ATrain Education

 

Continuing Education for Health Professionals

Bloodborne Pathogens: HBV, HCV, and HIV

Module 2

Workplaces Subject to the OSHA Standard

The federal OSHA Bloodborne Pathogens Standard specifies that “each employer having an employee(s) with occupational exposure as defined by paragraph (b) of this section shall establish a written Exposure Control Plan designed to eliminate or minimize employee exposure.” Paragraph (b) says:

Occupational Exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. (OSHA, 2013a)

In other words, if any workers may reasonably expect to have contact with blood or body fluids on the job, this law does apply to their workplace. All healthcare workers—both licensed and non-licensed—risk exposure to bloodborne pathogens, whether they work in hospitals, nursing homes, home care, or correctional institutions.

Work Areas of Special Concern

Research has identified home care and correctional institutions as work areas with increased risk of bloodborne pathogen transmission. Work practices such as extended work schedules and understaffing also increase the risk of percutaneous injuries (Trinkoff et al., 2007).

Home Care

Earlier discharge from hospitals means that patients are going home “sicker and quicker,” and may have health needs that demand complex nursing skills. Studies show that both RNs and aides/personal care assistants (PCAs) are experiencing sharps injuries at significant levels. One study found that 14% of RNs reported one or more sharps injuries in the previous three years. These injuries were associated with lack of compliance with Standard Precautions, recapping of needles, exposure to household stressors, exposure to violence, and mandatory overtime (Gershon et al., 2009).

Another study found that PCAs are at increased risk when performing nursing-related activities for which they are inexperienced and/or lack training (Lipscomb et al., 2009). A third study showed that 35% of nurses and 6.4% of aides experienced at least one sharps injury during their home healthcare career. Procedures contributing to sharps injuries were injecting medications, administering finger sticks and heel sticks, and drawing blood. Sharps disposal, contact with waste, and patient handling also contributed to sharps injuries. Sharps with safety features were not used much (Quinn et al., 2009), despite requirements of recent laws. Two of the studies found that nearly half of the sharps injuries were not formally reported.

Another study evaluated the experiences of 355 home healthcare nurses and 30 Medicare Certified Home Healthcare Agency and hospice employers in one state and found that some employer policies and nurse practices were out of compliance with OSHA Bloodborne Pathogens Standard. Thirty-eight home healthcare nurses from 12 of the 30 employers reported sharps injuries within the past year but the employers reported only 18 such injuries in that same year (Scharf et al., 2009). More effective education, training, and enforcement of OSHA standards are needed to reduce the incidence of sharps injuries in these areas of practice.

An Exposure Control Plan that includes safety sharps and training on how to use them correctly is required by the Bloodborne Pathogens Standard. Talk with your employer if you are concerned about exposure risk on the job.

Correctional Institutions

All healthcare workers risk occupational exposure to bloodborne pathogens but those who work in correctional facilities face additional challenges:

  • Jails and prisons can be unpredictable work settings.
  • Security issues are often a higher priority than infection control.
  • Inmates may have a higher rate of bloodborne diseases. The rate of AIDS in prison is 2.5 times the rate in the U.S. general population. (USDOJ, 2009)

Correctional healthcare workers may be bitten or stabbed during an inmate assault, punctured with a used needle, or splashed in the face with blood. Any of these situations can expose workers to bloodborne diseases (CDC, 2013b). Education and training of correctional healthcare workers is essential to prevent exposure in these high-risk work settings.

Research and Production Facilities

The OSHA Bloodborne Pathogens Standard includes a section on protection of workers of these specialized types of work sites where risk of exposure to HBV and HIV is significantly higher (OSHA, 3013a). Protective measures for these worksites are much more stringent. If your workplace is not this type of facility, these more stringent requirements do not apply to it.

Exposure Control Plans

[Material in this section is largely from OSHA, 2013a.]

Employers are required to create and implement a written exposure control plan (ECP) specific to each workplace to eliminate or minimize employee exposures. The plan must be updated annually to reflect technological changes that help eliminate or reduce exposure to bloodborne pathogens. In the plan, employers must include information about the infection control system used in the workplace.

The ECP should contain annual documentation of consideration and implementation (if feasible) of appropriate, commercially available safer medical devices designed to eliminate or minimize occupational exposure. Employers must also document that they have solicited input from non-managerial workers in identifying, evaluating, and selecting engineering controls. The ECP must be available to workers. You may legally ask your employer how you can review it.

The exposure control plan should also include a written exposure determination that includes those job classifications and positions in which employees have the potential for occupational exposures. The exposure determination should be made without taking into consideration the use of personal protective clothing or equipment. Employees who are required or expected to administer first aid must be included.

In addition to possible presence in blood, bloodborne pathogens may be present in other potentially infectious material (OPIM). OPIM includes:

  • Human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids
  • Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
  • HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV

OSHA (the law) requires Universal Precautions for the OPIM listed above. Note that the list does not specify precautions with urine or feces, which may be heavily loaded with bacteria other than the bloodborne pathogens about which we are concerned here.

Standard Precautions, as described by the CDC, are broader than Universal Precautions, covering more bacteria and viruses than the three—HBV, HCV, and HIV—that are of primary concern as bloodborne pathogens. Standard Precautions specify that contact with all body fluids from all patients should be avoided. These will be reviewed in more detail in Module 5.

OSHA requires the use of Engineering Controls, Work Practice Controls, and Personal Protective Equipment—in that order, because the most effective protections for workers take priority.

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