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Safety protocols no lab can ignore.

Now that OSHA's final blood-borne pathogen standard is in effect,[1] health care personnel are expected to take biosafety in the workplace more seriously. These regulations have come none too soon. In the clinical laboratory environment, it is vital that laboratorians follow certain daily procedures that will lessen their chances of being exposed to the dangerous materials they work with so frequently.

Last month's article discussed employee training requirements and explained how to make instruction more effective. Now it's time to discuss the nuts and bolts of the standard, including rules that are calling for big changes in the lab--and causing quite a few heads to turn.

* Defining dangers. As OSHA was completing its final standard, many health care groups urged the agency to expand its definition of potentially infectious materials to include virtually all body fluids and substances, from tears to urine. While discrepancies remain between the new regulations and the Centers for Disease Control's biosafety recommendations, OSHA chose to follow the CDC's definition of universal precautions.[2] Accordingly, these human body fluids have been defined as potentially infectious: blood and blood components, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, and body fluid that is visibly contaminated with blood.

Besides these, OSHA has added to its list saliva in dental procedures; unfixed human tissue (dead or live), such as a frozen section of breast tissue sent from the operating room; and any tissue culture, cells, or fluid known to be HIV-infected. To protect employees further, the agency has stated that when the origin of a specimen cannot be identified--for example, when a container is labeled with terminology too technical for an employee to interpret--or is otherwise not clearly specified, the specimen must be handled as if known to be infectious.

* Phlebotomist protection. All employees are now required to wear gloves when performing a procedure involving vascular access (Figure I). Phlebotomists working in volunteer blood donation centers are exempt from this regulation except during training, when they have a cut or scratch on one or both hands, or if blood contamination is likely--for instance, when a patient is anxious and may pull away during the procedure. Employers at blood donation centers are now required to provide a sufficient supply of gloves to any phlebotomist who elects to wear them routinely.

During OSHA's public hearings and comment period, professionals presented evidence showing that even the most skilled phlebotomist is at risk of occupational exposure. Dr. Joseph H. Coggin, an expert witness for OSHA, stated: "I witnessed a phlebotomist drawing blood in the emergency room from a gentleman with chest pains. Several ounces of blood were released onto the emergency room table while [the phlebotomist was] changing tubes on the needle set." A similar scenario was echoed by testimony from Pam Talbot, a staff nurse for the American Red Cross and a skilled phlebotomist with 12 years of experience. "Sometimes it won't happen [getting blood on my hands while changing blood tubes] for three or four days," she said, "and some days it "will happen every time [I perform the procedure]."

In response to the claim by many phlebotomists that wearing gloves decreases tactile sensation, thus reducing dexterity, OSHA cited a study conducted by the American Dental Hygienists Association, which noted the following: "Gynecologists, ophthalmologists, neurosurgeons, and other medical personnel who require a high degree of tactile sensitivity wear gloves when performing examinations as well as in surgical procedures.... The reluctance [of phlebotomists] to wear gloves may be based more on habit than on actual loss of tactile sensitivity."

Gloves of various sizes and materials must be readily accessible to employees, including powdered hypoallergenic gloves, glove liners, and powderless gloves. Because OSHA found no compelling evidence on which type of glove provides the best protection for workers, the standard does not stipulate whether gloves should be made of vinyl or latex.[3]

Since no gloves are 100% effective, OSHA requires employees to wash their hands immediately after removing their gloves or as soon thereafter as possible. Disposable gloves are not to be washed or decontaminated for future use. Gloves that can be reused, such as those worn to conduct autopsies or to clean blood spills, should be replaced when they become torn or punctured or when their protective ability is otherwise compromised.

* Personal equipment. Employers' responsibilities to employees who work with infectious materials do not end with supplying gloves. Lab coats and protective devices for the eyes, nose, and mouth must be dispensed as well (Figure II). Glasses with solid side shields, goggles, and full-length face shields are effective protection from the splash of dangerous fluids.

Gowns and aprons should be accessible to laboratorians who perform procedures that increase their chances of exposure to contaminated materials. For instance, a splash can occur during the disposal of test tubes. Lab workers who anticipate gross contamination--when about to perform an autopsy, for example--must wear surgical caps or hoods and shoe covers or boots.

Protective equipment should be readily accessible at the worksite; for example, face shields hung on hooks near lab benches rather than locked away in a storeroom. When used under normal conditions, effective personal protective equipment prevents blood and body fluids from coming in contact with employees' work clothes, street clothes, undergarments, skin, and mucous membranes, including the eyes and mouth. Equipment that no longer serves this purpose should be replaced immediately.

