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DR. SHAYMAA EL SAYED EL ARABI APRIL 2014

BLOODBORNE DISEASES TRANSMISSION AMONG HEALTHCARE WORKERS AND PATIENTS CHALLENGES AND SOLUTIONS. DR. SHAYMAA EL SAYED EL ARABI APRIL 2014 . Personal Introduction. Dr. Shaymaa Elsayed ElArabi Employee Clinic Physician Aseer central hospital, 450 bed referral hospital in southern region KSA

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DR. SHAYMAA EL SAYED EL ARABI APRIL 2014

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  1. BLOODBORNE DISEASES TRANSMISSION AMONG HEALTHCARE WORKERS AND PATIENTS CHALLENGES AND SOLUTIONS DR. SHAYMAA EL SAYED EL ARABI APRIL 2014

  2. Personal Introduction • Dr. Shaymaa Elsayed ElArabi • Employee Clinic Physician • Aseer central hospital, 450 bed referral hospital in southern region KSA • Accredited by Central Board of Accreditation for Healthcare Institutions 2010 and Joint Commission International 2013

  3. Bloodborne pathogens • Challenges facing healthcare setting • Necessary exposure control plan

  4. Patientsafety THERE IS A POTENTIAL SYNERGY BETWEEN PATIENT SAFETY AND HEATHCARE WORKER SAFETY ACTIVITIES. HCW safety

  5. facts • Bloodborne Disease is a disease that can spread through contamination by blood and other body fluids. The most common examples are HIV, hepatitis B, hepatitis C • the risk could include more than 20 others. Challenge

  6. facts • Occupational exposure to blood borne diseases occurs either through direct contact ( needle stick and sharps injury or infected blood and body fluid exposure ) or indirect contact

  7. Patients to healthcare worker • WHO indicates that worldwide 2 million out of 35 million health care workers experience percutaneous exposure to infectious diseases each year (1) •  OSHA estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodbornepathogens (2) (1) SUSAN Q et al, Preventing Needlestick Injuries among Healthcare Workers: A WHO–ICN Collaboration INT J OCCUP ENVIRON HEALTH 2004;10:451-6 (2) OSHA, Healthcare Wide Hazards, Needlestick/Sharps Injuries

  8. The Center for Disease Control and Prevention (CDC) estimates as many as 385,000 sharps injuries are incurred by hospital-based personnel each year in the United States (1) • A 2008 survey by the American Nurses Association revealed that 64% of nurse respondents reported having an accidental sharps injury. (2) (1) National Institute for Occupational Safety and Health (NIOSH) Education and Information Division, last reviewed: June 26, 2013 (2) 2008 Study of Nurses’ Views on Workplace Safety and NeedlestickInjuries An Independent Study Sponsored by American Nurses Association (ANA) and Inviro Medical Devices

  9. The exact number of exposures is not known and part of the problem is under reporting: it has been estimated that approximately 50-67% of all needlesticks and exposures to bloodborne pathogens are not reported * * Bernard, J.A., Datillo, J.R., LaPorte, D.M. (2013). The incidence and reporting of sharps exposure among medical students, orthopedic residents, and faculty at one institution. Journal of Surgical Education. 70 (5), 660-668. Challenge

  10. HEPATITIS B VIRUS

  11. Hepatitis B VIRUS • HBV is comparatively stable in the environment; it is resistant to drying, simple detergents, and alcohol, and has been found to remain viable at room temperatures for 7 days or longer.* • Infectious levels of HBV DNA can be detected on environmental surfaces in the absence of visible blood.* • * Beltrami EM, Williams IT, Shapiro CN, et al. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev 2000;13:385–407 Challenge

  12. Challenge Hepatitis B VIRUS ( cont. ) • The average incubation period of hepatitis B is 75 days (1) • No specific treatment exists for acute hepatitis B • The fatality rate among persons with reported cases of acute hepatitis B is 0.5% to 1.0% (2) • World Health Organization. Media Centre: Hepatitis B. July 2013. • Lawrence S , handbook of liver disease 2012

  13. RISK OF HBV INFECTION INsusceptible HCP, in the absence of PEP CDC. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis.MMWR. 2001;50(RR-11):1-42

  14. * WHO Hepatitis B Fact sheet N°204  Updated July 2013

  15. Hepatitis B Vaccine ( cont. ) • After widespread vaccination of HCW ,the estimated number of HBV infections among HCP in the United States has decreased from >10,000 in 1983to fewer than 400 in 2002 Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory care settings. Clin Infect Dis 2004;38:1592–8.

