Emerging Infectious Diseases

Heavy metals, sharps, cleaners, blood, blood products and other infectious materials, are abundant in hospital stings.. The risk for infection and cross-contamination exists in every area of every hospital. Wet or soiled dressings, devices used in diagnostics and treatment, and surfaces such as doorknobs, floors and toilets can all act as vehicles for the transmission of infection. The stakes are high. But infection can be limited and reduced.

Infectious waste  in the OR.

Training, policies and regulations are tools not cures. An effective waste management program incorporates all aspects of infection prevention, beginning with the acquisition of materials that eventually become waste, to appropriate training, safe handling, labelling, storage, segregation, disposal and other healthy workplace initiatives. We most often think of infection control from the patient to healthcare worker and sometimes from the healthcare worker to the patient. Rarely do we think about patient to patient, healthcare worker to apparatus or apparatus (even as simple as a garbage disposal) to healthcare worker transmissions. Since there are such a wide variety of ways to get infected, members of your infection control team need to work with waste management and with environmental services (laundry, cleaning) to ensure that all employees are well trained.

Train each employee several times using employee orientation programs, annual updates and as-needed while doing rounds. Remember that each individual learns differently, so use different training methods, including lots of physical examples of wastes, during training. Ensure your training schedule catches all staff, including relief and night shifts. Adapt your training to the needs of different departments (emergency versus ICU) and different stakeholders, especially physicians working in the operating room versus nurses doing emergency intake.

Consider introducing departmental specific policies, which work in areas such as laboratories. Work with lab employees and the infection control team to identify appropriate methods of segregation for pipettes, syringes, loops and other items. Gather the various items together and make decisions based on regional regulations and local input. Then write down what you have decided, and create posters with pictures that indicate each type of waste. Ensure that all new lab personnel are trained in proper waste segregation and do annual “reminder” training with all lab staff.

Legislation is in place at the federal, state and local level to ensure waste is handled and disposed of in ways that will prevent the spread of infection. Different facilities have different rules depending on who, what and how much waste is produced. It’s up to us to know what laws and rules apply to our own particular facility. Under the Resource Conservation and Recovery Act (RCRA) for example, hospitals are required to minimize waste generation, but toxins still slip through the cracks, down drains that flow into rivers and lakes, into landfills that contaminate soil and streams, or into the air through incineration. We still see the dangerous practice of mixing materials (infectious waste with food leftovers, batteries and chemicals with newspaper, memos and coffee cups) and using unnecessary and costly high-level treatments.

Before any improvement in infection prevention can occur we need to establish good definitions of waste, outline who handles waste and identify the processes for disposing of all these infectious materials. The three main categories of waste are:

1. Hazardous materials; Raw materials or products stored and used in a healthcare facility. These materials are considered to pose a significant risk to people or property.
2. Hazardous wastes; Applies to certain materials generated as wastes from processes at your facility. Materials meet criteria in the federal Resource Conservation and Recovery Act.
3. Universal wastes; A category of wastes established by the Environmental Protection Agency (EPA) to encourage recycling of items that may otherwise be classified as hazardous wastes. Examples include batteries, thermostats, lamps and pesticides.

The Joint Commission for the Accreditation of Health Care Organizations has been developing a set of standards on the Environment of Care, which includes policies for the management of hazardous materials and workers’ safety. Under this plan when standards fail to be met a hospital would be refused accreditation. Many states anticipated stricter regulations and already have waste management plans that meet the EPA’s MACT rule. Various Acts, such as the Resource Recovery and Conservation Act, the Clean Air Act, and the Clean Water Act are also in place to guide our actions. Several other agencies are involved in regulating hazardous waste and materials, including the EPA, the Occupational Safety and Health Administration (OSHA), and the U.S. Department of Transportation. Ensure you know the rules, and how the management of waste can impact infection prevention procedures.

Who Is Responsible For Safety?

It’s not enough to just know our job anymore. We need to know the hazards associated with our industry, how to prevent incidents and what to do in an emergency. Training for infection control needs to be thorough, relevant and understood, built into every employee orientation session, updated and reinforced at regular intervals. Infection prevention is everyone’s responsibility.

