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Since early last year the world has been abuzz with news of the 2009 influenza A (H1N1) virus. A major threat this flu season because of the lack of prior immunity to this new virus strain, H1N1 joins the ranks of other infectious diseases against which we must fortify ourselves and others. The health care community, especially, has a responsibility to protect its employees and patients, and to educate others on optimal infection control practices.
Many of these tactics follow the same advice offered by moms everywhere: wash your hands, turn away when you sneeze or cough, and stay at home in bed when you are sick. Channeling those home-cooked methods benefits both patients and health care workers alike.
H1N1 virus
H1N1, commonly known as the swine flu because of its perceived similarity to the flu that affects pigs, began spreading from person to person in April 2009. On June 11, 2009, Margaret Chan, MD, director-general of the World Health Organization, declared “the start of the 2009 influenza pandemic.”
According to the Occupational Safety and Health Administration (OSHA), the H1N1 virus currently is not more severe than the seasonal flu. Still, the health care community needs to be prepared for a range of situations. If H1N1 mutates into a more severe disease, OSHA said, health care facilities may experience more infected patients and may become short-staffed.
Lieutenant commander John Halpin, MD, MPH, at the Centers for Disease Control and Prevention (CDC), emphasized that, although this year a novel influenza virus is circulating among the season’s flu strains, the same responsibility to practice high-quality infection control in health care settings applies, as it has every year. The level of concern does not need to be any higher than it always should be for seasonal flu, he said, because the transmission characteristics and virulence of this new strain are similar.
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“The important difference, however, is that people generally have no prior immunity to this new strain of influenza, so there are some differences to how we recommend the approach to infection control this year,” Halpin, medical epidemiologist at The National Institute for Occupational Safety and Health (NIOSH) Emergency Preparedness and Response Office of the CDC, said. “This includes the need for two different influenza vaccinations, both the H1N1 vaccine and the seasonal flu vaccine, as well as some changes to the type of personal protective equipment recommended for health care workers interacting with influenza patients.”
He stressed that vaccination is the first step to prevention, and is particularly important for health care workers, because of exposures that may occur at home as well as in the workplace.
Health threats
Aside from the cold or flu you can catch from anyone close enough to sneeze on you, members of the O&P community must worry about the more menacing illnesses that emerge in health care settings.
Health care workers are exposed to a wide-range of other issues that can threaten their health, such as injuries from patient lifting and handling, and contact dermatitis from cleaning solutions, gloves and equipment, a spokesperson for OSHA told O&P Business News. In addition to these threats, health care workers also have an increased risk of exposure to infectious diseases like methicillin-resistant Staphylococcus aureus (MRSA) and tuberculosis and bloodborne pathogens. Bloodborne pathogens are disease-producing organisms inside the blood — including malaria, syphilis, hepatitis B, hepatitis C and human immunodeficiency virus (HIV) — that spread through contact with infected blood.
O&P professionals are in constant physical contact with their patients — an occupational hazard, but necessary when taking impressions of residual limbs or determining firmness of tissue.
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“We’re what I call a touchy-feely profession,” John F. Schulte, CPO, FAAOP, clinical educator at the Fillauer Companies, said. “As a field, we just don’t consistantly follow the personal protective equipment rules. Some dentists now look like they’re getting ready to go on the space station. The same thing is true in the operative suite. The rest of the medical profession really does protect themselves, but we’re lacking in that area now.”
Disease spread
Practitioners must be cautious when treating all patients, but especially patients with open wounds or newly amputated limbs. Practitioners should take the appropriate infection control precautions, including using gloves and gowns as necessary, OSHA said.
Another issue is the disposal of medical dressings, like those covering open draining wounds, for example. When fitting or casting patients with these issues, practitioners should be sure to properly dispose of the dressings as biohazard waste by sealing them in a red biohazard bag or container. Practitioners can check with nearby hospitals or physician’s offices that employ medical waste disposal services to determine an appropriate drop-off point.
Diabetic patients might leave behind this type of waste with their insulin needles, which must be deposited into a sharps container and disposed of in the same manner as other biohazard waste.
Dangerous infectious particles also can be spread through unlikely sources during O&P treatment. Pre-worn orthotic and prosthetic devices, with the O&P practitioner for repair or modifications, are one such breeding ground.
“Heat relieving, sanding or grinding on these devices sends particles throughout the entire office, including dressing and exam rooms, billing and counseling areas, and throughout the entire building via the HVAC system,” Schulte said.
Influenza and other communicable illnesses are spread through physical contact with mucus membranes like the nose and mouth, as well as through the air. Standing within 6 feet of a person with the H1N1 virus can transmit the virus through the air. The flu walks through the door of the health care workplace masked as a sick patient or a sick employee; it then becomes the responsibility of the workplace to prevent it from spreading further.
