INFECTION CONTROL: PROTECTION EMPLOYERS AND EMPLOYEES
Until recently, self-protection from diseases was addressed primarily from the perspective of bloodborne diseases such as HIV Infection and hepatitis viruses A, B, and C. While bloodborne diseases still present major occupational health risks for emergency care providers, airborne transmissible diseases such as measles, tuberculosis, and meningitis are having a resurgence. The approach to self-protection, consequently, must be broadened. It is most important that primary providers of emergency medical care, such as members of the fire service, follow the same current guidelines and recommendations as members of the EMS.
Compliance Directive-CAL 2-2.4411 was issued by the Occupational Safety & Health Administration on February 27, 1990. This directive makes the OSHA Proposed Blood-Borne Pathogens Ruling applicable to the fire service through its “General Duty” clause. Page three of this document states: “The State is also responsible for extending coverage under its procedures for addressing occupational exposure to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) in the public sector, such as police, fire, ambulance and other emergency response* workers.”2 OSHA currently is inspecting fire and rescue facilities to verify compliance with the directive’s mandates, such as the implementation of an infectioncontrol plan Failure to comply results in citations and substantial fines. Note that the majority of OSHA inspections are initiated by anonymous worker complaints.
In addition, new guidelines and recommendations pertaining to measles and tuberculosis epidemics issued by the Centers for Disease Control (CDC) must be addressed in your department’s day-to-day activities even though they are not covered in the OSHA directive. They include evaluating employees relative to the need for revaccination against measles and administering skin tests to determine exposure to tuberculosis on a routine basis.
Don’t be misled into believing that complying with CDC guidelines and recommendations is optional. These published documents are interpreted as the “standard of care.” Thus, each department should implement CDC guidelines and recommendations.
NFPA 1581 (proposed), which was to have been voted on in May (after press time), also contains many new standards relative to infection control The standards will address both field application of personal protection and station living issues designed to promote a more healthful environment. The need for an overall infection-control program is addressed in this standard as well as in the OSHA compliance directive.
INFECTION-CONTROL PROGRAM COMPONENTS
The components necessary to implement an infection-control program include, but are not limited to, the following:
Occupational health history’. Information relative to allergies that might preclude an individual from using some type of personal protective equipment or receiving a hepatitis B vaccine must be collected.
Education and training regarding bloodbome pathogens. Ten specific requirements must be addressed (see sidebar on page 50). Education and training records must be kept on file for at least five years. Education and training must be offered to every new department member within 60 days of hire and on an annual basis thereafter.
Availability of personal protective equipment. This equipment must be readily available for members, and it must be on the site of the work being performed. Placing items such as gloves, masks, protective eyewear, and handwash substitutes in a central storage room at the station instead of on the unit or truck does not meet the requirement.
Immunizations. The number of immunizations to be offered to department members has grown. The proposed NFPA 1581 standard would add tetanus/diphtheria boosters, measles/mumps/rubella vaccines, PPD skin testing for exposure to tuberculosis, and an annual flu vaccine. The recommendations for PPD skin testing and measles vaccines are in accordance w ith current CDC recommendations. The entire list of immunizations is taken from the current recommendations of the Advisory Committee on Immunization Practices (ACIP), which were designed to improve the immunization status of adults in the United States.
Procedures for cleaning!disinfecting and sterilization. You must have written policies and procedures for all major tasks performed, especially those related to patient care and patient-care equipment. A hag/mask ventilation device, for example, must be “sterilized” after each use. for most part by using a high-level disinfectant if a hospital-exchange program is not in place or a disposable product is not used ⅜ You must develop storage procedures for maintaining clean equipment
Notification of exposure. Notify -ing personnel that they have been exposed to a patient with a communicable disease has been a major problem nationwide. Most states have developed laws to address this issue, but many of the laws are not complete. Some address only bloodborne diseases and do not make provisions for airborne transmissible diseases. Each department must review its state laws on this issue. Of special note, in August 1990 President Bush signed into law the “Ryan White Bill’’ (AIDS Prevention Act of 1990). This bill contains a mandatory notification bill for emergency response personnel. It outlines how each hospital and department should handle the notification process. This law’, however, is pending until the CDC publishes a list of the diseases currently defined as “communicable.” This list was to have been out within 90 days of the bill’s passage, but that deadline has long passed. If the list is not published soon, pressure may have to be applied to our representatives.
This law’ also specifies that an infection-control liaison officer be designated for each department. Defining this role and providing adequate education for the officer will help the infection-control program to run smoothly.
Post-exposure protocols for medical follow-up. These protocols must be developed and made part of the education and training program. Members should know which forms to complete, whom to notify, where to seek treatment/counseling, and the treatment they should receive. Doing this is important to ensure that members receive the proper treatment for each exposure—and within the prescribed period of time following the exposure. OSHA outlines key items to be documented following an exposure. You must be sure that your forms request all of the required information. OSHA also requires that records on exposures and medical follow-up be retained for the duration of employment plus 30 years.
• Quality and compliance monitoring.” An important component of the program, monitoring assists in ensuring that members are practicing prevention and following protocols outlined by the department. Monitoring should be done on a random basis. Noncompliance should be documented, as should any and all discussions with members regarding their noncompliance activities. When noncompliance is noted, the member should be counseled, educated, or retrained. If compliance still is not improved, then disciplinary action should be taken.
During recent inspections, OSHA personnel have been asking to review department disciplinary action policies. If your department does not already have one, therefore, it is important that you develop one.
Compliance monitoring reinforces the concept that infection control is a two-way street: The employer has the responsibility to provide a safe workplace, and the employee has a responsibility to follow department policies and protocols.
At first glance, implementing an infection-control program might appear overwhelming and expensive. There are, however, many ways to show the cost/benefit ratio of having an ongoing program. A strong point is the dollar amounts of the OSHA fines, which the agency recently has been authorized to increase sevenfold (see box on page 48).
An effective, ongoing infection-control program also serves to demonstrate concern for department members and may assist with recruitment and retention within your department. Risk management will see the value of the infection-control program in reducing costs for unprotected exposure medical follow-up and the potential for liability. Infection control is a positive; infection of personnel or patients can be a very costly negative.
- Tire Service Prime Emergency Medical Care Provider,” Fire Engineering, May 1991; 144 (5 ):29.
- “Enforcement Procedures for Occupational Exposure to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).” Office of Health Compliance Assistance, U.S. Department of Labor/Occupational Safety tk Health, Washington, DC; Feb. 27, 1990.
- West. KH: Infectious Disease Handbook for Emergency (tire Personnel (J.B. Eippincott 1988).
- t Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (Public I .aw 101-381), August 18, 1990.
- “Occupational Exposure to Bloodborne Pathogens; Proposed Rule and Notice of Hearing,” Department of Dibor/Occupational Safety & Health Administration, led end Register; May 30, 1989.