Employers are responsible for safe handling policies and clearly establishing roles and responsibilities. They are also obligated to keep staff in the loop concerning all new health and safety requirements, for ensuring incidents are properly investigated and reported and for monitoring practices within the organization.

Employees are responsible for being familiar with emergency and waste management policies and must act in their own best interest as well as their coworkers, patients and the facility. Employees should be prepared to:

• Report any unsafe condition involving waste materials or substances, with the goal of eliminating a hazard before it causes a problem.
• Assist with the reporting process. Keeping track of incidents may point to a need for additional training or a new process. Analyzing what went wrong is critical to reducing the possibility of a reoccurrence.
• Ensure waste is correctly sealed and labelled prior to being collected and transported. All waste must be handled and correctly disposed of by trained, authorized staff.
• Assist in waste reduction initiatives and recommend safe work practices.

Segregation

To determine what waste poses the most risk, we must have a clear knowledge of the waste stream. Failure to properly separate wastes means some of the waste leaving our facilities is potentially infectious and hazardous. Colors indicate specific waste types; however, these color categories may vary at your facility. Normally, colors mean:

• Red—Biohazardous, biomedical, infectious, regulated medical;
• Yellow, White—Chemotheraphy—trace/debris or hazardous waste;
• Blue—Chemotherapy—trace/debris;
• Purple, Magenta, Yellow—Radioactive;
• Dark Blue—Hazardous waste.

When handling waste, always use appropriate protective clothing and equipment (gloves, aprons, etc.) and maintain good hand hygiene. To prevent the risk of spills or injury do not carry waste bags for long distances and restrict storage areas to authorized personnel only. Keys to proper segregation include:

• Standardize all waste receptacles, placement and signage;
• Place Red bags in a central location;
• Use open containers for clean waste, closed for Red bag waste;
• Use signage above and on all containers to explain acceptable waste;
• Avoid placing Red bag waste containers under sinks and in hallways;
• Always place a non-regulated waste container beside the regulated container;
• Remove Red bag containers from patient rooms except those in isolation;
• Check state regulations regarding isolation waste requirements;
• Pay special attention to high generating areas (operating room, labs and dialysis);
• Monitor work areas;
• Consider tracking generation rates, employee training and rounding through the Hazardous Material and Waste Management Plan.

Special Items to Consider

Waste generated by healthcare facilities includes sharps and non-sharps, blood, body parts, chemicals, medical devices and other materials, some more likely to cause infection than others.

Sharps

Healthcare workers are at greatest risk for sharps injuries. Sharps are singled out for special regulatory provisions by many states. The Centers for Disease Control and Prevention (CDC) estimates that more than 800,000 accidental needlesticks occur each year among healthcare workers. Sharps (syringes, needles, scalpels, lancets, contaminated glassware or plastics such as vials, tubes and slides) should be placed in rigid, puncture and leak-resistant containers that cannot be easily opened after locking. Research identifies the ideal mounting height of 52 to 56 inches from the floor to the collector opening. Containers should be placed in visible locations away from pedestrian traffic, swinging doors and other obstacles. Containers must be clearly marked with the biohazard symbol and placed in bio-hazardous waste containers.

Best practice should emphasize the need for correct handling before, during and after use, and the safe disposal of sharps. Consider purchasing sharps that have built-in safety features that are aimed at reducing the risk of needlestick injuries. Safety features can be classified as:

• Integrated safety features that form part of the basic design of the device and cannot be removed;
• Passive safety features that don’t need users to activate them and are effective before, during and after use;
• Active safety features that need users to activate them before the device is used.

Ensure your sharps containers are puncture-resistant and leak-proof even if they are dropped or fall over. To reduce infection transmission, the containers should have an opening aperture that when the container is being used normally doesn’t allow the contents to be removed, but is of a size such that items can be disposed into the container using one hand without contaminating the outside of the container.

Other points to keep in mind:

• Do not re-sheath needles by hand;
• Do not bend or break needles before or after use;
• Do not pass sharps directly from hand to hand—an exception to this may be when passing the scalpel to/from the scrub nurse to the surgeon, though many facilities have chosen hands-free methods for this as well;
• Only dispose of syringes/cartridges and needles intact;
• Never overfill sharps containers (keep below the manufacturer’s fill line);
• Do not mix sharps with other clinical waste;
• Do not place sharps containers in yellow bags for disposal;
• Position sharps bins away from public areas, and out of reach of children;
• Do not remove sharps from clinical settings.

