Environmental Services Professional Training

Course

Morning Schedule

(15 min.) Introductions

(15 min.) Course Development and Objective, Pre-test, Overview of Occupational Hazards,

Definitions

(60 min.) Microorganisms & Infectious Agents (show 27 min.

video before lecture/discussion)

(15 min.) Break

(75 min.) Infectious Waste (includes 22 min. video)

(40 min.) Cleaning for Health

(50 min.) Lunch

Morning Schedule

(40 min.) Hazardous Material Safety

(40 min.) Needlestick and Injury Prevention

(15 min.) Break

(30 min.) Spill Response

(60 min.) Regulated Medical Waste Transportation

Requirements

(45 min.) Post Test and Course Evaluations

Afternoon Schedule

Course Objective - to provide environmental services professionals with the information they need to do their jobs safely.

• Occupational hazards associated with handling infectious waste, disinfecting contaminated surfaces, and responding to infectious materials incidents

• Infection control on the job

• Material Safety Data Sheets and hazards associated with the use of chemical disinfectants

• Selection of proper personal protective equipment

• Housekeeping and spill response procedures

• The American Hospital Association’s infectious waste reduction initiative sponsored by the EPA

• Requirements for packaging and transporting infectious or regulated medical waste

Occupational Hazards

1.0 Overview of Occupational Hazards

When they enter patient rooms, they may become exposed to infectious diseases.

They risk exposure to bloodborne pathogens from dirty needles that are occasionally thrown away in the biohazard and general waste streams.

They work with chemicals that are often corrosive and dangerous if not handled properly.

They are a category of worker at risk of latex allergy from ongoing latex exposure.

They may become injured from slips, trips, and falls, or heavy lifting.

Microorganisms & Infectious Agents

2.0 Microorganisms & Infectious Agents1. Bacterial agents - Tuberculosis (TB), Staphylococcus (staph), or Legionella

2. Fungal agents - Aspergillus (mold), Tinea (ringworm)

3. Viruses - Hepatitis B, Hepatitis C, HIV

4. Parasitic agents - Giardia and Trichomoniasis

5. Prions - Kuru and Creutzfeldt-Jakob Disease

6. Rickettsial agents - Rocky Mountain spotted fever and Lyme Disease

In order for an infectious agent to make a person sick, it must first come into contact with that person. This contact is called an exposure.

EXAMPLE 1 - Tuberculosis

In a 1995 publication, CDC researchers reported the results of a study that found the annual risk of contracting TB was higher for hospital housekeepers than nurses.

EXAMPLE 2 - Hepatitis B

There are two ways to reduce the rate of HBV transmission from needlestick injuries and they are:

1) To get a Hepatitis B vaccination

2) To report all needlestick injuries to the infection control nurse and accept post-exposure treatment.

Environmental services professionals can prevent the spread of infectious agents among patients and healthcare workers by protecting themselves in the following ways:

• Wearing puncture resistant gloves while handling any form of hospital waste to include biohazard bags, infectious waste containers, and trash bags of any color

• If puncture resistant gloves are worn, wash gloves between patient rooms to avoid transfer of microorganisms from one patient to another

• Wear proper personal protective equipment when cleaning up spills of potentially infectious material

• Use an antibacterial soap to wash gloves immediately after contact with blood and/or body fluids, soiled linen, or contaminated equipment

• Immediately report needlestick and other sharps-related injuries to the infection control staff

• Follow any recommendations made by the infection control staff after a potential exposure to prevent infection

• Follow recommended infection prevention practices to include receiving the hepatitis B vaccination

• Participate in OSHA bloodborne pathogen training

• Wash hands immediately after removing gloves

• Wash hands before and after eating, smoking, applying cosmetics, or preparing food

• Stay home to rest when feverish and sick with a cold, flu, or other infection

Infectious Waste

3.0 Infectious Waste• Isolation wastes are those made in isolation rooms where patients with infectious diseases are cared for.

• Cultures and stocks are wastes generally made in the laboratory and may include specimen cultures, discarded vaccines, culture dishes, and devices used to transfer, inoculate, and mix cultures.

• Human blood and blood products are wastes that can be found anywhere in the health care facility but most often they are found in the laboratory, operating rooms, and labor and delivery areas - these wastes include blood, serum, plasma, and other blood products.