  16. HEPATITIS C VIRUS

  17. Hepatitis C VIRUS • Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in US • The potential for environmental survival of HCV suggests that environmental contamination with blood containing HCV could pose a risk for transmission in the healthcare setting.

  18. Hepatitis C VIRUS ( cont. ) • The incubation period for acute HCV infection ranges from 2 to 24weeks (1) • currently no PEP for HCV (1) Koretz R. L., et al  (1993) Non-A, non-B posttransfusion hepatitis: comparing C and non-C hepatitis. Hepatology 17:361–365. Challenge

  19. Hepatitis C VIRUS ( cont. ) • HCP exposed to infected blood through needlestick injuries may acquire HCV infection; the transmission risk per exposure is approximately 1.8% Elise M. Beltrami et al, Risk and Management of Blood-Borne Infections in Health Care Workers ClinMicrobiol Rev. Jul 2000; 13(3): 385–407

  20. HUMAN IMMUNE DEFICIENCY VIRUS

  21. Human Immunodeficiency Virus • The magnitude of risk depends on the severity of exposure 1. On the average, is about 0.3% after percutaneous injury 2. About 0.09% after mucosal exposure Elise M. Beltrami et al, Risk and Management of Blood-Borne Infections in Health Care Workers ClinMicrobiol Rev. Jul 2000; 13(3): 385–407

  22. Human Immunodeficiency Virus ( cont. ) • 3. The risk of transmission can increase up to 5% if the needle or sharp is contaminated by an HIV-infected patient with a high viral load ,the health care worker sustains a deep cut with lots of blood, and the procedure involved accessing the patient’s vein or artery. American Nurses Association’s needlestick prevention guide 2002

  23. Human Immunodeficiency Virus ( cont. ) • Since 1996, the U.S. Public Health Service (PHS) has recommended postexposurechemoprophylaxis with antiretroviral agents after certain needlestick, mucous membrane, and nonintact skin exposures to HIV-infected sources that pose a risk of infection Panlilio AL et al. Updated U.S. Public Health Service guidelines for the management of occupational Exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2005;54(RR-9):1–17.

  24. Human Immunodeficiency Virus ( cont. ) • Prophylaxis antiviral activity is diminished when treatment is delayed for more than 24 hours. * Challenge * Panlilio AL et al. Updated U.S. Public Health Service guidelines for the management of occupational Exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2005;54(RR-9):1–17.

  25. Needle stick and sharp injuries costs • Psychological disturbance for the HCW and their families • Workers compensation and overtime, • Expenses related to recruitment and training of staff to replace a worker who becomes ill. (American Hospital Association)

  26. Needle stick and sharp injuries costs ( cont. ) 4. Expenses related to follow-up for a high-risk exposure • almost $3,000 per needlestick injury, even when no infection occurs • one case of serious infection by bloodborne pathogens can soon add up to $1 million or more in expenditures for testing, follow-up, lost time, and disability payments Challenge (American Hospital Association)

  27. Prevention is cost effective COSTS BENEFITS

  28. Hierarchy of controls frameworkto bloodborne pathogen LEAST EFFECTIVE Exposure control plan MOST EFFECTIVE OSHA and NIOSH

  29. ELIMINATION OF HAZARDS • Remove sharps and needles and eliminate all unnecessary injections. Jet injectors may substitute for syringes and needles. Other example includes elimination of unnecessary sharps like towel clips

