≥92% of participants will learn the importance of using standard precautions and to update the healthcare professional on current treatment for occupational exposure to a bloodborne pathogen.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥92% of participants will learn the importance of using standard precautions and to update the healthcare professional on current treatment for occupational exposure to a bloodborne pathogen.
After completing this course, the learner will be able to:
Exposure to bloodborne pathogens, particularly hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV), is a constant risk for healthcare workers (Aljohan et al., 2021; CDC, 2019a; CDC, 2016a; Shenoy & Weber, 2021; Weber, 2020). Transmission of and infection with HBV, HCV, and HIV after an occupational exposure is very uncommon (CDC, 2016a). Still, needlestick and sharps injuries and splashes with blood and body fluids, situations that put healthcare workers at risk, are not (Mengitsu et al., 2021). This module will discuss the epidemiology and transmission of HBV, HCV, and HIV in healthcare settings and the prevention and treatment of exposure to these pathogens.
The term occupational exposure is frequently used in this module, and it refers to exposure in a healthcare setting.
A nurse working in an emergency room (ER) is caring for a patient who has almost certainly taken an overdose of fentanyl. The patient has been treated many times before for fentanyl overdoses, and today he was found at home and had the characteristic signs and symptoms of opioid poisoning. The emergency medical services personnel at the scene determined that at the time, the patient could be safely managed and transported with the use of supplemental oxygen alone.
The nurse begins to insert an IV catheter into the patient's arm. However, before he can complete the procedure, the patient wakes up, he forcefully pulls back his arm, and the IV catheter — which is visibly covered with blood — slips out of the patient's arm, and the tip punctures the nurse's finger. The nurse places a pressure dressing on the catheter insertion site. He removes his gloves, washes the puncture wound with soap and water, and registers as a patient in the ER. The nurse is 29 years old, and he does not have any acute or chronic medical problems.
Because the nurse suffered a penetrating needlestick injury, the needle was contaminated with blood, and the source has a high risk of being infected with a bloodborne pathogen. This incident is an exposure that puts the employee at risk for infection with a bloodborne pathogen. The OSHA Bloodborne Pathogens Standard's definition of exposure is "a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties."
The triage nurse draws a blood sample from the nurse, and the sample is sent to the laboratory to be tested for HCV antibodies and HIV antigen, and HIV antibodies. The nurse has completed the HBV vaccination series, and his post-vaccination HBV surface antibody level was ≥ 10 IU/mL, so he is protected against HBV infection. A sample of the patient's blood is sent to the laboratory. It will be tested for HBV antigen and HBV antibodies, HCV antigen and HCV antibodies, and HIV antigen and HIV antibodies. A rapid-result HIV test will be done for the employee and the source, and the results of these tests should be available within ~ 20 minutes. Post-exposure prophylaxis (PEP) for HIV should be started within several hours after exposure, so the nurse and the provider decide to wait for the test results and not begin PEP. The provider explains to the nurse that there is no effective prophylaxis for HCV.
The nurse and the patient are HIV-negative, but the patient has a measurable level of HCV RNA; the nurse's HCV tests are negative. The patient will be referred to a clinician for evaluation. The nurse makes an appointment to have an HCV RNA test done in three to six weeks. This test is negative, and a follow-up HCV antibody test four to six months after the exposure is done. This test is negative, and no further testing is needed.
Hepatitis B, HCV, and HIV are transmitted by contact with blood or infected body fluids; the contact can occur by a percutaneous injury, e.g., a needlestick or a sharps injury, by contact with a mucous membrane, or by exposure to non-intact skin. (CDC, 2020a; Fauci et al., 2018; Shenoy & Weber, 2021; Weber, 2020).
The Occupational Safety and Health Organization (OSHA) definition of blood is blood, human blood components, and other products made from human blood (OSHA, 2016). The Occupational Safety and Health Administration considers these body fluids potentially infectious:
Also, OSHA states that any bodily fluids visibly stained with blood should be considered potentially infectious (OSHA, 2016). Body fluids should be considered potentially infectious "in situations where it is difficult or impossible to differentiate between body fluids (OSHA, 2016)."
