Report for Transportation and Public Works Committee June ...



|Recommendation: |

|That the June 8, 2005, Asset Management and Public Works Department|

|report 2005PWW078 be received for information. |

Report Summary

This report responds to questions related to the safeguarding of civic employees who handle harmful materials and to the City seeking designation as a World Health Organization (WHO) Safe Community.

Previous Council/Committee Action

At the February 1, 2005, Transportation and Public Works Committee meeting, the following motion was passed:

1. That the January 17, 2005, Asset Management and Public Works Department report 2005PWW016 be received for information.

2. That Administration prepare a report for the June 14, 2005, Transportation and Public Works Committee meeting on corporate efforts made to address workplace risks of handling improperly discarded waste materials (such as sharp objects, needles and bodily fluids), including:

a. Information on the protocols, policies and preventative measures in place to deal with workplace incidents of handling harmful materials;

b. The number of workplace incidents in the past five years, related to handling improperly discarded waste materials;

c. Costs associated with lost employee time due to those incidents;

d. Recommendations for more aggressive global strategies to deal with workplace risks of handling hazardous materials, including an educational component for the public and City employees.

3. That Administration prepare a report for the Transportation and Public Works Committee meeting, outlining requirements for the City of Edmonton to be designated a Safe Community by the World Health Organization.

Report

Protocols, Policies and Preventative Measures

• Procedures are in place to assist the City workforce to avoid needle stick injuries and to provide guidance for needle sticks or exposure to blood in their line of work. Examples are:

1. The Community Leisure Centres Infection Control Resource Manual that contains preventative measures extracted as Attachment #1.

2. The Waste Management Branch procedure for employees to follow should a needle stick injury occur (Attachment #2).

3. The Emergency Medical Services Branch’s use of a needle free injection method for patient care as a means to reduce potential injury to EMS workers.

• A list of operational policies, protocols and preventative measures currently used to safeguard city employees who handle hazardous materials while at work is included as Attachment #3. The special nature of the services performed by Emergency Medical Services and Fire Rescue Services require an Infection Control Program and dedicated support of an Infection Control Officer. Attachment #4 is the information specific to these services.

• These operational policies, protocols and preventative measures notwithstanding, the City’s Occupational Health & Safety Business Plan (OHSBP) is reviewed annually and revised as required by the Occupational Health and Safety Steering Committee. The Committee uses the Provincial Occupational Health and Safety Code and emerging issues to guide it. Needle sticks/sharps were among a number of items identified in 2004 as issues requiring further attention, and action has been taken in this regard as explained later on in this report.

Statistics on Workplace Incidents

• Following are corporate statistics related to needle stick injuries between January 1, 2000, and April 30, 2005. These data represent incidents that are reported by staff.

1. Overall, 42 or 0.55 percent of the total 7,658 injury incidents reported can be classified as needle stick injuries based upon the incident description.

2. AMPW reported five (one in Mobile Equipment Services Branch, one in Lands and Buildings Branch, three in Waste Management Branch).

3. Community Services reported 28 (two in Parkland Services Branch, six in Fire Rescue Services Branch, 20 in Emergency Medical Services Branch).

4. Edmonton Police Service reported nine.

• A breakdown of the 42 incidents follows:

- 'Near Miss' - an event which could have resulted in a work-related injury or illness had the circumstances been slightly different – accounted for one.

- 'No Treatment' - a minor injury or illness was incurred, but the worker did not receive any treatment – accounted for eight.

- 'First Aids'- minor injury or illness was incurred, and first aid was applied (wound dressing etc.) – accounted for three.

- 'Medical Aids'- an event in which medical attention is sought (emergency room, medicentre, trip to a family physician etc.) – accounted for 26.

- 'Lost Time' - an event in which an injury or illness was incurred, and the affected worker did not complete their next scheduled work shift – accounted for four, all from Edmonton Police Service.

Costs Associated with Lost Time

• There is no direct costing information readily available.

• An estimated cost incurred through the Health Care System for testing and treatment after a needle stick is $1,500 to $2,000, based on a negative outcome after one year.

Strategies

• The development of corporate infectious disease protocols is included in the 2005 workplan of the OHSBP. Completion is expected in the spring of 2006.

• In addition, the 2005 workplan of the OHSBP includes the development and delivery of the Safe Needle Disposal and Awareness Plan. This is described in Attachment #5 and is underway.

Safe Communities/World Health Organization

• The first step in receiving World Health Organization (WHO) designation is to become a Safe Community. Once a city or region has operated as a Safe Community for three years, it is eligible to seek WHO designation.