• Pathological wastes are wastes generally found in the pathology labs and autopsy suites - these wastes include tissues, organs, body parts, and body fluids that are removed during surgery and autopsy.

• Contaminated sharps are wastes that can be found in areas where patients are treated and the laboratory - these wastes include hypodermic needles, syringes, glass pipettes, broken glass, and scalpel blades.

• Contaminated carcasses, body parts, and bedding are wastes that can be found in a medical research laboratory where animals are exposed to infectious microorganisms.

• Miscellaneous wastes are those items that are probably contaminated with infectious microorganisms - they include contaminated materials found in the dialysis units, surgery and autopsy suites, and laboratory areas.

If an item has come in to contact with blood or body fluids, it is considered contaminated and probably infectious, therefore, it should be treated as infectious waste.

All infectious waste must be disposed of properly in accordance with a federal law known as the OSHA Bloodborne Pathogens Standard. Proper disposal means the following:

• All needles and other contaminated sharps must be placed in a closable, puncture-resistant, leakproof, red or biohazard-labeled container.

• All other infectious wastes must be placed in closable, leakproof, red or biohazard-labeled bags or containers.

Biohazard Label

Biohazard Labeled Bag or Container

Red Bag

Hospitals produce approximately two million tons of solid waste per year. Of this amount, ten to fifteen percent is categorized as infectious and the rest is general waste made up of paper and paper board, plastics, food waste, metal, glass, wood and other materials. All of the solid waste is sent to landfills or incinerators for disposal.

Only about 10% of the waste is actually infectious ...

And 2% of the waste is pathological, requiring incineration.

If 100% of hospital solid waste is disposed of in red bags...

• According to the EPA, medical waste incinerators are the fourth largest known releasers of mercury to the environment.

• Mercury waste is being improperly disposed of in biohazard bags along with other solid wastes that are not considered infectious.

• Mercury cannot be destroyed by incineration.

• Thirty nine states have issued over 1,600 warnings against eating mercury contaminated fish found in their waterways.

Because of all of the environmental health problems caused by medical waste incinerators, the American Hospital Association and the EPA have reached an agreement to work together to reduce the amount of waste within the hospital system by half by the year 2010.

A number of actions can be taken to reduce the amount of solid waste within the hospital system that is sent in biohazard bags to medical waste incinerators for disposal.

• Work with hospital administrators to develop policies that support biohazard bag reduction efforts.

• Provide information to all hospital staff about the toxic contaminants created by medical waste incineration.

• Educate staff about different categories of infectious waste and teach them to place only infectious wastes in biohazard bag containers.

• Place and maintain special biohazard-labeled containers in areas where pathological wastes are likely to be made and teach staff to only place pathological wastes in them.

• Place and maintain biohazard bag containers only in those areas where infectious wastes are likely to be made.

• Keep pathological wastes separate from the other infectious wastes.

• Send only pathological wastes to a medical waste incinerator for disposal.

• Make alternative arrangements to properly treat and dispose of all other infectious waste (e.g. autoclaves, microwaves, chemical treatment).

Cleaning for Health

4.0 Cleaning for HealthThe goal of a health care facility cleaning program is to prevent the spread of infectious agents among patients and healthcare workers and to maintain a healthy indoor environment. A healthy indoor environment is one that is free of hazardous pollutants.

• Organic Pollutants - chemical compounds such as formaldehyde, pesticides, and disinfectants

• Inorganic Pollutants - particles such as asbestos and lead

• Radiation - pollutants include both ionizing (e.g. radon) and non-ionizing (e.g. electromagnetic fields) types.

• Complex Mixtures - examples include soot and tobacco, both of which contain organic and inorganic matter.

• Biological Contaminants - referred to as bio-pollutants. Examples include bacteria, viruses, algae, fungi, ragweed, mites.

Biological contaminants are the most hazardous pollutants found in the indoor healthcare facility environment.

They are living organisms, or come from living organisms, and can be found under certain environmental conditions:

1. There must be a comfortable home or reservoir in which to hang out which is just about anyplace, and

2. They need nourishment just like us in the form of food and water.

What kind of food do these organisms “eat?”

in the building ventilation system in areas where organic matter (dust) and water are present. Where would you expect to find this organism in a health care facility? Can this organism kill a patient?

