module 9 safety and supportive care in the work setting
TRANSCRIPT
Module 9
Safety and Supportive Care in the Work Setting
Malawi PMTCT Training Package 2
Module Objectives
Describe how Universal Precautions can prevent healthcare workers (HCWs) from exposure to bloodborne pathogens.
Outline strategies for preventing HIV transmission in the healthcare setting.
Identify key steps in the decontamination, cleaning, disinfection and sterilization of equipment and materials.
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Module Objectives (continued)
Discuss risk reduction in obstetric settings.
Describe the management of occupational exposure to HIV.
Outline the National PEP regimen. Identify personal strategies to manage
burnout.
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Unit 1:
Universal Precautions
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Unit 1 Objective
Describe how Universal Precautions can prevent healthcare workers (HCWs) from exposure to bloodborne pathogens.
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Basic Concepts of HIV Infection Prevention
HIV and other bloodborne diseases may be transmitted in healthcare settings: From client to HCW From HCW to client From client to client
Primarily spread through blood HIV transmission to HCWs almost always
associated with needlestick injuries
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Basic Concepts of HIV Infection Prevention
In practice, transmission occurs during: Intravenous injections Blood donations Dialysis Transfusions
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Basic Concepts of HIV Infection Prevention (continued)
Client-to-client transmission prevented by disinfecting or sterilizing equipment/devices used to puncture skin
Transmission of infectious agents in healthcare setting prevented by: Wash hands with soap and water Adhere to Universal Precautions and safe
environmental practices Provide ongoing education for employees about
infection prevention
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Universal Precautions
Definition Universal Precautions are simple set of
effective practices designed to protect HCWs and clients from infection with a range of pathogens, including bloodborne viruses such as HIV. These practices are used when caring for ALL clients regardless of diagnosis.
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Creating Safe Work Environment
Not feasible or cost-effective to test all clients for all pathogens before providing care
Level of precautions employed should be based on nature of procedure involved, not on client’s actual or assumed HIV status
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Managing the Work Environment
To reduce occupational risks: Assess risks in work setting Explore strategies for meeting resource needs Develop standards and protocols that address safety Attain and maintain appropriate staffing levels Ensure staff have appropriate workloads Orient new staff to infection prevention procedures Provide ongoing staff education and supervision Reduce staff stress, isolation, and burnout Acknowledge and address the needs of HIV-infected
HCWs
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Universal Precautions
Ensure that Universal Precautions are implemented, monitored, and evaluated.
Provide protective clothing and equipment, including gloves, plastic aprons, gowns, goggles, and other protective devices.
Provide and use appropriate disinfectants to clean up spills involving blood or other body fluids.
Increase availability and accessibility of puncture-resistant sharps containers
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Ongoing Education for Employees
Orient staff to infection prevention policies
Ensure workers routinely exposed to blood and body fluids receive preliminary and ongoing training
Require that supervisors observe and assess safety practices and remedy deficiencies
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Unit 2
Handling and Decontamination of Equipment and Materials
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Unit 2 Objectives
Outline strategies for preventing HIV transmission in the healthcare setting.
Identify key steps in the decontamination, cleaning disinfection and sterilization of equipment and materials.
Discuss risk reduction in obstetric settings.
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Hand Washing
Hand washing with plain soap and water is one of the most effective methods for preventing transmission of bloodborne pathogens and limiting the spread of infection. Soap and water hand washing, using friction under
running water for a minimum of 15 seconds. Alcohol-based hand rubs for routine decontamination
or hand antisepsis for hands not visibly soiled.
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Hand Hygiene Recommendations
Wash before:
Putting on gloves Examining a patient Performing any procedure that involves contact with blood or body
fluids Handling contaminated items Eating
Wash after:
Removing gloves Examining a patient Performing any procedure that involves contact with blood or body
fluids Handling contaminated or soiled items Making contact with body fluids, mucous membranes, non-intact
skin, or wound dressings Using a toilet
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Personal Protective Equipment
Personal protective equipment safeguards clients and staff. Gloves Aprons or gowns Eyewear Footwear
When resources for purchasing protective equipment are limited, purchasing gloves should receive priority.
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Gloves
Use separate pair of gloves for each client Protection with gloves recommended when:
Reasonable chance of hand contact with blood, other body fluids, mucous membranes
HCW has skin lesions on their hand. Sterile gloves are required for surgical procedures.
Gloves not required for routine care activities in which contact is limited to client’s intact skin.