Occupational exposures to bloodborne pathogens are common. Each year, it has been estimated that in the United States, 600,000 to 800,000 healthcare workers get a needlestick or a sharps injury (Fauci et al., 2018). Mengitsu et al. (2021) did a systematic review and meta-analysis of the published literature. The authors found that worldwide, the career and the previous year prevalence of needlestick injuries in healthcare workers was 56.2% and 32.4%.
Transmission of and subsequent infection with HBV after occupational exposure to the virus is common; transmission of and subsequent infection with HCV and HIV after an occupational exposure is not.
The risk of transmission of and infection with HBV, HCV, or HIV to healthcare workers depends on the HBV vaccination status of the employee, how common these viruses are in the patient population, the viral load of the source, and how the exposure occurred (Weber, 2020; Zachary, 2019). Transmission and infection are more likely to occur if the patient has a high viral load; if the needlestick was from a hollow bore needle; if the needle had been in an artery or a vein; the injury is deep; there was visible blood on the needle/instrument, or if a large volume of blood was involved (Weber, 2020; Zachary, 2019).
Situations that increase the risk of a needlestick injury include, but are not limited to:
Avoiding occupational blood exposures is the primary way to prevent the transmission of bloodborne pathogens in healthcare settings. The Occupational Safety and Health Administration Standard 1910.1030, Bloodborne Pathogens, mandates that in a workplace in which employees may be or are exposed to bloodborne pathogens, the employer must develop a written exposure control plan "designed to eliminate or minimize employee exposure” (OSHA, 2016). An exposure control plan has many parts; the ones that directly concern healthcare professionals include:
The recommendations in Standard 1910.1030 differ slightly from infection control advice from the CDC and other authoritative sources. These differences are not important; the essential content and the basic recommendations are the same.
Standard 1910.1030 states that employers must offer hepatitis B vaccination to at-risk employees at no cost (OSHA, 2016). Employees are exempt if they are vaccinated, antibody testing shows that they are immune, or the use of the vaccine is contraindicated (OSHA, 2016; OSHA, 2011).
Engineering controls are devices, equipment, and procedures that help reduce the risk of exposure to bloodborne pathogens (OSHA, 2016). Examples of engineering controls mentioned in Standard 1910.1030 are disposal containers for needles and sharps, needleless systems for self-sheathing needles, and sharps with built-in injury protection (OSHA, 2016). Example:
The OSHA Bloodborne Pathogens standard recommends using Universal Precautions. Universal Precautions were the original CDC infection guidelines for preventing exposure to and transmission of bloodborne pathogens. Standard Precautions, which were developed later, added to and expanded Universal Precautions. Standard Precautions are universally used by healthcare facilities today, and Standard Precautions will be covered.
Standard Precautions include:
The safe use of needles and syringes as per the OSHA Bloodborne Pathogens Standard will also be covered.
Hand hygiene has been identified as the most important method of preventing and reducing the transmission of pathogens from one patient to another and from an infected site on a patient to a clean site on the same patient (Anderson, 2020; Gammon & Hunt, 2020). Unfortunately, compliance with hand hygiene by healthcare workers is often sub-optimal (Hoffman et al., 2020). The OSHA Bloodborne Pathogens standard states that employers are required to provide handwashing equipment and facilities (OSHA, 2016), and employees are required to know when and how to wash their hands (OSHA, 2016).
Hand hygiene can be done with an alcohol-based hand sanitizer or soap and water (CDC, 2021b). Alcohol-based hand sanitizers are preferred because:
An alcohol-based hand sanitizer should be used in these situations:
To use an alcohol-based hand sanitizer, put the recommended amount on your hands. Rub your hands together, covering every part of your hands and fingers until they are dry; this usually requires about 20 seconds (CDC, 2021b)
Soap and water should be used in these situations:
To wash your hands with soap and water, wet your hands. Apply the recommended amount of soap and then rub your hands together, covering every part of your hands and fingers; do this for 15 to 20 seconds. Rinse your hands and fingers, use a paper towel to dry them, use the towel to turn the faucet handle to the off position, and discard the towel. The recommended time of 15 to 20 seconds is a guideline (CDC, 2019b). The CDC recommends that you should wash your hands for at least 15 seconds and that the length of time "is less important than making sure you clean all areas of your hands." (CDC, 2019b).
