Fluid Waste Management and Disposal

Workers in many professions, not just health care, must know how to apply preventive techniques in routine practice and in unusual situations.

PRIOR to the early 1980s and the introduction of AIDS into our society, infection control practices were designed almost exclusively to protect the patient from developing a nosocomial infection--an infection acquired after admission to the hospital. Protocols were focused on protecting the patient, with little or no emphasis on the health care worker's potential to become infected.

Hepatitis B has been a significant occupational hazard for health care workers for decades. It is 100 times more infectious than the AIDS virus, but it was the AIDS epidemic in the early '80s that brought an awareness of workers' vulnerability to exposure to bloodborne pathogens. This awareness led to the development of the first protocols designed to protect health care workers, the "Guideline for Infection Control in Hospital Personnel" published by the Centers for Disease Control and Prevention in 1983.

Most workers are covered by either federal or state health and safety legislation and/or regulations with the goal of preventing accidents and illness arising out of, linked with, or occurring in the course of employment. Protection from occupational exposure to bloodborne pathogens is provided by a combination of laws and regulations. While specific legislation varies by jurisdiction, all jurisdictions have similar labor statutes in place.

The federal regulations were published in December 1991 as the OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030). This regulation was designed to protect the workers from risk of infection during their normal job duties. Complete information on the OSHA directive and educational information is available on OSHA's Web site, www.osha.gov.

Education for workers is critical to emphasize risks that exist in a health care workplace. The factors involved with exposure include the infectious agent (bloodborne pathogen), transportation of the agent (either through body fluids or aerosol means), and the host of the agent. A very common and neglected issue in preventing transmission is proper disinfection and personal protective equipment for the worker's hands. Many of the microbial inhabitants of the hands are capable of colonizing and infecting wounds, cuts, and other susceptible sites. The single most effective means of preventing the transmission of infection is conscientious hand washing.

New technologies should be introduced promptly to replace less effective or less safe practices, if an evaluation indicates there is a benefit to be gained from their use. The emphasis should be on (a) reducing exposure to needles or other sharp items; (b) reducing exposure of cuts or mucous membranes to blood and fluids capable of transmitting bloodborne pathogens; (c) decreased contamination of working environments; (d) redesign of reusable instruments to enable effective cleaning and disinfection; and (e) implementing safety devices based on the risk level of various types of exposure incidents.

Reducing Exposure to Pathogens
Equipment designed to decrease potential exposure to sharps and to blood and fluids capable of transmitting bloodborne pathogens in operating rooms should be made available wherever it could be used to decrease occupational exposures. These can include, for example, magnetic pads on which to place needles and other sharp instruments, guards to prevent splatter, blunted surgical implements, and thimbles to protect the forefinger of the non-operating hand.

Some risk may remain, despite the use of risk-reduction measures. Personal protective equipment serves as a barrier against direct contact with bloodborne pathogens. Suitable PPE includes gloves, eye protection, faceshields, masks, gowns, aprons, and protective footwear. One study concluded that among surgical personnel, the use of faceshields, waterproof gowns, and waterproof boots could have prevented more than half of the observed cutaneous exposures involving sites other than the hand.

Gloves are available in a variety of materials, including latex, vinyl, nitrile, neoprene, copolymer, and polyethylene. Gloves in all of these materials, when intact, will serve as adequate barriers to bloodborne pathogens (except in cases of a needlestick injury). Studies have shown that the barrier quality of new gloves varies from lot to lot. Some investigators have found glove lots with a high proportion of leakage, but others have found consistently good-quality gloves that adhere to current standards. Both vinyl and latex glove lots have been found to have leaks when gloves are tested new.

Also, the use of latex has been associated with adverse reactions. Latex allergies are an increasing problem through contact and inhalation routes. Mild adverse reactions occur to latex in about 10 percent of the occupationally exposed population; some experience severe systemic reactions. In order to minimize exposure to latex allergens, low protein, unpowdered latex gloves should be considered when latex gloves are chosen.

Nitrile gloves have shown to be the most effective for use in handling cleanup and providing safety from exposure. However, another point commonly overlooked in glove type for a blood spill kit is the potential reaction of the surface disinfectant with the glove material. Using the proper disinfectant during waste cleanup can prevent exposure and infections from occurring, both during the actual cleaning procedure and afterward from residual microbial activity from incubation. As with the matter of reaction with the PPE, there are many other factors to consider when using a disinfectant material, such as fluid containment and health issues.

Evaluating Cleanup Products
When deciding which product or material to consider for bodily fluid cleanup and disposal, compare the available products and look at the actual killing agent it includes.

Most commonly available products have an aldehyde, phenol, or chlorine killing agent. These disinfectants have a wide range of antimicrobial activity, and not all will kill what they come in contact with. In addition, their reaction with the personal protective equipment and surrounding surface areas that have been exposed to the bloodborne pathogen must be considered.