Aspergillus is a fungus found in dust and is an example of a common biological contaminant that lives well in soil, water and decaying material. In health care facilities, it may be found

Another deadly biological contaminant found in the healthcare facility is a bacteria named Vancomycin-resistant enterococci. (VRE). The reason why this bacteria is deadly is because it cannot easily be killed by antibiotics and many patients die once they become infected with it.

How do you think patients become infected with this bacteria?

If someone comes into the hospital carrying the VRE bacteria, then whatever that person touches may become contaminated with VRE. Deadly VRE can survive for weeks on environmental surfaces.

Patients may become infected with VRE by touching contaminated surfaces such as bedrails, sinks, faucets, and doorknobs, or coming into contact with health-care workers who do not wash their hands.

Environmental services professionals play a key role in controlling the spread of VRE throughout the healthcare facility by washing hands and wearing gloves properly, and diligently cleaning and disinfecting all environmental surfaces.

Surfaces with regular hand-contact are called high touch surfaces. High touch surfaces in patient care areas include items such as telephones, doorknobs, bedrails, light switches, faucets, and wall areas around the toilet. These surfaces must be cleaned and disinfected daily to protect the patient and reduce the spread of nosocomial diseases such as VRE.

Nosocomial diseases are illnesses that patients acquire during their stay in the hospital.

Clostridium difficile

The primary goal of a health care facility cleaning program is to prevent the spread of nosocomial disease among patients and healthcare workers. Environmental services professionals play an important role in achieving this goal.

Daily cleaning reduces the amount of microorganisms in the patient care environment.

Suggestions for improving the general cleaning and disinfecting process:

• When selecting a disinfectant for use, choose the least toxic and most effective cleaning product you can find.

• Always clean from least soiled to more soiled areas and from top to bottom in the patient rooms.

• Always change the disinfecting solution when it appears dirty (usually after every 3-4 patient rooms).

• Use a clean cloth or mop head each time a bucket of detergent/disinfectant is emptied and replaced with fresh, clean solution.

• Dusting reduces potential food for Aspergillus and prevents infection in hospitalized patients and allergies in employees.

• Dust can be removed without making patients sick by using a chemically treated cloth/mop or a cloth dampened with approved disinfectant.

• When dusting, it is important NOT to shake the cloth/mop because dust and fungal spores will then get in the air. If patients breathe in these spores, they may get sick and die.

• While dusting ceilings and vents, report any stains and/or wet areas immediately for repair. Fungus will start to grow on wet ceiling tiles within 72 hours.

Special care areas need additional attention.

What are special care areas?

Process improvement for special care areas :

• Use a bucket method for cleaning each special care area, where a clean cloth is dipped into a bucket filled with approved disinfectant and items are cleaned and left wet for ten minutes.

• Daily cleaning should include the washing and disinfecting of walls around light switches, doorknobs, and other high touch surfaces.

• Use CLEAN mops and CLEAN mop water for cleaning and disinfecting the floor in each special care or isolation room.

• When a patient is discharged from a special care area, throw away all disposable items, change any cubicle curtains, and disinfect all surfaces including chairs, tables, ledges, call lights, telephones, sinks, showers, and toilets.

• Avoid the use of cleaning equipment that produces mists.

• If a vacuum is needed to clean the floor in a special care area, use one with a clean HEPA filter on the exhaust. Keep the door to the special care area closed when vacuuming.

It can not be emphasized enough. Environmental services professionals play a key role in preventing the spread of infectious agents among patients and healthcare workers.

Diligent housekeeping keeps microorganisms and other bio-pollutants under control and reduces the spread of nosocomial disease.

What is nosocomial disease?

Hazardous Material Safety

5.0 Hazardous Material Safety

Environmental services professionals routinely use chemical disinfectants to clean surfaces and kill infectious agents in patient rooms and other areas of the health care facility. If not handled properly, these chemicals can cause serious injuries such as eye damage, respiratory problems, chemical burns, or severe skin irritation. To prevent such injuries, the OSHA Hazard Communication Standard requires all health care employers to provide information and training to their employees about the hazards associated with the chemicals in their workplace.