Note: The World Health Organization (WHO) Save Lives: Clean Your Hands program has a simple way to remember when to use hand hygiene: My Five Moments for Hand Hygiene:
Respiratory hygiene and cough etiquette were added to Standard Precautions in response to the severe acute respiratory syndrome (SARS) outbreak in 2003 (Siegel et al., 2019). The virus that caused the 2003 SARS outbreak and the COVID-19 virus cause respiratory infections. These viruses are transmitted by infected droplets that are spread when someone coughs, sneezes, talks, and airborne transmission to a lesser degree (McIntosh, 2020). Respiratory hygiene and cough etiquette can help prevent the transmission of viruses that cause respiratory infections, and this infection control technique includes the following measures:
Personal protective equipment is equipment that is designed to prevent the transmission of pathogens by direct contact. Personal protective equipment includes eye shields, face shields, foot/shoe covers, gloves, goggles, gowns, head covers, and respirators.
Employers are required to provide employees with the PPE they need to protect themselves and provide training on how to use PPE (OSHA, 2016), and employees are expected to know how and when to use PPE (CDC, 2020b).
Choose the PPE to use by assessing a situation and determining what you may be exposed to and how you may be exposed. Healthcare facilities must train employees on the proper use of PPE, but healthcare professionals must use their judgment to decide what PPE they need to use.
Example: The OSHA Bloodborne Pathogens Standard states:
“Masks, Eye Protection, and Face Shields. Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated." (OSHA, 2016).
Personal protective equipment must be donned and removed correctly to protect patients and healthcare workers.
Use these steps for donning PPE:
Use these steps for removing PPE:
Note: Handwashing and the proper use of gloves are effective infection control techniques. However, healthcare workers often do not follow handwashing recommendations (Moore et al., 2021), and gloves can tear and be penetrated (Zhang et al., 2021). The CDC's stance on the use of gloves and handwashing is: "The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves." (CDC, 2002). Gloves should be changed when they are damaged, when you move from a contaminated body site to a clean body site, and when the gloves are bloody, dirty, or contaminated by body fluids (CDC, 2019b)
Safe injection practices, also called injection safety, are practices and techniques that:
The CDC states, "A safe injection does not harm the recipient, does not expose the provider to any avoidable risks, and does not result in waste that is dangerous for the community (e.g., through inappropriate disposal of injection equipment)" (CDC, 2019c).
Safe injection practices were added to Standard Precautions after four large outbreaks of HBV and HCV occurred in patients who had been treated in ambulatory care centers, i.e., an endoscopy clinic, a hematology/oncology clinic, a pain clinic, and a private physician's office (Siegel et al., 2019). The outbreaks were caused by failing to use proper infection control techniques, e.g.:
The essential elements of Safe Injection Practices are listed below:
The OSHA Bloodborne Pathogens Standard recommendations for the safe use of needles and sharps are listed below:
One serious bloodborne infection can cost more than a million dollars for medications, follow-up laboratory testing, clinical evaluation, lost wages, and disability payments. The human costs after exposure are immeasurable. Employees may experience adjustment disorders, anxiety, crying spells, depression, panic attacks, post-traumatic stress disorder, and family, occupational, and sexual trouble dysfunction (Cooke & Stephens, 2017; Green & Griffiths, 2013).
The OSHA Bloodborne Pathogens Standard's definition of exposure is "a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties."
Employees should report exposure to blood, exposure to body fluids, a needlestick injury, or a sharps injury immediately or as soon as possible (CDC, 2016c). The importance of immediately reporting an exposure cannot be overstated; if the healthcare worker was exposed to HIV, post-exposure prophylaxis should be started within hours after the exposure.
After a needlestick or a sharps injury, immediately wash the wound with soap and water (Weber, 2020); if there has been an ocular or mucous membrane exposure, flush the area with water (Weber, 2020). An antiseptic can be applied to the area of a needlestick or a sharps injury, but do not inject anything into the area, do not apply bleach, and do not waste time squeezing the area of the wound to try and express blood/fluid from the wound (Weber, 2020).
The treatment for exposure to HBV or possible exposure to HBV focuses on the HBV status of the source and the employee's immune status (Schillie et al., 2018; Weber, 2020). There are multiple possible scenarios:
An employee exposed to an HBsAg positive source or a source whose HBsAg status is unknown should not donate blood, organs, plasma, semen, or tissues during the six-month follow-up period (Schille et al., 2018; Weber,2020). Sexual practices do not need to be changed, becoming pregnant is not contraindicated, and breastfeeding can be continued (Schillie et al., 2018). Also, the employee can continue their normal work responsibilities (Schillie et al., 2018).
