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Protecting employees from job-related diseases.

As safeguards against hepatitis B, AIDS, and other diseases, this medical group developed protocols for employee immunization,

needlestick accidents, and the handling of infectious materials.

This year's medical literature has exploded with further concern about the spread of hepatitis B and human immunodeficiency virus.

In past years, such concern focused on the infected patient. Now it has shifted to the responsibility of the health care organization, as an employer, to protect its employees from infection. We responded to this concern by introducing a policy in June 1987 with safeguards against hepatitis B, HIV, and other infections. Recently, we adopted fuller guidelines on HIV testing.

Our multispecialty medical group has about 200 employees, including 45 physicians. In the lab, there are seven medical technologists, two medical laboratory technicians, three phlebotomists, and one and a half laboratory assistants in full-time equivalents.

The medical director appointed a team of physicians and nurses to develop the policy to protect employees. The team decided to concentrate its efforts in three areas: employee immunization, needlestick protection protocols, and protocols for handling potentially infectious materials.

Past approaches taken in these areas were uncoordinated and fragmented. Our goal was to develop procedures that would be applied consistently.

The team's first task was to insure that employees at risk for infection due to close patient contact were immunized appropriately. To accomplish this, such employees had to ' be identified and screened to determine their immunization status on a wide range of communicable diseases.

The screening seemed particularly important because the group had recently added primary care physicians who treated pediatric patients. Children are often carriers of a wide spectrum of infectious diseases that can be dangerous to pregnant women, and many of the nurses working with the primary care physicians were of childbearing age.

The nursing director, helped by managers from different areas, assembled a list of more than 100 employees with patient contact. These employees were asked to complete an immunization history survey that asked whether they had ever been immunized against or contracted diphtheria, polio, tetanus, measles, mumps, rubella, and chicken pox.

The survey revealed that 11 employees needed a rubelia titer, six needed to be immunized for mumps, and 17 needed the tetanus vaccine. On the basis of the type of patient and specimen contact they had, 48 also were judged to need Recombivax hepatitis B vaccine. These included laboratory personnel, anyone drawing blood, and the surgical staff. Employees uncertain whether they had received a certain vaccination were, as a precautionary measure, counted among those requiring immunization.

We offered the appropriate immunizations free of charge. As a cost-saving measure, employees who appeared to require rubella vaccine were first asked to have a rubella titer drawn to check for immunity. For further economy, employees who needed immunization against rubella and mumps received the mumps-measies-rubella vaccine.

To guard against liability, we first asked employees to read information sheets on the vaccines they were to receive and sign a release form. The information sheets stated the reason for each vaccine, its effectiveness, considerations involved in taking the vaccine, and common adverse reactions. Employees not wishing to receive vaccinations were asked to indicate their refusal on the release form as well.

This aspect of the team's plan was very well accepted, and all employees identified as needing immunizations chose to receive them. To date, no employee has experienced harmful side effects from any of the vaccinations. It is too early to measure the results in terms of decreased incidence of disease.

Needlesticks were the next problem to be addressed. One source estimates the risk of seroconversion from a needlestick to be about 2 to 3 health care workers per 1,000 when the patient involved is positive for HIV and 110 to 330 health care workers per 1,000 when the patient is positive for hepatitis B infection . One to three of the hepatitis B seroconversion group would be expected to die from acute fulminate hepatitis.'

The Centers for Disease Control suggests that the risk of seroconversion from exposure to the blood of a patient who is hepatitis B-positive ranges from 6 per cent to 30 per cent. The CDC also estimates the risk of seroconversion from a patient who is positive for HIV to be less than 1 per cent.

Before the team developed new safeguards, employees experienced about 10 needlesticks per year. An incident report was filed for every needlestick, and the director of nursing studied it to see if similar occurrences could be prevented in the future. No consistent care protocol existed. Employees concerned about potential health effects of the needlestick sought advice or treatment from their own physicians.

Needlestick accidents tend to happen when the needle is recapped. To prevent such accidents, employees began using puncture-proof containers, which allowed for disposal of the whole syringe and needle without cutting off the needle or recapping it. The new containers were placed at many easily accessible sites throughout the office, and physicians and staff received instructions on their use.

Since the implementation of the needlestick protection initiatives, there has been only one needlestick incident.