Employers must provide training to their employees on the following topics:

• Ways or how to detect the presence or release of a hazardous chemical in the workplace

• The physical and health hazards of the chemicals in the workplace and the measures that can be taken by environmental services staff to protect themselves from these hazards, including safe work practices, emergency procedures, and personal protective equipment to be used

• The facility’s hazard communication labeling system, the hazard information provided by the MSDS, and how personnel can obtain and use the hazard information on the MSDS

In order to understand the hazard information provided by the MSDS, environmental services professionals must first learn something about the nature of chemicals. Chemicals are made up of single or multiple elements.

Oxygen - one element, two molecules of oxygen (02)

Water- two elements, two molecules of hydrogen and one molecule of oxygen (H20)

The most common chemicals in use are made up of three elements - carbon, hydrogen, and oxygen.

What are some chemicals used everyday in healthcare facilities?

Chemicals also come in different forms - solids, liquids, gases, or vapors, and can even be radioactive.

H-3, also known as Tritium, is an example of a radioactive material which is made up of three hydrogen molecules. It is often used by scientists in biomedical research laboratories.

Chemicals change from one form to another depending on temperatures and pressures. Water turns to ice when the temperature drops below 32 degrees F. When water is heated to the boiling point, it evaporates and turns into a vapor. Some chemicals evaporate at or below room temperatures becoming airborne vapors.

Gasoline is a common chemical that becomes an airborne vapor at and below room temperature. It is very flammable with a flash point of -45 degrees F.

In addition to being flammable, gasoline vapors are very dangerous because they are harmful to human health.

Any chemical can be harmful to human health. How harmful a chemical is depends on how much of it gets into the body and how toxic it is.

Chemicals can enter the body in one of four ways:

• They can be inhaled (breathed in);

• They can be ingested (swallowed);

• They can be absorbed through the skin or eyes; or

• They can be injected.

When a chemical enters the body, an exposure has taken place. The effects of the exposure can be either sudden or long term.

Example: The effects of formaldehyde exposure can either be sudden or long term. Formaldehyde is both corrosive and a suspected carcinogen.

It is very important to wear Personal Protective Equipment (PPE) when working with corrosive material.

OSHA has set guidelines for safe levels of exposure to many airborne contaminants including mists, gases, vapors, dusts, and fibers. These are known as Permissible Exposure Levels or PELs. The American Conference of Governmental Industrial Hygienists (ACGIH) has also set guidelines for safe levels of exposure to many contaminants. These are known as Threshold Limit Values or TLVs. If a safe exposure level has been identified by OSHA or the ACGIH for a particular material, then it will be provided on the MSDS.

Unsafe levels of exposure may occur in the work place at any time in the event of a spill or release of a hazardous material. It is therefore very important that workers know where hazardous materials are stored or used and how to detect a spill or release in their work place.

Some hazardous materials have warning properties that alert the worker to a potential exposure in the event of a release. Examples of warning properties include odor, headache, burning or tearing eyes, or coughing.

Not all hazardous materials have warning properties and in some cases the warning properties do not occur until after the employee has been exposed to a dangerous amount of material. In such cases, employers may install alarm systems that go off when levels of exposure are immediately dangerous to life and health.

Example: Ethylene oxide is a toxic gas that is used in many healthcare facilities to sterilize surgical instruments. It is considered a carcinogen and a reproductive hazard.

Some hospitals have eliminated the use of ethylene oxide altogether. They have found a less hazardous material to use in their sterilizers. Using a less hazardous material to do the same job is known as “substitution.”

If a substitute material cannot be found to do the job, a toxic or other hazardous material can be used safely in the work place as long as precautions and procedures are in place to protect the worker from exposure.

Safe work practices or precautions for using a particular chemical may be found in the MSDS or on the product label. Below are some common precaution statements found on product labels:

• Use with adequate ventilation;

• Keep away from sources of ignition (e.g. heat, flame);

• Wear chemical splash goggles;

• Wear rubber gloves to avoid skin contact.

The MSDS will state what type of PPE the worker needs to wear to prevent exposure while handling the material. If an exposure does occur, the MSDS also provides health hazard and emergency first aid information.

To summarize, manufacturers must develop a Material Safety Data Sheet (MSDS) and provide it to people and organizations that purchase their products. Employers such as hospital organizations are then required to train their employees on the hazard information provided by the MSDS.