According to OSHA, employees are prohibited from wearing any personal protective equipment outside the work area. When being used for protection, lab coats should not be worn in cafeterias, business offices, and break rooms. Such practice has become a chronic problem in many medical facilities. Protective gear should be properly discarded or washed and quickly decontaminated after removal.

* Extra protection. Engineering controls (safety equipment attached directly to work areas) provide excellent protection for employees. "Salad bar" biosafety barriers and portable benchtop biosafety shields protect workers from exposure to blood and body fluids without requiring them to remember to put something on. When employees are not standing behind an engineering control during a splash situation to protect themselves from mucous membrane contamination, they should be wearing personal protective equipment.

Also effective in preventing exposures are work practice controls, which require workers to alter the way they perform tasks to reduce the likelihood of contamination. Case in point: OSHA has stated that employees should not recap, bend, or remove needles from blood drawing adapters manually. Needles that cannot be thrown away should be stuck in rigid containers before adapters are unscrewed by hand.

Karen B. Feeney, M.H.A., MT(ASCP)DLM, laboratory manager of Bayshore Community Hospital in Holmdel, N.J., provides a striking example of the value of instituting work practice controls. Her lab uses special sharps containers that unscrew needles from their adapters mechanically and automatically. While these containers are almost twice as expensive as standard ones, they are worth the price, she says, since the needlestick rate at the facility has dropped almost fourfold since their arrival. Long-term savings have been realized in the reduced loss of time and resources that initially were needed for intensive follow-up, counseling, and testing associated with needlestick injuries.

Other work practice controls noted in the standard include the prohibition of eating, drinking, smoking, applying cosmetics, and handling contact lenses in work areas where there is risk of exposure. When test tubes filled with contaminated materials are dropped, workers may not pick up the broken glass with their hands, even if they are gloved; a glass shard could inject the AIDS or hepatitis virus. Such dangerous spills should be cleaned with a mechanical device such as tongs, forceps, or a brush and dustpan. Mouth pipetting is prohibited as well.

* Cleaning shop. Employers are responsible for teaching laboratorians when their personal protective equipment and work areas should be cleaned, providing documentation explaining how this should be done, and making sure that procedures are followed. A 1:10 dilution of household bleach has become a popular disinfectant in clinical labs for cleaning up spills and to clean lab benches and other work surfaces at the end of the day. The solution should be dated, stored within arm's reach of each workstation or lab bench, and replaced often, depending on the type used.

Employers should consider setting up a decontamination section in their labs. Posters could be hung outlining cleaning and decontamination procedures for all equipment in the area. This is an excellent alternative to expecting employees to muddle through hundreds of pages in a safety manual and an easy way to show OSHA inspectors that regulations are being enforced.

Employers are required to launder and/or dispose of protective equipment at no cost to employees. Expecting staff members to wash their contaminated garments at home is unacceptable--although not uncommon. A hospital lab manager in central New Jersey, for example, says that laboratorians at her facility have been required by hospital administrators not only to purchase their own lab coats but also to clean them at home. That policy must change.

After laboratorians have cleaned, disinfected, and stored their protective equipment, their last task of the day must be to wash their hands. Unless the sink has foot pedals, employees should grasp the faucets with a paper towel to turn them off. Otherwise, workers will put the same germs back on their hands that they intended to wash away.

* Lifesaver. OSHA's bloodborne pathogen standard has turned the CDC's universal precautions and other safety recommendations into mandated protective practices that employers must abide by and enforce. Sadly, this is the kind of pressure many employers needed before being willing to provide their laboratorians with a safe environment.

Clinical laboratory scientists should be proud of our Government for taking a bold and proactive stand. These new regulations will surely protect the well-being of our colleagues in the years to come.

This series will conclude next month with a discussion of OSHA's record-keeping requirements for personnel biosafety. [1.] Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens; final rule (29 CFR 1910 1030). Federal Register, pp. 64004-64182. Dec. 6, 1991. [2.] Centers for Disease Control. Update: Universal precautions for prevention of transmission of HIV, HBV, and other bloodborne pathogens in health-care settings MMWR 37: 377-388, 1988. [3.] Brown J.W., and Blackwell, H. Putting on gloves in the fight against AIDS. MLO 22(11): 47-49, 1990.

Dr. Brown, a member of MLO's Editorial Advisory Board, is director of microbiology and of health and environmental affairs at Roche Biomedical Laboratories, Raritan, N.J., where Blackwell is associate manager of health and environmental affairs.
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Title Annotation:part 2
Author:Brown, James W.; Blackwell, Helen
Publication:Medical Laboratory Observer
Date:May 1, 1992
Previous Article:Seven forces reshaping the clinical laboratory.
Next Article:I'm sick and can't come to work today.

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