UNIVERSAL HEALTH PRECAUTIONS an Update

Dr.T.V.Rao MD

What are Universal Precautions Universal precaution are control guidelines designed to protect workers from exposure to Diseases spread by Blood and other Body fluids.

Universal Precautions
Applied universally in caring for all patients

Hand washing
Decontamination of equipment and devices Use and disposal of needles and sharps safely (no recapping) Wearing protective items Prompt cleaning up of blood and body fluid spills Systems for safe collection of waste and disposal

Why Universal Precautions

DEFINITION
Standard Precautions
Previously known by various names including universal precautions Sstandard precautions are designed to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources to a susceptible host. They are the basic level of infection control precaution Hospital Infection is the result of a combination of factors: Microbial source + Transmission + Susceptible host = Infection

History of Infection Control Precautions

Year 1877,1910 1985 Infection Control Precautions Separates facilities, Antisepsis and disinfections ... etc UNIVERSAL PRECAUTIONS (guidelines for protecting healthcare worker because the emergence of HIV & other bloodborne pathogens) BODY SUBSTANCE ISOLATION ( focused on protecting patients and health personnel from all moist body fluids not just blood: semen, vaginal secretions, wound drainage, sputum, saliva etc STANDARD PRECAUTIONS:Two level approach: Standar Precautions which apply to all clients and patients attending healthcare facilities Transmission-based Precautions which apply only to hospitalized patients ISOLATION PRECAUTIONS (new pathogens; SARS, Avian Influenzae H5N1, H1N1)

1987

1996

2007

Every Procedure increases the Risk of Infection to HCW

Objectives:
Participants will:

Understand and become familiar with universal precautions. Learn the importance of good hygiene and hand washing. Learn proper hand washing techniques. Learn the proper technique for applying and removing gloves.

Why Universal health Precautions.

The concept of Universal Health Precautions emphasizes that all our patients should be treated as though they have potential blood born infections, and can infect the caring health care workers. ( CDC )

We Do Not Know who is Infected

Human materials/Tissues considered Highly Infectious

1 Blood 2 Semen 3 Vaginal secretions 4CSF 5 Synovial fluids 6 Amniotic fluid 7 All other body fluids

Not Infectious unless contaminated with Blood or Body fluids.

Feces, Nasal secretions, Sputum, Sweat, Tears, Urine / Vomitus, Saliva unless blood stained.

Hand washing is the most important method of disease prevention

Bacteria and bacteria can be spread via dirty hands and the are too small to see with the human eye. You must wash you hands properly in order to remove them.

HAND WASHING
There is no Health precaution like Hand washing. Washing with simple toilet soap - reduces the rate of transmission of common infections including the HIV.

How to Wash our hands

Indications for Hand Washing

In prolonged contact with patient. Before taking care of Immune supressed,New born infants, patients in ICU / ICCU, Dialysis Units, Burns Units. Before and after touching wounds. When Microbial contamination of Hands, likely to occur when in contact with mucous membranes, body fluids, and other secretions contaminated with Blood, and serous fluids.

What to be used for hand washing

In most circumstances Non medicated soaps and detergents are effective in removing most transient contaminants. In demanding circumstances, in handling potentially harmful infections, use Ethyl or Isopropyl alcohol. Detergent formulations containing Chlorhexidine Povidone,or Hexachlorophene are effective in prevention of spread of infections.

Words of Wisdom on Hand Washing

Soap, water and Common sense are still be Best Antiseptics
William Osler

This I do believe ! The single most important thing that you can do to stop the spread of any germs is to wash your hands

Use of Gloves
Use of a pair of disposable plastic gloves can protect if chances of contact with Blood or Body fluid is
anticipated/inevitable.

Use of Mask, Cap, Eye Wear

Will certainly protect us from splashes of Blood or Body fluids. Don't underestimate the importance of Use of Cap and Mask. It equally protects our patients.