There is no effective prophylactic treatment for acute exposure to HCV (Moorman et al., 2020; Weber, 2020). Direct-acting antivirals effectively treat chronic HCV infection, but there is no evidence that they are effective prophylactic (Weber, 2020).
The source should be tested, preferably within 48 hours after the exposure, preferably using a nucleic acid test that detects HCV RNA (Moorman et al., 2020). The alternative is to test the source for the presence of HCV antibodies and then test for HCV RNA if the antibody test is positive (Moorman et al., 2020).
Suppose the source has or is suspected of having had recent behavioral risk factors for HCV exposure like IV drug use. In that case, HCV RNA measurement should be done (Moorman) as someone who was recently infected may not have HCV antibodies yet, but they will have HCV RNA (Weber, 2020).
Post-exposure prophylaxis should be given:
Post-exposure prophylaxis should be started within one to two hours post-exposure, or sooner if possible (National Clinical Consultation Center, 2021; Zachary, 2019); do not wait for test results. Authoritative sources recommend that PEP should not be given ≥ 72 hours post-exposure (National Clinical Consultation Center; Zachary, 2019). However, this recommendation is based on drug testing in animals (National Clinical Consultation Center, 2021; Zachary, 2019), and Zachary (2019) wrote:
"For most HCP, we do not initiate PEP if more than 72 hours have elapsed after the initial exposure . . .However, we do offer PEP after a longer interval to patients with a very high-risk exposure (e.g., sharps injuries from a needle that was in an artery or vein of an HIV-infected source patient)."
It is recommended that clinicians get a consultation if they intend to prescribe PEP > 72 hours post-exposure (National Clinical Consultation Center, 2021). For advice about using PEP for an employee exposed > 72 hours ago, call National Clinical Consultation Center at 1-888-448-4911.
If the source's rapid HIV test is negative, the employee can discontinue using the PEP (National Clinical Consultation Center, 2021).
The recommended PEP drug regimen is:
The risk of vertical transmission of HIV is high (National Clinical Consultation Center, 2021; Whiteley, 2019), breastfeeding can transmit HIV (National clinical Consultation Center, 2021), and the available information has shown that antiretroviral therapy during pregnancy is effective and safe (Hughes & Cu-Uvin, 2021; National Clinical Consultation Center, 2021; Rogers & Roberts, 2022). A pregnant employee who has been or may have been exposed to HIV should be evaluated and treated using the standard protocol that was previously described (National Clinical Consultation Center, 2021). Pregnant women prescribed antiretroviral therapy should be enrolled in the Antiretroviral Pregnancy Registry, www.apregistry.com (National Clinical Consultation Center, 2021). The Registry is intended to detect the teratogenic effects of antiretroviral drugs and pregnancy outcomes when used.
The recommended PEP for a pregnant employee after an HIV exposure is:
Breastfeeding is not contraindicated during antiretroviral therapy (National Clinical Consultation Center, 2021).
Post-Exposure Testing and Monitoring"
The National Clinical Consultation Center provides telephone consultation by physicians and other healthcare professionals for occupational and non-occupational exposures to bloodborne pathogens. The service is available from 9 a.m. to 8 p.m., eastern time, Monday through Friday, and 11 a.m. to 8 p.m., Saturday, Sunday, and holidays. The Center's website has detailed instructions for treating exposure to a bloodborne pathogen if the exposure happens outside of its operating hours. 1-888-448-4911.
Healthcare workers are continually at risk for exposure to HBV, HCV, and HIV. Needlestick injuries and other exposures are common. Although the transmission of a bloodborne pathogen is uncommon to rare, the consequences can be costly and emotionally and psychologically devastating.
Fortunately, HBV vaccination, engineering and workplace controls, Standard Precautions — hand hygiene, respiratory hygiene/cough etiquette, the use of PPE, and safe injection practices — can significantly reduce the risk of exposure to and transmission of bloodborne pathogens. Also, post-exposure treatment can effectively reduce the risk of developing HBV or HIV infection from occupational exposure to these pathogens.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.