Many splash-creating activities are conducted without the proper PPE because there is a lower perceived risk.

Splashes & Sharps: Occupational Exposures in the Health Care Setting

Many risky, splash-creating activities are conducted without the proper PPE because there is a lower perceived risk.

When it comes to health care occupational risks, slips, trips, and falls are often the first to come to mind. Sharps also make the top of the list, but what is often overlooked is the cousin to sharps: splashes. Also known as mucocutaneous blood exposures, splashes are a notable risk for health care workers. Splashes—from routine activities such as cutting catheter bags, cleaning bedpans, and emptying suction cups—can land on a caregiver, where it can transfer a pathogen through the eyes, nose, or mouth.

Every year, the Centers for Disease Control and Prevention estimates that nearly 385,000 health care works in hospitals suffer sharps-related injuries. 1 By comparison, a study led by Doebbeling, et al. at the Veterans Administration found that in the previous three months, roughly 38 percent of all RNs had experienced a splash. Making the risk even more serious, they found that more than a quarter of these splashes went unreported. 2

Splashes, like sharps, can present serious risks to health care employees. This is because they can cause occupational-related infections, ranging from human immunodeficiency virus (HIV) to hepatitis B virus (HBV) to hepatitis C virus (HCV).3. Occupational exposures such as splashes can lead to lost work days, financial burden, and physical impairment. They also can take an emotional toll on those exposed.

We'll explore solutions to address these risks, from implementing disinfection appliances—such as bedpan washers—to improving methods of storing PPE and creating a culture of safety. Each of these efforts can help transform workplace safety and curb the risks of infections.

History of Standards and Procedures to Limit Exposure
To combat these exposures, new standards and procedures have been implemented across the United States. In 1991, the Occupational Health and Safety Administration released the Bloodborne Pathogens Standard, 29 CFR 1910.1030.4 These standards aim to require the implementation of engineering controls and work practice controls to reduce health care worker exposure to bloodborne pathogens and other potentially infectious materials.

Prior to the issue of this standard, CDC introduced proposed guidance utilizing barrier precautions for anticipated exposure to blood and other potentially infectious materials (OPIM). This guidance, released in 1987, was known as universal precautions and further defined in the June 24, 1988, weekly Morbidity and Mortality Weekly Report.5

Designed to address both the risk of sticks and splashes, these universal precautions recommend the use of barriers in the form of personal protective equipment to protect the health care worker from coming in contact with a potentially infectious disease. In 1996, this guidance expanded and CDC combined universal precautions with body substance isolation recommendations into what is known and recognized as standard precautions.

However, due in part to the underreporting of splash-related incidents, these precautions have been practiced unevenly. Many risky, splash-creating activities are conducted without the proper PPE because there is a lower perceived risk.

What We're Doing Today
Today, standard precautions are the foundation of infection prevention measures and are recognized as the absolute minimum necessary steps to protect the health care worker and prevent the spread of infections among patients. Standard precautions are an essential element of any successful infection prevention program regardless of suspected or confirmed infection status of the patient.

Included in Standard Precautions are:

  • Hand hygiene;
  • Use of PPE;
  • Respiratory hygiene and cough etiquette;
  • Safe injection practices; and
  • Safe handling of potentially contaminated equipment or surfaces in the patient environment.

Implementation of standard precautions hinges on the strength of the exposure control plan as required by OSHA.6 OSHA states that health care facilities must have a plan that includes a risk assessment to determine which employees have the greatest likelihood to be exposed to blood and body fluids, risk reduction strategies that are prioritized, and a process to measure data relative to exposures. The process for plan development factors in the implementation of engineering controls, work practice controls, and administrative controls.

Due to the "wide open" nature of the Bloodborne Pathogens Standard requirement, the selection of certain controls is left up to the individual facility and is not specific to design, function, or reliability. This has left the field of medical technology up for grabs, and numerous safety devices and other products for safer health care have been developed.

Improving Compliance
Implementing new controls and providing proper PPE won't prevent exposures if health care workers are not compliant with national and facility standards. However, identifying non-compliance and the reasons for it is a difficult task because underreporting of blood and body fluids may occur, as noted in a survey of health care students and trainees.