UP recommends the use of Personal Protective Equipment

Gloves Aprons Gowns Protective eyewear Face shields Masks

Uses of Cap and Mask

Stringent use of Mask and Cap can save several Lives in the Hospital

Use of Foot wear

Wearing foot wear covering entire sole protects the entry of Microbes from the contaminated floors with Blood and Body fluids. Remember many of us have cracks on our feet.

Use of Impervious Gown

A simple thin Plastic apron underneath the linen is of great help in preventing the soaking our inner clothes and exposure to harmful microbes.

Universal Precautions also include: Proper handling and disposal of needles. Taking precautions to prevent injury from scalpels, needles, and other sharp instruments.

Disposal of Needles and Sharps

All used needles and sharps should be deposited in thick walled puncture resistant containers. Bending, Reshaping, should be prohibited. Do not recap the needles to avoid needle stick injures, All used Disposable syringes and needles should be discarded into Bleach solution at the work station before final disposal.

Dealing with Used Needle

Shredding continues to be Important Method Of dealing with used Needle

Managing Occupational Exposure to HIV Infection

Post-Exposure Prophylaxis (PEP:

PEP Following occupational HIV exposure, shortcourse of ARV drugs can be used to reduce the likelihood of infection Register occupational exposures
Ensure that HIV counselling, testing,and ARV drugs are available Educate healthcare workers

Post-Exposure Prophylaxis (PEP)

Immediate steps post- exposure
Wash exposed wound or skin with soap and water
For needle or sharp injury, allow to bleed for a few seconds before washing

Inform supervisor of type of exposure and the actions taken

Assure confidentiality to the HCW

Ensure support and referral for treatment

Guidelines for PEP

Ideally, initiate PEP treatment within 2 hours of exposure If source patient is HIV negative, discontinue PEP and retest at 6 weeks, 3 months, and 6 months If source patient is HIV positive, counsel, support, and refer the HCW for continued treatment

Guidelines for PEP (continued)

Follow approved PEP regimen( suggested) Examples
ZDV 200 mg 3 times daily for 4 weeks Combivir tablet (300 mg ZDV and 150 mg lamivudine) twice daily +

Indinavir 800 mg 3 times daily for 4 weeks

Dealing with Needle stick Injuries

Consider all Needle stick injuries as a serious health hazard in the era of AIDS All events of Needle stick injuries to be reported to the supervisory staff. Wash the injured areas with soap and water. Encourage bleeding if any. Prophylaxis for prevention of HIV/HBV is top priority. Anti retroviral prophylaxis, if necessary should started within 2 hours, ( if injury is from HIV positive or high risk group).

Avoid Needle Stick Injuries

Hazards of Needle stick Injuries HIV HBV and HCV viral infections can spread by Needle stick Injuries Nursing staff are at greater risk Several Injuries are preventable

Decontamination of Hospital Linen All the linen contaminated with Blood or Body fluids should be soaked in 1: 100 bleach solution for 30 minutes. Advised Autoclaving, as the most ideal procedure for decontaminating Linen

Spillage of Blood/Body fluids

A common health hazard in the working environment. Never wipe the spillage with working wet mop. Always cover the spills with paper and pour 1 % Hypochlorite or Bleaching powder to decontaminate the spills with HIV/HBV virus.

Care of Endoscopes
Endoscopes are delicate/precious instruments. Follow the instruction of Manufacturers. It is commonly cleaned with 2 % Glutaraldehyde solution. Specified time schedules to be followed to decontaminate for HIV. Mycobacterium needs even > 2 hours for decontmination.

Decontamination of Metal Instruments

Hold all contaminated instruments with Gloved hands. Subject all metal instruments to washing with soap and water. Treat all contaminated instruments with 2% Glutaraldehyde. For at least 30 minutes. Many consider sterilizing in Hot air oven if not sharp instruments.

Anesthetic Tubing's and other Equipment's

Since they are in intimate contact with Human secretion need utmost attention in decontamination. Treat all Non disposable as highly hazardous, if used without safe practices can infect the next patient undergoing procedures. Soaking in 2 % Glutaraldehyde is common practice in Developing world.