  30. ENGINEERING CONTROL • Engineering Controls are measures (e.g., sharps disposal containers, safer medical devices) that isolate or remove the bloodborne pathogens hazard from the workplace

  31. ENGINEERING CONTROL ( CONT. ) • Use puncture-proof containers to dispose of sharps and needles. Containers must be closed, puncture resistant, leak proof, color coded, and changed routinely to prevent overfilling

  32. ENGINEERING CONTROL ( CONT. ) • Use of devices with safety features: • Syringes and Injection Equipment (Needleless or jet injection- Retractable needle- Protective sheath- Hinged re-cap-) • . IV Access –Insertion equipment (Retractable- Shielded IV catheters- Hemodialysis safety fistula sets (butterfly)

  33. Blood collection and phlebotomy (Retractable needle- Shielded butterfly needle- Self-blunting needle- Plastic blood collection tubes • Suture Needles (Blunt suture needles) • Lancets (Retracting lancet) • Surgical Scalpels (Retracting scalpel- Quick-release scalpel blade handles)

  34. Needleless/no sharps alternatives (alternative cutting methods such as blunt electro-cautery and laser devices when appropriate-Substitute endoscopy surgery for open surgery when possible)

  35. ENGINEERING CONTROL ( CONT. ) • Needleless systems that administer medication and fluids through a catheter port using nonneedle connections and jet-injection systems that deliver liquid medication beneath the skin or through a muscle.

  36. Desirable Characteristics of Safety Devices • The device is needleless. • The safety feature is built into the device. • The device works passively • The user can easily tell whether the safety feature has been activated.

  37. Desirable Characteristics of Safety Devices ( cont. ) • The safety feature cannot be deactivated and remains protective through disposal. • If the device uses needles, it performs reliably with all needle sizes. • The device is easy to use and practical. • The device is safe and effective in patient care

  38. ENGINEERING CONTROL ( CONT. ) • Make safer needles and other sharps with integrated safety features available in syringes, blood collection devices, IV access products, lancets, and blunt suture needles.

  39. Safety devices and needlestick injury • Needleless or protected-needle IV systems decreased needlestick injuries related to IV connectors by 62% to 88%. . NIOSH Alert

  40. Safety devices and needlestick injury(CONT.) • Phlebotomy injuries were reduced by: 76% with a self-blunting needle, NIOSH Alert

  41. Safety devices and needlestick injury(CONT.) Reduced by: 66% with a hinged needle shield, NIOSH Alert

  42. Safety devices and needlestick injury(CONT.) Reduced by: 23% with a sliding-shield,. NIOSH Alert

  43. Safety devices and needlestick injury (CONT.) winged-steel(butterfly-type) needle. •

  44. Safety devices and needlestick injury(CONT.) • Safer IV catheters that encase the needle after use reduced needlestick injuries related to IV insertion by 83% in three hospitals NIOSH Alert

  45. Hierarchy of controls frameworkto bloodborne pathogen LEAST EFFECTIVE Exposure control plan MOST EFFECTIVE OSHA and NIOSH

  46. EXPOSURE CONTROL PLAN • Written exposure control plan should be available and procedure in case of exposure known to all HCWs • Exposure control plan should be reviewed annually to update the new available technology

  47. EXPOSURE CONTROL PLAN ( cont. ) • Develop strategies for improved needle-stick injury reporting procedures • Provide access, within two hours, for the post exposure prophylaxis in time • Make the hepatitis B vaccine available at no cost to employees

  48. EXPOSURE CONTROL PLAN ( cont. ) • Prohibit work practices of bending, re-capping, or removing needles unless required by a specific medical or dental procedure • Clean and decontaminate all work surfaces after contact with blood and other infectious body fluids following CDC guidelines.

  49. EXPOSURE CONTROL PLAN ( cont. ) • Provide PPE including gloves, gowns, goggles, masks or face shields. These devices must be in sizes that fit all workers, of good quality and readily available

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