This is eleventh in a series of articles from MONOC Mobile Health Services, New Jersey's largest provider of EMS and medical transportation and first CAAS-accredited agency. The goal of this series is to provide insight and solutions for the different managerial and operational challenges facing the EMS leaders of tomorrow. For more, see www.monoc.org.
We see more and stories in the news these days about "super bugs," Methicillin-resistant staph aureus (MRSA), "deadly infections" and "killer bacteria."
According to a Centers for Disease Control and Prevention (CDC) study, MRSA caused more than 94,000 life-threatening infections and nearly 19,000 deaths in the United States in 2005. The study also found about 85% of invasive MRSA infections were associated with healthcare settings. If you think that this doesn't apply to EMS, think again. Recent studies conducted in both the United States and England found that most ambulances and their equipment were infected with at least MRSA when tested.
Because of risks like these, as well as those more familiar to us in EMS such as infections acquired from direct patient contact, the Occupational Safety and Health Administration (OSHA) requires all agencies write, maintain and enforce an exposure control plan. The official citation is OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030. Its main purpose is to eliminate or minimize employee exposures. While there are templates that can be used to write your exposure control plan, the important concept to remember is the plan must be customized to your agency's individual needs.
Some agencies are not subject to OSHA standards. There are 22 states and jurisdictions operating complete state plans (covering both the private sector and state and local government employees) and five which cover public employees only. In some cases, these state plans are known as Public Employee Occupational Safety and Health (PEOSH) programs. Regardless of their name, all plans must be approved by OSHA and have standards which are identical to, or at least as effective as, federal OSHA standards, including the bloodborne pathogens and hazard communications standards.
What's Considered an Exposure?
Exposure is classified as either respiratory or contact. Respiratory exposure generally refers to contact with a patient closer than three feet without the use of a particulate respirator like an N-95 mask. Because of the variations in patient condition such as coughing, sneezing, etc., the best practice is to wear a particulate respirator whenever dealing with a patient you suspect may have an airborne communicable disease, regardless of proximity. The specific details on respiratory protection are spelled out in OSHA standard 1910.134.
When it comes to contact exposures, according to the CDC, "An exposure that might place Health Care Personnel at risk for HBV, HCV, or HIV infection is defined as a percutaneous injury (e.g., a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious body fluids. Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they contain blood. The risk for transmission of HBV, HCV, and HIV infection from these fluids and materials is extremely low." One thing to keep in mind, however, is that other diseases such as e.Coli may be transmitted via some of these fluids.
Tips for Writing Your Plan
Outlined below are nine of the most critical elements to consider when writing your exposure control plan:
1. Exposure Determination: Create a list of jobs in which all employees have occupational exposure; a list of jobs in which some employees have occupational exposure; and a list of all tasks and procedures in which the occupational exposure occurs. Exposure determination should be made without regard to the use of personal protective equipment (PPE). For example, an EMT or paramedic has occupational exposure while a person in the billing department would not.
2. Methods of Compliance: In healthcare, methods of compliance include the use of standard precautions also known as universal precautions. The main premise that guides this element is that all body fluids should be considered potentially infectious and PPE should be worn when appropriate.
3. Engineering and Work Practice Controls: Utilize engineering and work practice controls to eliminate or minimize exposures wherever possible. Examples include hand washing, handling and transporting of waste and linens, sharps management, use of safer medical devices, mucous membrane exposure prevention, transporting of bloods and equipment servicing and maintenance.
4. Personal Protective Equipment: Personal protective equipment must be provided by the employer at no cost to the employee. Include appropriate PPE such as gloves, gowns, face masks and eye protection in a variety of sizes that are easily accessible. Additionally, the employer is responsible for laundering, disposal and replacement of PPE should an exposure occur.
5. Housekeeping: Housekeeping relates to the employer's responsibility to ensure that the worksite (in our case the ambulances and crew quarters) is maintained in a clean and sanitary condition. While employers don't have to hire someone to complete these tasks, they do have to provide the policy and resources needed to complete routine cleaning, disinfecting, spill clean-up and waste management.
6. Hepatitis B Vaccination: The Hepatitis B vaccination and vaccination series must be made available to all employees who have potential occupational exposure. It must be provided at no cost and made available upon employment at a reasonable time and place. Any employee who wishes to decline the vaccination must complete a declination statement that must be kept on file.
7. Post Exposure Evaluation and Follow Up: Every agency must appoint a person, usually a manager or officer, to be its designated officer (DO) in the event of an exposure. It will be his/her responsibility to work with staff, the hospital that received the source patient and the agency chosen to complete the follow-up care on the exposed employee. Post exposure evaluation and follow up must be made immediately available after any exposure. Document the route and circumstances of the exposure as well as identification of the source individual. If indicated, obtain consent to test the source patient for HIV and HBV. Once the results are received, notify the employee of the results and provide post-exposure follow up and prophylaxis if indicated. Having a good preexisting relationship with the infection control officer at the hospitals you serve will make fact finding and follow up much easier.
8. Record Keeping: Maintain training records for a minimum of three years. Include a summary of the training session, names and qualifications of the people who conducted the training as well as the names and job titles of the people who attended the training. An example of this would be the initial and annual bloodborne pathogen training.
9. Injury Log: An injury log, also known as the OSHA 300 log, must be maintained by the employer for at least five years. Include documentation about how the incident occurred and where the injury took place. If a sharp was involved, note the type and brand of the device used in a separate log called the OSHA 300A sharps log. This log is often the first thing OSHA looks at when conducting an inspection or investigation.
In the Event of an Exposure
In the event of an exposure, the employee must immediately notify his/her DO. The DO will work with the employee to collect and document all of the facts surrounding the exposure, determine that the employee was indeed exposed, and then refer the employee to proper follow-up care. Additionally, the DO will contact the hospital where the source patient was received and work with its infection control department to seek consent from the patient for HIV and Hepatitis testing if a needle stick or splash of blood into a mucous membrane or open wound is involved. In any case, the DO will work with the infection control department to determine what, if any, infectious pathogen was involved, and what recommended treatment should follow.
While most hospitals work cooperatively with EMS to protect staff in the case of a possible exposure, a federal law is in place that ensures first responders will be properly notified in the event they were exposed. The law is called the "Ryan White HIV/AIDS Treatment Extension Act of 2009." While the majority of the law has to do with initiatives to control, detect and prevent the spread of HIV and AIDS, section G has to do with the notification of possible exposure to infectious diseases.
Review and update an exposure control plan annually or as needed. On an annual basis, the employer should document consideration and implementation of appropriate commercially available and effective safer medical devices. Additionally, they should solicit input from non-managerial employees responsible for direct patient care who may be potentially exposed.
Keys to success for an effective infection control program include:
Scott A. Matin, MBA, NREMT-P, is the Vice President of Clinical & Business Services for MONOC Mobile Health Services in Wall Township, New Jersey. His responsibilities include oversight of MONOC's clinical, education, Q/I, research, public relations, marketing, government affairs and business development services. In addition to his present position at MONOC, Scott is adjunct faculty for the School of Administrative Science at Fairleigh Dickinson University and an on-site team leader for the Commission on Accreditation of Ambulance Services (CAAS). Scott has been involved in Emergency Medical Services for over 25 years and is an established manager, educator and Nationally Registered Paramedic. Scott is also the author of numerous articles and research studies, a member of several editorial review boards and a frequent presenter at professional conferences throughout the country.