Infectious Substances and Materials

This waste includes infectious or potentially infectious pathological waste, blood, other body fluids, waste cultures and stocks. One area to look at to reduce infection from these wastes is in the OR. Suction canisters can be responsible for up to 40 percent of infectious waste in the OR. Because a solidifying material is usually added to the canister, employees can be exposed to splashing and spills when adding the solidifier. Fluid management systems offering mechanical disposal of waste and disinfection of the canisters may help reduce risk of exposure. Mechanical disposal and disinfection reduces transportation cost, removes canisters from the waste stream and meets OSHA’s standards. Canister-free vacuum systems reduce the risk of employee exposure and the amount of waste needing to be shipped out.

Laundry

Soiled laundry, except from patients in isolation, represents a small risk of infection as long as commonsense prevails for handling, processing and storage. Minimal handling and agitation of soiled laundry to prevent air and surface contamination is recommended. These textiles should be bagged or placed in labelled or color-coded containers at the location in which they were used. Linens contaminated with blood or body fluids require leak-proof bags.

Chemicals, Cleaners, Pesticides

While we recognize cleaning, disinfection and sterilization processes are designed to maintain a safe environment, the chemicals used in these procedures have a degree of toxicity necessary to kill micro-organisms. Chemicals are technically hazardous materials that produce hazardous wastes, but are sometimes not managed as such. To minimize exposure to chemicals, select the lowest level of product or process that will still do the job.

Reviewing your operations may lead to new ways of reducing infection. Remove carpeting from areas where moisture is present, and install walk-off mats at entrances to reduce use of harsh cleaners. Replace sprays with pour-and-wipe products to reduce airborne contaminants. Buffing floors can aerosolize polymers and because respiratory problems, however vacuum attachments help minimize exposure. Relatively new introductions such as microfiber mops, auto-scrubbers and extraction machines are also helping to reduce chemical use, while providing the same if not a better level of infection prevention.

Weak Link

These are just a few of the processes and innovations taking place in everyday healthcare to manage waste and prevent infection. Does it seem like we’ve thought of everything? Unfortunately, we have not. There’s always the unknown. The human component is both our greatest weakness and our strongest defense in the fight against infection. Take care, arm yourself with information, get to know your surroundings, ask questions and learn what you can do to contribute to a safer workplace. Help train others and be a role model for them. Remember that infection can be transmitted in many ways, some that we may not normally think of, and from many different places and people in your facility.

Sources

• www.nihe.org/elevreng.html: The Nightingale Institute for Health and the Environment—The Joint Commission for the Accreditation of Health Care Organizations has been developing a set of standards on the Environment of Care, which includes policies for the management of hazardous materials and workers’ safety. The plan is when standards fail to be met a hospital would be refused accreditation. Many states anticipated stricter regulations some years ago and have already taken steps to develop waste management plans that meet the EPA’s new MACT rule.
• www.oeconline.org/our-work/kidshealth/toxics/air/dioxins: Dioxin link to birth defects may be found here and on several other Web sites.
• www.leedsteachinghospitals.com/sites/infection_control/documents/uniinf00.pdf:Universal Infection Control Precautions—Sharps.
• www.wildirismedical.com/courses/167/index_mand.html: Infection Control Guidelines (Continued education) CDC recommendations for blood, fluids, ground tissues.
• www.surgistrategies.com/articles/or-arena-jan-09-wastemanagement.html: Sharps container placement.
• www.practicegreenhealth.org
• www.osha.gov/SLTC/hazardcommunications/whatishazcom
• www.epa.gov/epawaste/hazard/wastetypes
• www.cdc.gov
• www.des.state.nh.us/nhppp/Healthcare_p2/default.asp?link=faq5.
• www.healthcarea2z.org/stdPage.aspx/home/Wastemanagement/CoreContent/Sharpsmanagement#sec_780
• The federal Resource Conservation and Recovery Act.