The team also revised the incident-report protocols for accidental needlesticks. The employee is instructed to cleanse the wound promptly. An incident report is filled out with the name of the patient whose blood was drawn, if known, the name of the patient's physician, the patient's diagnosis, any clinical observation of jaundice in the patient, and the patient's history of blood transfusions. The medical director evaluates the incident reports as they are issued. They are also reviewed retrospectively to help the medical group develop educational programs or materials and any other prevention techniques.

As of late June, our policy has called for HIV testing to be done routinely following an accident with a contaminated needle (similar testing for hepatitis B has been required since last year). Before, it was left to the medical director to evaluate the need for HIV testing after each needlestick incident.

The patient is told: "There has been a needlestick. In the event of a needlestick, for the protection of our employees, it is our policy to obtain a blood test for hepatitis and human immune deficiency virus . This will be done at no charge to you. May I escort you down to the laboratory?"

Both the patient and the employee are asked for consent to have such testing performed on their blood specimens. Informed consent is implicit in obtaining permission to test their blood. If they refuse, they sign a waiver stating that they have been informed of the implications of not being tested.

If they agree to be tested and either is positive for HIV antibody, we perform a Western blot test for confirmation. Even if the employee becomes infected, however, the likesihood is that he or she will be negative for HIV antibody immediately after a needlestick. We nevertheless test the employee at that time to establish a baseline, then test again at six weeks after exposure, 12 weeks, six months, and one, two, and three years. This goes beyond CDC recommendations, which stop at one year.

The patient's blood is also tested for hepatitis B surface antigen and hepatitis B core antibody, and the employee's blood is tested for hepatitis B surface antigen and hepatitis B surface antibody. The algorithm shown in Figure I lists the protocols for dealing with the results of these tests.

When a patient tests positive for hepatitis B (or when the patient cannot be identified), the employee is given hepatitis B immune globulin and the Recombivax vaccine. If the employee has had previous hepatitis B vaccinations, however, his or her blood is drawn for hepatitis B surface antibody with a titer or ratio. If the titer is greater than 10, the immunity is presumed to be intact. If the titer Is less than or equal to 10, and the patient's blood is positive for hepatitis B surface antigen, then treatment with hepatitis B immune globulin and a hepatitis B vaccine booster dose is recommended.

The same treatement regimen would apply if the patient's blood is negative for hepatitis B surface antigen but positive for core antibody and the employee's titer is less than or equal to 10.

The final group of protocols developed by the team dealt with the protection of employees who handle potentially infectious materials. Previously, employees took special precautions, such as wearing rubber gloves while performing routine procedures, only when dealing with patients or the blood or body fluids of patients who appeared to be at high risk for diseases such as acquired immune deficiency syndrome.

Now, however, the CDC has advised that health care organizations operate under the basic assumption that all patients are potentially infectious. The CDC recommends that all employees and physicians routinely use barrier precautions to prevent mucous membrane and skin exposure to contaminated materials.

Gloves and masks need to be worn for all invasive procedures (e. g., incision and drainage of abscesses, wound dressing changes, and surgical procedures). Gloves should be worn whenever a health care worker must touch blood, body fluids, mucous membranes, or the nonintact skin of a patient.

Gloves, aprons, and laboratory coats are needed for procedures that may result in splashes of blood. If a procedure could generate a spray of blood droplets or other body fluids, a full face shield should be worn.

A germicide soap should be used to wash contaminated skin surfaces. Bloody dressings and towels should be placed in plastic bags labeled "blood precautions" and disposed of in special containers. In the event of blood or body fluid spills, the affected area should be cleansed thoroughly, then decontaminated with 0.5 per cent sodium hypochlorite (a 1 to 10 dilution of household bleach)

Our medical group adopted all of these CDC recommendations. Employees received educational material explaining the new policies on needlesticks and handling of potentially infectious materials. We also required employees to attend an in-service session on the new protocols at the time they were implemented.

Most diseases contracted by employees who work in health care settings are preventable. It is the responsibility of health care organizations to set standards that will protect their employees and to educate employees on workplace prevention of unnecessary illness.

Our employees welcomed the establishment of protocols dealing with immunizations, needlesticks, and the handling of infectious materials. Although it is too soon to measure the health effects, the existence of a consistent set of policies and procedures has satisfied employees concerned about their susceptibility to infectious diseases.
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Author:Gundlach, David C.
Publication:Medical Laboratory Observer
Date:Aug 1, 1988
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