Needlestick and Injury Prevention

6.0 Needlestick and Injury Prevention

It is estimated that 600,000 to 800,000 needlestick and other percutaneous injuries occur annually among health care workers in the United States. About half of these injuries go unreported. Data suggests that at an average hospital, approximately 30 needlestick injuries occur per year for every 100 beds.

How many beds are in the hospital that you work at?

Of the reported needlestick injuries, approximately 41% occur for the following reasons:

• Improperly disposed sharp;

• Disposal-related causes;

• Collision with health care worker or sharp; and

• Cleanup.

To reduce the risk of needlestick and other injuries, the following control measures are recommended to protect the environmental services professional:

• Always wear whatever personal protective equipment is necessary to do the task safely to protect your skin, work clothes, and mucous membranes from contact with potentially infectious materials (e.g. gloves, masks, face shields, gowns, and aprons).

• A gown or apron should be worn if there is a possibility of contact with infectious materials on your work clothes.

• A mask and goggles or eye protection should be worn if there is a possibility of contact with infectious materials in your eyes, nose, or mouth.

• Gloves should be worn to protect your hands from contact with chemicals and potentially infectious materials.

• Wear puncture resistant gloves when performing high risk tasks (e.g., changing out needle boxes, cleaning up broken glass, handling infectious waste containers).

• Report to management any needles or other sharp items not properly disposed of by the health care providers.

• Locate puncture resistant leak-proof containers for sharps and needle disposal in areas where they are convenient and likely to be used by health care providers.

• Ensure that sharps and needle disposal containers are emptied before they become full.

• Report to management any sharps containers that are mounted too high or are not easily accessible to health care providers.

• Use a brush and dust pan to pick up broken glass which may be contaminated with blood or other body fluids.

• Handle contaminated laundry including sheets as little as possible. Do not shake out these items. Hold them away from your body and place in the linen hamper without pressing down on them.

• Carry red bags or other containers of medical waste away from your body.

• When cleaning up contaminated areas, minimize splashing, spraying, and spattering.

• Bandage any cuts on your hands before putting on gloves.

• If latex gloves are worn, always wash and remove them after cleaning a patient’s room or any other potentially contaminated area.

• Dirty gloves should never be worn after the cleaning job is done - wearing them around the hospital contaminates surfaces and spreads disease among the patients.

• Always wash hands after removing gloves and whenever they are dirty.

• Always wash hands in between patient rooms.

• Follow safe work practices (e.g., do not eat, drink, smoke, apply lip balm, or handle contact lenses where there might be exposure to blood or other potentially infectious materials).

• Keep food and drinks away from areas where blood or other potentially infectious materials are present.

• Report needlestick injuries and other potential bloodborne pathogen exposures to the infection control staff at your health care facility.

• Follow any recommendations made by the infection control staff after a potential exposure.

• Ask the infection control staff at your health care facility about the free Hepatitis B vaccine that is provided to environmental services professionals

Spill Response

7.0 Spill Response

Environmental services professionals routinely respond to calls for assistance in cleaning up spilled materials on the patient wards and other areas of the hospital. The spilled materials often consist of human body fluids such as urine, blood, and feces that may or may not be infectious. Regardless of whether or not the material is actually infectious, any human body fluid must be considered potentially infectious.

The environmental services professional should receive training on the following topics:

• The health care facility emergency response plan for hazardous materials spills (e.g. notification, personal protective equipment (PPE), spill response and equipment maintenance procedures, etc…);

• The different types of micro-organisms potentially found in their workplace to which they are susceptible (e.g. E. coli, MRSA, VRE) along with definitions and symptoms of exposure;

• Spill site security and control;

• The measures that environmental services professionals can take to protect themselves to minimize their risks of exposure during cleanup operations to include wearing proper PPE;

• Contaminated surface cleaning procedures;

• Disinfectant selection and effective decontamination procedures;

• Proper disposal procedures for potentially infectious waste materials;

• Removing PPE, decontamination and/or disposal procedures; and

• The health care facility exposure control plan for bloodborne pathogens and employee health and medical surveillance program.

Do environmental services professionals require special training to clean up hazardous material spills in the hospital environment?

