reduce risk of transmission of infection.

Post-exposure prophylaxis (PEP) is short-term antiretroviral prophylaxis that reduces the risk of HIV infection after occupational exposure. The regimen (one tablet of Duovir twice a day for 30 days) should be started within 1-2 hours of exposure.

Burnout is related to intense, prolonged job stress but can be managed, even prevented through personal strategies, particularly if there is organizational support.

Module 9: Key Points (continued)

Module 9 Safety and Supportive Care in the Work Setting.

Documents

Transcript of Module 9 Safety and Supportive Care in the Work Setting.