• Criteria for becoming a Safe Community are described in Attachment #6

• Edmonton is well positioned to transition to Safe Community status if funding were made available for a full- time position and promotional materials dedicated to this effort. If office space and administrative support were provided for this position, the budget need for one staff and promotional material could be limited to $100,000 annually for two to three years.

• In addition, Edmonton already has in place a network supportive of Safe Communities, including the Capital Region Health Authority, private businesses, Safer Cities, and Administration.

• A coordinator from Safe Communities is available to assist dedicated City staff to establish contact with key stakeholders, identify existing programs and determine areas of need, and begin development of a business plan (a requirement for Safe Communities designation).

• As information, Calgary City Council passed a proclamation in support of Safe Communities and allocated $200,000 in the first year to facilitate the development and implementation of Safer Calgary.

• At the time of application, the City of Calgary had 24 members on the Safer Calgary Board representing the areas of violence prevention, injury prevention, environment safety and urban safety, with participation from members representing aboriginal persons, persons with disability, elders, youth, children, women, gay and lesbian persons and persons of racial diversity.

• Also at the time of application to become a Safe Community, a City of Calgary Alderman was appointed to chair the organizing committee.

• A similar approach to Calgary - proclamation, chair occupied by Councillor and adequate funding - is desirable if Edmonton were to proceed towards Safe Community status.

Background Information Attached

1. Preventative measure

2. Needle Stick Injury Procedure

3. Protocols, policies and preventative measures

4. Emergency Medical Services and Fire Rescue Services Summary Report

5. Safe Needle Disposal Awareness Plan

6. Safe Communities Criteria

Others Approving this Report

• J. Tustian, General Manager, Corporate Services Department

• D. Kloster, General Manager, Community Services Department

• R. Millican, General Manager, Transportation and Streets Department

Universal Precautions

The concept of `universal precautions"(UP) was developed by the Centre for Disease Control (CDC) in the United States in 1987 to protect health care workers from blood born pathogens, specifically the Hepatitis B and Human Immunodeficiency viruses. This concept was accepted in the same year in Canada by the Laboratory Centre for Disease Control (LCDC), Health and Welfare Canada. "Universal precautions," as defined by CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodborne pathogens. Since medical history and examination cannot reliably identify all patients infected with HIV or other blood-borne pathogens, blood and body fluid precautions should be consistently used for ALL patients. This approach referred to as "universal blood and body-fluid precautions" or "universal precautions," should be used in the care of ALL patients, especially including those in emergency-care settings in which the risk of blood exposure is increased and the infection status of the patient is usually unknown.

Body Substance Isolation (BSI) was introduced in 1987. It is a strategy intended to prevent transmission of potential pathogens between patients using protective barriers and changing workplace design. BSI expands the principles of UP to all fluids. BSI replaces traditional isolation strategies with the exception of isolation for airborne infection.

Infection Control protocols are evolving as the knowledge and awareness of infection control issues increase and the need for better or more complete protocols becomes apparent. In 1994, the CDC put out a draft infectious disease isolation strategy entitled Standard Precautions. Standard Precautions has been proposed as a total system of isolation to replace UP, BSI and all other isolation strategies in the United States. Standard Precautions has not been widely accepted, UP is still the `industry standard. The LCDC m Canada does not endorse Standard Precautions at this time.

Universal precautions do not deal with infectious diseases e.g. meningitis, TB, hepatitis A that can be transmitted by the body fluids that are listed above. As well, the emergency service worker may not always be able to tell if blood is present in a body fluid. FOR THIS REASON, ALL BODY FLUIDS MUST BE CONSIDERED HAZARDOUS.

Body Fluids to Which Universal Precautions Apply

Universal precautions apply to blood and to other body fluids containing visible blood. Occupational transmission of HIV and HBV to health-care workers by blood is documented. Blood is the single most important source of HIV, HBV, and other bloodborne pathogens in the occupational setting. Infection control efforts for HIV, HBV, and other bloodborne pathogens must focus on preventing exposures to blood as well as on delivery of HBV immunization.

Universal precautions apply to semen and vaginal secretions. Although both of these fluids have been implicated in the sexual transmission of HIV and HBV, they have not been implicated in occupational transmission from patient to health-care worker.

Universal precautions also apply to cerebrospinal fluid (CSF)) (surrounds brain and spinal cord), synovial fluid (found inside joints), pleural fluid (found inside chest cavity but outside lung), peritoneal fluid (found `inside abdominal cavity), pericardial fluid (surrounds the heart), and amniotic fluid (surrounds fetus in the uterus). The risk of transmission of HIV and HBV from these fluids is unknown; epidemiologic studies in the health-care and community setting are currently inadequate to assess the potential risk to health-care workers from occupational exposures to them.