Depends on whether or not the spill is considered “incidental.”

An incidental spill is a release of hazardous material which does not have the potential to become an emergency within a short time frame. Incidental releases are limited in quantity, exposure potential, or toxicity and present minor safety or health hazards to employees in the immediate work area or those assigned to clean them up. An incidental spill may be safely cleaned up by an employee who is familiar with the hazards of the material.

It is up to management personnel to decide whether or not a spill is incidental.

Medical Waste Transportation

8.0 Regulated Medical Waste Management, Disposal, and Transportation RequirementsThere is a great deal of concern about the proper management of health care facility wastes. Environmental services professionals are responsible for picking up the waste at each point of generation and transporting it to the designated place of disposal or storage at the facility. If certain wastes are mishandled or improperly disposed of, health care facilities may be subject to fines. Some of the waste generated in the health care setting could be infectious and transmit disease if improperly handled or disposed of.

It is important that environmental services professionals receive training on the following topics:

• The health care facility waste management plan

• The different types of waste streams at the facility for which they will be responsible

• The definition and/or designation of infectious waste including where it is likely to be generated and how it is to be segregated from the other waste streams

• Proper segregation, containment, and labeling of wastes in the health care facility

• Department of Transportation (DOT) shipping regulations for infectious and/or regulated medical waste transported off-site for treatment/incineration

• State or local regulations for medical and/or infectious waste disposalOSHA regulates infectious waste in the workplace by enforcing the requirements of the Bloodborne Pathogens Standard. When environmental services professionals pick up infectious waste at each point of generation in the healthcare facility and transport it to the designated place of treatment or storage at the facility they must do so “in accordance with OSHA regulations”. What does this mean?

The infectious waste may or may not be treated on-site at the health care facility prior to shipment off-site for final disposal. If the waste is treated on-site at the facility so that it no longer poses the hazard of an infectious substance, then it is no longer considered infectious and may be transported off-site as general waste to a solid waste disposal facility (e.g. landfill, transfer station) regulated by state or local authorities.

If the waste is not treated on-site, then it is considered infectious and a DOT hazardous material, and it must be transported off-site in accordance with DOT shipping regulations for hazardous materials.

DOT regulations require that all infectious substances, including regulated medical waste, be prepared for shipment off-site by trained personnel. Specifically, personnel must receive initial and recurrent training (every two years) that meets the DOT training requirements in three subject areas.

1. General awareness/familiarization training to enable the employee to recognize and identify regulated medical waste as defined by DOT;

DOT Definition of Regulated Medical Waste - a waste, or reusable material, that contains an infectious substance and is generated in the diagnosis, treatment, or research of humans or animals2. Function-specific training to familiarize the employee with the DOT shipping requirements related to the job that he/she performs;

3. Safety training concerning the specific hazards associated with regulated medical waste, safe handling of packages containing regulated medical waste, and the emergency response procedures and information required by DOT for every regulated medical waste shipment in the event of an accidental release.

DOT requires that personnel be tested after receiving the training on the three subject areas.

A record of current training must be kept by the health care facility for each employee that prepares regulated medical waste for shipment off-site to a treatment facility.

Each record must include the employee’s name, the most recent training date, a copy of the training materials, the name and address of the trainer, and a certification that the employee was trained and tested.

In accordance with DOT shipping regulations, regulated medical waste must be shipped in packages that are properly labeled and marked (see DOT brochure).

A shipping paper must also be prepared for every regulated medical waste shipment that leaves the health care facility.

A description of the regulated medical waste shipment must be included on the shipping paper as well as the name of the health care facility and an emergency response telephone number. The description of the waste shipment on the shipping paper must include:

• The proper shipping name, Regulated Medical Waste;

• The hazard class, 6.2;

• The identification number, NA 3291; and

• Packing group, II.

The total quantity of the medical waste being shipped off-site for treatment must also be entered on the shipping paper (see example).

It is important for environmental services professionals to understand that untreated regulated medical waste is considered an infectious substance and a DOT hazardous material. It must be transported from the health care facility in accordance with DOT shipping regulations.

If untreated regulated medical waste is improperly disposed of in the general solid waste stream and transported off-site to a transfer station or landfill, the healthcare facility will be subject to fines levied by the local government and the federal DOT.

$25,000.00