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Tips for Effective Glove Use
Wear correct size gloves Use water-soluble hand lotions and moisturizers Avoid oil-based hand lotions or creams Do not wear rings Keep fingernails short Store gloves where they are protected from
extreme temperatures
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Personal Protective Equipment
Aprons or gowns Aprons provide protective waterproof barrier. Gown should be worn to protect skin and prevent soiling
of clothingEyewear Eyewear protects eyes from accidental splashesFootwear Gum boots or leather shoes provide protection to the
feet from injury by sharps or heavy items that accidentally fall
Avoid wearing sandals, thongs, or shoes made of soft materials
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Strategies for Resource-Constrained Settings
Universal Precaution measures are difficult to practise when supplies are low and protective equipment not available
Use resources cost-effectively by prioritising the purchase and use of supplies
Reduce occupational exposure to HIV by reducing contact with blood
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Equipment & Materials
Handling and disposal of sharps Most HIV transmission to HCWs is the
result of skin puncture with contaminated needles or sharps
Injuries more likely when sharps are recapped, cleaned, or inappropriately discarded.
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Equipment & Materials
Recommendations for use of sterile injection equipment
Use new, quality-controlled disposable syringes & needles
Avoid recapping of needles If recapping necessary, use single-handed scoop technique.
Collect used syringes and needles at point of use in puncture/leak-proof sharps container
Destroy or burn used needles and syringes so people cannot access them
Wear gloves Handle all laboratory specimens with care Use holders for all blades
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Careful Handling of Sharps
Always point sharp end away from yourself and others.
Pass scalpels and other sharps with the sharp end pointing away from other person.
Whenever possible, place sharp on flat surface (a tray) to pass to other person.
Pick up sharps one at a time and never pass handfuls of sharp instruments or needles.
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Single-handed Recap Method
Step 1:
Scoop up the cap
Step 2:
Push cap firmly down
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Sharps Containers
Using sharps disposal containers helps prevent injuries from disposable sharps
Sharps containers should be fitted with a cover, and should be puncture-proof, leak-proof, and tamper-proof
If safety boxes unavailable, many available objects can substitute as sharps containers: Tin with a lid Thick plastic bottle Heavy plastic box Heavy cardboard box
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Safe Use of Sharps Containers
All sharps containers should be clearly marked “SHARPS”
Place sharps containers away from high-traffic areas and as close as possible to where the sharps will be used.
Attach containers to walls or other surfaces if possible.
Never reuse sharps containers for other purposes.
Seal and close containers when ¾ full.
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Decontamination, Cleaning, High Level Disinfection, & Sterilization
Method used to decontaminate equipment or supplies should be based on:
Risk of infection associated Decontamination process the object can tolerateRoutine procedures: Use heavy gloves Dismantle all equipment before cleaning Wear additional protective clothing such as
aprons, gowns, goggles, and masks when at risk for being splashed with body fluid
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Decontamination of Equipment & Materials
DefinitionDecontamination is a process that makes
inanimate objects safer to be handled by staff before cleaning
Soak contaminated items for 10 minutes in 0.5% chlorine solution
Larger surfaces should be decontaminated by wiping with disinfectant (e.g., 0.5% chlorine solution or 1–2% phenol).
Decontamination should be done at point of use immediately after the procedure.
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How to Prepare 0.5% Chlorine Solution
•Brand of Bleach, % chlorine
•To obtain a 0.5% chlorine solution
Household bleach, 5% chorine
1 part household bleach to 9 parts water
Jik, 3.5% chlorine 1 part Jik bleach to 6 parts water
Powder bleach, 35% chlorine
14.2 grams of dry powder to 1 litre of water
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DefinitionCleaning is a process that physically removes all
visible dust, soil, blood or other body fluids from inanimate objects as well as removing sufficient numbers of microorganisms to reduce risks for those who touch the skin or handle the object
Consists of washing with soap or detergent and water, rinsing with clean water and drying
If tap water contaminated, use water that has been boiled for 10 minutes and filtered to remove particulate matter
OR use chlorinated water
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Cleaning of Equipment
Any instrument or equipment that comes into contact with intact skin should be cleaned before use
Any instrument or equipment should be thoroughly cleaned & rinsed before further processing
Use personal protective equipment during cleaning
Can be performed in department, unit, and ward or in a central sterilization department/area.
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Definition
High-level disinfection (HLD) is a process that eliminates nearly all microorganisms, except some bacterial endospores, from inanimate objects by boiling, steaming, or using chemical disinfectants.
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Any instrument or equipment that comes into contact with non-sterile tissue should be high-level disinfected or sterilized before it is used.
Decontaminate, clean instruments and equipment prior to HLD.
HLD is not a sterilization process. HLD by:
Boiling or steaming instruments and other items for 20 minutes. Soaking the instruments and other items for 20 minutes in 2–
4% glutaraldehyde solution, 8% formaldehyde solution, or 0.1% chlorine solution and rinse with sterile or HLD water
High-Level Disinfection (HLD)
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Sterilization is a process that eliminates all microorganisms (bacteria, viruses, fungi and parasites) including bacterial endospores from inanimate objects by high-pressure steam (autoclave), dry heat (oven), chemical sterilants or radiation.