Pregnant Health Care Workers

Not at more risk than other, Health care workers. Should adopt Universal Health Precautions with more dedication, If neglected the Unborn is at grave risk of attaining congenital infections. The Laboratory supervisors should monitor/ guide the HCWs for adherence to scientific practices.

Operating on HIV/High risk groups

It is a concern all should be cared equally. HIV infected carries the risk of being neglected at the time of crisis. Law many not change for equality but motivated health workers should bring in change of attitude. Adherence of Universal Health precaution bring in safety to all HCW. Follow the precautions even in Non HIV patients as some of our patients are in window period and more dangerous than truly positive with Sero testing.

Caution on Operating HIV Sero Negative Patients

Universal precaution apply to all our patients irrespective of Blood tests we undertake. We handle so many patients in emergency situation with out any details. Education on Universal precautions
participation of you and educating your subordinates/Juniors will make a lot of Difference in the work Environment.

Precaution for Invasive Procedures

All HCWs who participate in invasive procedures must routinely use appropriate barrier precautions. All Health care workers who perform/assist vaginal, and cesarean deliveries should wear gloves and gowns when handling, the placenta, and the new born, till blood and amniotic fluid has been removed from infants. Amniotic fluid is rich in HIV/HBV virus, in infected mothers.

Handling Dentistry Patients

Blood, Saliva, Gingival fluid from all Dental patients should be considered infective, Dental, workers should wear surgical mask, gloves and eye wear

Caring Bleeding Patients

Primary health care workers who handle the patients in Emergencies, and Accidents to be trained in basic principles of Universal Health care precautions. Mouth to Mouth resuscitation is life saving in the Critically injured accident victims. May be neglected because of fear of HIV infection. If the situation warrants, Bleeding from mouth can be wiped out with clean cloth, or Handkerchief, and still one can do resuscitation.

Importance of Vaccination in Hepatitis B Infection.

We have > 400 Million carriers with Hepatitis B infections. Every HCW is at risk of Contacting infection. Vaccination is safe -Genetically Engineered vaccination remains the great hope for prevention, apart from Major component of Universal precautions.

Vaccination for HBV infection

All HCWs must take at least three doses of Vaccine, At 0 1 6 months. without discontinuation of the schedule. All Health care workers many not attain equal response. High risk HCWs should undergo estimation of anti HB s ( antibodies ) to know whether they were well protected.

Problem of HBV vaccines in the Developing world

Who pays for the Vaccine. Many who work in unorganized sector, do not get Institutional support of Vaccine. Life, at risk if Infected with HBV More Awareness to be brought in by Managers of the Hospitals, to promote to vaccinate their Employees.

Transmission-Based Precautions
Used in addition to Standard Precautions for Specified Patients Designed for the Care of Specified Patients known or suspected to be infected by epidemiologically important pathogens

spread by: airborne, droplet, or contact

transmission.

Droplet Transmission
For infectious agents with droplet nuclei > 5 microns Examples:
Pertussis Meningococcal meningitis

Precaution Examples:
Private room Mask if within 3 of patient

Droplet Precautions
Prevent infection by large droplets from
Sneezing Coughing Talking Examples
Neisseria meningitidis Pertussis Influenza

Airborne Transmission
For infectious agents with droplet nuclei < 5 microns Examples: Tuberculosis Measles Precaution Examples Isolation rooms under negative pressure N95 or HEPA respirator use

Patient care equipment

Handle equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of pathogens to other patients or the environment. Clean, disinfect, and reprocess reusable equipment appropriately before use with another patient.

Contact Precautions
For protection against skin-to-skin contact and physical transfer of microorganisms to a host from a source Precaution Examples: Private room Hand washing Glove changes Examples Scabies VRE

Never forget to take Hepatitis B Vaccine if You are a HCW

Majority of OSHA CDC, and NIOSH guidelines are incorporated.

 The Programme created by Dr.T.V.Rao MD for the Medical and Health Care Personal in the Developing World

Email doctortvrao@gmail.com