Finally, and most important, consider what the product does to the residual waste, once treated. Is it simply absorbed on a granular material or polymer, where it can still be in a fluid state? Or is it solidified, as in a cementatious reaction, where no visible liquid is available either visually or during handling of the waste? The spilled material should be in a solid form that will not be moldable or pliable and will not release the fluids back out in handling during transportation or from landfill burial. Asking the supplier for Material Safety Data Sheet information about its products should provide satisfactory results.

Workplace Spill Procedures
Prepacked spill kits should be available in the workplace for use when a spill of infectious waste occurs. At a minimum, a kit should have disposable gloves, protective eyewear, disposable face mask, disposable gown/apron, protective shoe covers, and spill powder. Additional needed items are antiseptic towelettes, germicidal solution, collection tools, and a disposable red medical waste bag with proper labeling. Whenever a spill occurs, use universal precautions and treat all blood or potentially infectious bodily fluids as though they are contaminated.

Evacuate the scene of the incident to control the risk exposure of outside people to the materials and reduce the spread of infection. If people were physically exposed to the material, remove all blood-contaminated clothing as soon as possible. Otherwise, fluids can seep through the cloth to come into contact with skin. Handle contaminated laundry as little as possible and place it in an appropriately labeled bag or container until it is decontaminated, disposed of, or laundered.

Don all PPE, including double gloves, and make sure no skin areas are exposed. Containment of the spill is of the utmost importance, from both an airborne issue as well as spreading of the fluid. Apply the solidification powder to form a perimeter around the spill and contain it. This allows for the chemical treatment to occur while the threat of exposure has been reduced.

With proper tools, scoop up any sharps that may have resulted from the spill and breakage of the container. Place the materials within a lined, thick walled container to reduce the risk of punctures. Be alert not to create aerosols while collecting the debris.

At this point, the treated fluid waste should have solid properties that will allow for collection of the spill. A true solidifier will continue to set up even after it is placed in the disposal bag. Apply any additional powder to the spill to collect and treat any remaining fluid. Wiping down the affected area with wipes will require the same attention as the spill powder in regard to killing agents and potential reaction with PPE. The CDC recommends a 5.25 percent sodium hypochlorite (standard bleach), diluted in water to a concentration of 0.05 percent, for decontamination of a blood spill. To avoid causing aerosols, do not apply the liquid solution directly to the spilled area; rather, apply to a cloth and wipe, working into the area. Allow several minutes for disinfection, then repeat the procedure.

Upon completion of the cleanup and collection of the spilled materials, pay meticulous attention to the removal and collection of the soiled, disposable PPE. Begin by removing the gown/protective apron, followed by the outer layer of gloves. This allows removing the facemask and goggles without having to use soiled gloves, thus preventing the introduction of blood or other potentially infectious material to the mucous membranes of the face via a contaminated glove. Once all used PPE, spill control equipment, and other potentially contaminated items are in the red bag, add a mixture of powder to the waste container so no fluid will be released. All materials are encased in a solid mass. Seal the bag securely for disposal.

Wash your hands with a non-abrasive, preferably germicidal, soap and inspect for any possible exposure. If your skin or mucous membranes came into contact with another person's blood/bodily fluids, flush with water into the sanitary sewer system as soon as possible. Immediately contact the medical office if you are involved with any blood or bodily fluid exposure incident. This organization will conduct a confidential medical evaluation and follow-up that includes the documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred, along with identification and documentation of the source individual. Collection and testing of the exposed person's blood for HBV and HIV, along with consultation and progress reports, should be done, along with any post-exposure treatment.

Proper Training
Not all cleaning of bodily fluids is going to be performed in a workplace or hospital. Firefighters and emergency medical personnel, dental clinic workers, crime scene cleanup specialists, mortuary and autopsy suite employees, law enforcement and correctional facility officers, and clinical laboratory workers have to deal with infectious waste cleanup.

While the circumstances they encounter may be different, the same careful handling of the resulting bodily fluids is necessary, and the same disposal steps must be followed and enforced. Also, implement the same procedures to reduce sharps injuries. With any handling of tainted materials, an exposure plan should spell out procedures for sharps disposal and usage of preventive technology.

All health care and public service workers must receive infection prevention and control education regarding bloodborne pathogens and safe practice in the workplace, before beginning work and on an ongoing basis thereafter (e.g., annually). Educational programming should be based on practical situations faced by workers in the performance of their specific duties. The content should include general information about infection prevention and control (stressing the importance of hand washing); information about bloodborne pathogen transmission; assessing the risk of exposure; preventing exposures; immunization (HBV vaccine); specific policies and procedures for individual work areas, including protocols following an exposure; and resources for further assistance.

Workers need to know how to apply preventive techniques in routine practice and in unusual situations. Time must be given for workers to question, absorb, and apply the information. It is critical that educational programs enable workers to express and work through their concerns about caring for individuals with a bloodborne infection. Records of their participation should be maintained as needed to satisfy legal requirements.

This article originally appeared in the April 2003 issue of Occupational Health & Safety.

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