Definition
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Sterilization
All instruments and equipment should be decontaminated, cleaned, and dried prior to sterilization.
Any instrument or equipment used to enter sterile tissue or the vascular system of a client, should be sterilized before it is used.
Microwaves ovens, pressure cookers, dishwashers, ultraviolet cabinets, ultrasonic cleaners, and similar devices do not sterilize and should not be used for this purpose.
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If using steam sterilization: Observe recommended temperature,
pressure and holding time. For most autoclaves (unless otherwise recommended by the manufacturer): Temperature should be 121C (250F) Pressure should be 106 kPa (15 lbs/in2) Time should be 20 minutes for unwrapped
items, 30 minutes for wrapped items
Sterilization (continued)
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Sterilization (continued)
If using dry heat sterilization: Unless otherwise recommended by the manufacturer,
recommended temperature and times are as follows: Sterilize at 170C (340F) for 1 hour (total cycle time—placing
instruments in oven, heating to 170C, timing for 1 hour, and then cooling—is from 2–2.5 hours), OR
Sterilize at 160C (320F) for 2 hours (total cycle time is from 3–3.5 hours).
All packed and wrapped instruments and equipment should be stored in a manner that ensures sterility is maintained.
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If using chemical sterilization: Some high-level disinfectants will kill endospores after
prolonged (10–24 hour) exposure. Common disinfectants used for chemical sterilization
include glutaraldehydes and formaldehyde. Sterilize by soaking at least 10 hours in 2–4%
glutaraldehyde solution or at least 24 hours in 8% formaldehyde.
Both glutaraldehydes and formaldehyde require special handling and leave a residue on treated instruments; therefore, rinse with sterile water afterwards
Sterilization (continued)
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Use gloves Collect linen in bags or fold with the
soiled parts inside for transport (do not rinse or sort in the patient care area)
Soak in 0.5% chlorine solution for ten minutes
Wash in hot soapy water and air dry If the linen is to be used in theatre, it
should be sterilized.
Handling of Soiled Linen
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Potential for exposure to HIV-contaminated blood and body fluids is highest during labour and delivery.
Wash hands Cover broken skin or open wounds with
watertight dressings Wear gloves Wear a waterproof plastic apron during delivery Cover the cord with gloved hand or gauze
before cutting
Reducing Risk of Occupational Exposure in the Obstetric Setting
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Reducing Risk of Occupational Exposure in the Obstetric Setting (continued)
Wear eye shield during episiotomy and suturing Use needle holders when suturing Pass all sharp instruments on a tray, rather than hand-to-
hand When episiotomy is necessary, use appropriate-sized
needle (21 gauge, 4 cm, curved) and needle holder If blood splashes on skin, immediately wash the area
with soap and water. If splashed in the eye, wash the eye with water only. If blood splashes on floor, wash with chlorine solution Dispose of solid waste according to local procedures
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Promoting a Safe Work Environment Resource List:
Group Discussion
Exercise 9.1
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Reducing HIV transmission Risk in MCH Settings:
Case Study
Exercise 9.2
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Managing Occupational Exposure to HIV
Unit 3
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Describe the management of occupational exposure to HIV.
Outline the National PEP regimen.
Unit 3 Objectives
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Occupational risk of becoming HIV-infected due to needle-stick is low (less than 1%)
Risk of exposure from needle-sticks and contact with blood and body fluids exists in settings where: Safe needle procedures and Universal Infection
Prevention Precautions are not followed Waste management protocols are inadequate or not
consistently implemented Protective gear is in short supply Rates of HIV infection in the client population are
high
Managing Occupational Exposure to HIV Infection
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Promotes retention of staff who are concerned about the risk of exposure to HIV
Increases staff willingness to work with HIV-infected people
Reduces the occurrence of occupationally-acquired HIV infection in HCWs
A comprehensive PEP protocol outlines the methods for preventing occupational exposure to HIV and other bloodborne pathogens.
Benefits of Making PEP Available for HCWs:
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“PEP” refers to treatment (using ARV drugs) of the HCW who has experienced an occupational exposure.
ARV therapy started immediately after exposure to HIV may prevent HIV infection, although not 100% effective.
Treatment should be initiated within 1-2 hours of exposure, but PEP can be started up to 72 hours after exposure.
HIV exposure is classified as either low risk or high risk.
PEP: Low risk and High risk
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High risk exposures: Percutaneous injuries with hollow needles and large volume of blood onto a mucosal surface from a source person who is known or highly likely to be HIV-positive
Low risk exposures: All other exposures, including percutaneous injuries with solid needles, exposures to fluids other than blood, and exposures to non-intact skin.