Protection plan
For this reason, every O&P practice must have in place a protection plan, as well as a strategy to implement it within the office. Although the responsibility ultimately falls to the business owner, that person may appoint a health and safety officer to enforce the plan.
“It is common sense, if you put yourself in that mind frame,” Schulte said.
Prior to treating any patient, practitioners should complete a thorough patient intake interview to determine any potential risks to the staff and other patients. This simple conversation will alert practitioners to potential dangers and illnesses, from the seasonal flu to HIV. Once any risks are determined, practitioners can decide the safest method of treatment for the patient and for themselves.
One of the most important aspects of the protection plan is personal protective equipment (PPE), such as proper gloves and appropriate respiratory protection — in this case, an N95 respirator.
Practitioners should be certain they obtain a NIOSH-certified N95, Halpin said.
The protection plan should contain information about how to properly sanitize exam rooms after each patient, including wiping down all hard surfaces like the top of the exam table, replacing exam table paper, and cleaning any hand tools that were used during the patient exam. If a practitioner inadvertently scratches a patient’s skin with a cast saw blade and then uses it for another patient without cleaning it, pathogens could spread from that patient to subsequent patients, Schulte said.
“The other thing that drives me crazy are plastic disposable tape measures,” he said. “They’re made to be disposable. When I teach and do presentations, I’ll find someone in the audience who has one in their pocket and take an alcohol wipe and run it down the tape measure, and show that it’s filthy. They use it for multiple patients.”
The protection plan should account for upkeep of first aid kits, a dust extraction unit to remove airborne bacteria, and replacements for HVAC filters.
Under circumstances where employees are sick, the practice’s health and safety officer should ensure they take sick leave from the office for the appropriate amount of time so as not to infect others. The CDC recommends that sick employees remain home from work for at least 24 hours past the time when their fever subsides, without the use of fever-reducing medication. In the case of the influenza virus, the fever usually lasts for 2 to 4 days; employees, then, should plan to be out of work for 3 to 5 days.
cAn outbreak in an O&P office, where a number of patients and employees become ill, demonstrates that somewhere along the line, the guidelines for infection control have not been optimal, Halpin said. The first thing to do in that situation is to review protection practices to see where there is a need for improvement.
Schulte pointed out that, while the program for facility accreditation requires that facility owners be aware of these issues, it does not, as of yet, require a protection plan for bloodborne pathogens.
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Hand hygiene
Proper hand hygiene is paramount in protecting yourself, your patients and your employees, and everyone else you might come into contact with, Schulte said. The risk of exposure to various diseases comes from contact with any number of hard and soft surfaces like pens, telephones, computer keyboards, desk surfaces, hand tools and door knobs. Aside from cold and flu germs that might be present on these surfaces, practitioners also risk the transfer of pests such as mites, commonly known as scabies. After touching patients or any of these other items, practitioners should lessen the danger of infection with thorough hand hygiene.
Proper hand washing consists of a vigorous scrub with soap and warm water for at least 30 seconds. Before coming into contact with a patient, practitioners should wear gloves, latex or nitrile, as a barrier between their skin and the patient’s. Schulte does not remove his gloves until after he has completed the visit and has shaken hands with the patient.
He also keeps hand sanitizing lotion in his lab coat.
“When I can’t [wash my hands], I’ll use the hand sanitizer. Then as soon as I’m able to get to a clean sink to wash up, I will,” he said.
Best care
The overriding message in the fight against these types of communicable diseases is to be aware of measures that will help protect your staff, your patients, your loved ones and yourself. From a predetermined protection plan implemented by the health care institution to deciding on an individual level to always wear protective gear when dealing with patients, there are many options available for infection control.
“During my 35-plus years involved in medicine and O&P, we paid little attention to infectious diseases, personal protective equipment, eye or respiratory protection,” Schulte said. “Today, there are multiple avenues to cause [exposure] to a multitude of serious and even career- or life-ending diseases. We need to be diligent in protecting ourselves, co-workers and the people charged with our care from these diseases and super bugs.”
His advice? Follow a bloodborne pathogens and PPE plan to the letter in order to keep your staff and office safe, and to offer the best care possible.
OSHA provides a place for people to turn when these needs are not met.
“Health care employers are required to provide a safe and healthful workplace for their employees,” a spokesperson for the organization said. “In facilities where workers aren’t being protected against hazards (e.g. when OSHA requirements are not in place), health care workers have the right to file a confidential complaint by calling the local OSHA office or online.” — by Stephanie Z. Pavlou
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