Adding to the evidence of underreporting, a study by Kessler, et al. found that, over the course of their career, 33 percent of health care workers experienced an occupational exposure and did not report the incident.7 This could be due partly to the prominence of, and therefore desensitization to, the risk of sharps and mucocutaneous exposures.

Furthermore, a study examining knowledge and compliance with universal precautions among emergency medical service providers found inconsistency in utilizing universal precautions. Harris and Nicolai found that nearly all of the EMS providers reported exposures and expressed concern over the risks. Despite this, many were non-compliant in their practice of wearing gloves and appropriately disposing of contaminated items.8

To help boost compliance, educating health care workers on standards and procedures is critical. In addition, facilities need to take extra steps to curb the risks of infections.

Risk Reduction Strategies
There are a variety of controls and safety devices health care facilities can incorporate to encourage compliance. For example, having employees be part of the PPE selection process can be very beneficial. Choosing eye protection that doesn't obscure vision and is easily worn, and faceshields with attached masks that offer protection from oral mucosa, help employees work not only more comfortably, but also more safely.

In addition, PPE should be displayed where it is visually promoted for use and can be readily restocked. For example, facilities can incorporate see-through cabinetry to store their PPE. This ensures employees are aware when PPE supply is low and needs to be replaced.

The Association for Operating Room Nurses (AORN) published its recommended practices for sharps safety and included a hierarchy of controls.9 The hierarchy begins with hazard elimination, which is the most logical though not always feasible, so therefore other options must be considered. By examining the room design and functionality to ensure appropriate sharps disposal container height and accessibility and the location of alcohol-based hand rub (ABHR) dispensers, health care administrators can help to reduce infections.

Furthermore, the health care industry has responded with new technology to tackle the issue of splashes, such as disinfection appliances (colloquially known as bedpan washers). Used throughout Europe and the developed world, bedpan washers reduce the risk of splash and spray from manual cleaning of a bedpan. Bedpan washers also can reduce the need to empty urinals, suction cups, and other collections devices by hand. Each of these items presents a splash risk to health care workers on a daily basis. A health care worker just has to kick the appliance open and place the soiled item within for it to be emptied and sanitized. As workers handle waste far less, the risk for infection greatly decreases.

Conclusions
A safe work environment should be the expectation of every health care worker. To ensure this safe environment, an exposure control plan should be reviewed and updated annually or more frequently to include modified or new tasks and/or procedures that affect occupational exposures. Equally important, the plan should be made available to every department in a health care facility and should be included as part of the infection control manual.

To encourage compliance with this plan, allow safety device selection to include those who use the products. Room design and functionality also should be considered when new construction or renovation is under way. Lastly, one should continuously seek and explore new technology to ensure the best available product or process is being utilized to prevent occupational exposures.

References
1. The National Institute for Occupational Safety and Health (NIOSH) http://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html accessed Dec. 18, 2014
2. Doebbeling BN, Vaughn TE, McCoy KD, Beekmann SE, Woolson RF, Ferguson KJ, Torner JC. (2003). Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care providers still at risk? Clin Infect Dis, 37(8), 1006-13.
3. Bahdori, M, Sadigh, G. Occupational Exposure to Blood and Body Fluid. www.theijoem.com, Vol 1 Number 1, January 2010, retrieved Dec. 18, 2014.
4. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final rule, 29 CFR 1910.1030, 56 Federal Register 2235 64004-64182 (1991)
5. MMWR June 24, 1988/37(24);377-388 http://www.cdc.gov/mmwr/index.html accessed Dec. 12, 2014
6. Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens OSHA: final rule Fed Register 119:56:64004-64182 1910.1030(c)(1)(ii) https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 retrieved Dec. 12, 2014
7. Kessler, C, McGuinn, M Spec, A Christensen, J Baragi, R and Hershow, R. Underreporting of blood and body fluid exposures among health care students and trainees in the acute care setting: a 2007 survey, American Journal of Infection Control, March 2011, Vol. 39 No. 2 pages 129-133
8. Harris, S Nicolai, L Occupational exposures in emergency medical service providers and knowledge of and compliance with universal precautions American Journal of Infection Control, March 2010, Vol 38 No.2 pages 86-92
9. Ford, Donna Implementing AORN Recommended Practices for Sharps Safety, AORN Journal, Vol 99 No 1, January 2014, page 110

This article originally appeared in the April 2015 issue of Occupational Health & Safety.

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