Exposure of blood or other fluids to intact skin is not a risk
Post-Exposure Prophylaxis (PEP): Low risk and High risk (continued)
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First aid and other immediate measures: To reduce contact time with source person’s blood or
body fluid and decontaminate the site of the exposure Use soap and water to rinse any wound or skin site in
contact with infected blood or fluid. Rinse exposed mucous membranes thoroughly with
water. Irrigate generously any open wound with sterile saline
or disinfectant solution (2-5 minutes). Irrigate eyes with clear water, saline, or sterile eye
irrigants. Report exposure to the clinician on duty as soon as
possible.
After Occupational Exposure
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Each health facility should keep a bottle of AZT+3TC (Duovir®) in designated unit for easy/secure access.
HCW should immediately report the exposure to senior staff
3-day supply of AZT+3TC given to HCW to begin PEP regimen as soon as possible after the exposure.
HCWs must be counselled about ARV side effects
Operational Considerations
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National PEP ProtocolThe source client If HIV-positive, then PEP is indicated. If HIV-negative discontinue PEP If HIV-negative and possibly in the “window period”,
seek specialist advice. The HCW Encouraged to undergo HIV testing and counselling
immediately or within 72 hours of exposure. If HCW is HIV-positive, then PEP is not necessary HCW who tests HIV-negative should receive follow-up
HIV testing at 3 and 6 months. If negative at 6 months, counsel as if negative as a result of the exposure
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PEP Regimen
Drug Zidovudine (AZT) 300mg/Lamivudine (3TC) 150mg (Duovir) Dose Frequency Duration One tablet
Twice a day (BD)
30 days
Duovir should be available at every health facility and at central medical stores. In some cases, lopinavir/ritonavir can be added to the Duovir therapy: specialist advice is necessary.
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Monitoring and management of PEP toxicity If PEP used, HCWs should be monitored for
drug toxicity by laboratory testing at baseline and 2 weeks
May experience adverse symptoms including nausea, malaise, headache, and anorexia.
Pregnant workers or women of childbearing age who may be pregnant may receive PEP.
PMTCT services should support workers while they take PEP and help manage side effects.
Guidelines for Providing PEP
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PEP Case Study:
Small-Group Discussion
Exercise 9.3
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Supportive Care for the Carer
Unit 4
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Identify personal strategies to manage burnout.
Unit 4 Objective
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Burnout Burnout syndrome stems from extended
exposure to intense job-related stress and strain. Emotional exhaustion: feelings of helplessness,
depression, anger, and impatience Depersonalisation: detachment from the job and an
increasingly cynical view of clients and co-workers Decreased productivity: due to real or perceived
sense that their efforts are not worthwhile and do not seem to have an impact
Care for the Carer
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Signs and Symptoms of Burnout
Behavioural Frequent changes in mood Eating too much or too little Drinking alcohol and/or smoking
too much Becoming “accident prone” Cognitive Unable to make decisions Forgetful, poor concentration Sensitive to criticism
Physical High blood pressure Palpitations, trembling Dry mouth, sweating Stomach upset Occupational Taking more days off Arguing with co-workers Working more hours but getting
less done Having low energy, less motivated
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Institutional or job-related risk factors for burnout Work overload, limited or no breaks Long working hours Poorly structured work assignment (worker not able to
use skills effectively) Inadequate leadership and support Lack of training and skill-building specific to your jobPersonal risk factors for burnout Unrealistic goals and job expectations Low self-esteem Anxiety Caring for clients with a fatal disease
Risk Factors for Burnout
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Tips for Managing Burnout
Find or establish a support group of peers
Search out a mentor Read books or listen to
tapes Take a course to learn
about a subject relevant to your work
Take structured breaks during work hours
Make time for yourself and your family
Exercise, eat properly, and get enough rest
Link with social groups, social functions or services that can provide support
Where possible, delegate some work-related responsibilities to colleagues
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Burnout in the PMTCT Service:
Large Group Discussion
Exercise 9.4
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Creating a safe work environment involves practising: Universal Precautions Management of the work environment Ongoing education of employees in all
aspects of infection prevention
Module 9: Key Points
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Universal Precautions apply to all clients, regardless of diagnosis. Key components include: Hand washing Use of personal protective equipment Decontamination of equipment Safe handling and disposal of sharps Safe disposal of infectious waste materials Safe environmental practices
Module 9: Key Points (continued)
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Decontaminated, cleaning, high-level disinfection, and/or sterilized of all instruments used in invasive procedures reduce risk of transmission of infection.
Post-exposure prophylaxis (PEP) is short-term antiretroviral prophylaxis that reduces the risk of HIV infection after occupational exposure. The regimen (one tablet of Duovir twice a day for 30 days) should be started within 1-2 hours of exposure.
Burnout is related to intense, prolonged job stress but can be managed, even prevented through personal strategies, particularly if there is organizational support.
Module 9: Key Points (continued)