Body Fluids to Which Universal Precautions Do Not Apply

Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent.

Saliva of some persons infected with HBV has been shown to contain HBV-DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum. HBsAg-positive saliva has been shown to be infectious when injected into experimental animals and in human bite exposures. However, HBsAg-positive saliva has not been shown to be infectious when applied to oral mucous membranes in experimental primate studies or through contamination of musical instruments or cardiopulmonary resuscitation dummies used by HBV carriers.

Use of Protective Barriers

Protective barriers reduce the risk of exposure of the lifeguards skin or mucous membranes to potentially infective materials. For universal precautions, protective barriers reduce the risk of exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks, and protective eyewear, Gloves should reduce the incidence of contamination of hands, but they cannot prevent penetrating injuries due to needles or other sharp instruments. Masks and protective eyewear or face shields should reduce the incidence of contamination of mucous membranes of the mouth, nose, and eyes.

Universal precautions are intended to supplement rather than replace recommendations for routine infection control, such as handwashing and using gloves to prevent gross microbial contamination of hands. Because specifying the types of barriers needed for every possible situation is impractical, some judgment must be exercised.

Protective Barriers as Part of Universal Precautions

All staff should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure during contact with any patient's blood or body fluids that require universal precautions.

Gloves should be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids.

Gloves should be changed after contact with each patient.

Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands should be washed immediately after gloves are removed.

Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable.

Staff who has exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment until the condition resolves.

Pregnant health-care workers are not known to be at greater risk of contracting HIV infection than health-care workers who are not pregnant; however, if a health-care worker develops HIV infection during pregnancy, the infant is at risk of infection resulting from Perinatal transmission. Because of this risk, pregnant health-care workers should be especially familiar with and strictly adhere to precautions to minimize the risk of HIV transmission.

Why Are Needles Dangerous?

Hepatitis B and C is a concern for workers who may be exposed to blood, as in the case of a needlestick injury. After needles and syringes have been used, they can contain very small amounts of blood. If the blood came from an infected person, it may contain viruses, which can cause such diseases as Hepatitis B, Hepatitis C and AIDS (Acquired Immune Deficiency Syndrome). HIV is the virus responsible for the eventual development of AIDS. Since even small amounts of blood can contain these viruses, it is possible that a person could become infected following an injury with a used needle. To minimize the risk of exposure to infectious agents, blood and body fluids should all be considered potentially infected. Employees should be issued puncture resistant gloves and proper storage containers if they are likely to encounter used needles during the course of their workday.

Steps to Follow

1. Puncture or cuts should be allowed to bleed, then washed thoroughly, with soap and water. Blood splashes to eyes require immediate washing.

2. Contact your supervisor. Seek medical attention promptly. Go to the emergency department at either the University of Alberta (U of A) or Royal Alexandra Hospital (RAH). The doctor on duty will do a risk assessment, draw a blood sample, and decide whether to prescribe medication to you. (Ask that the results of testing also be sent to Dr. P. Sperka at Employee Health Services, City of Edmonton, 9th Floor Century Place, 9803-102A Avenue, Edmonton, AB T6J 3A3)

3. Depending on specific circumstances, blood should be drawn by the medical personnel for Hepatitis B surface antigen (HBsAG), Hepatitis B Antibody (HBs Ab), HIV and Hepatitis C.

4. If negative for the Hepatitis B Antibody (HBs Ab), a vaccination against Hepatitis B is usually recommended within 7 days of exposure, preferably within 24 hours. This vaccine is Hepatitis B immuniglobulin (HBIG) which is administered only at hospital emergency departments.

5. Persons receiving HBIG as a result of a needlestick exposure should start a course of Hepatitis B vaccine within one month of administration of HBIG. Hepatitis B vaccine is given at 0-1-6 month intervals.

6. Follow up blood testing for HIV, Hep B and Hep C is usually carried out at three-month intervals up to six months. This should be arranged through Employee Health Services at the City of Edmonton (Phone: 496-7850) or the individual's own physician.

7. Report all incidents of needlestick injuries, blood or body fluid exposures to the departmental safety unit.

8. For further information or post-exposure counseling please contact Employee Health Services at 496-7850. Our hours are Monday to Friday, 7:30 a.m. – 4:00 p.m.

G:/Hdalth/Needlestick/Needlestickprocedure Updated: May 17, 2005

The following Departments and Branches have operational policies, protocols and preventative measures in place to safeguard city employees who handle hazardous materials while at work.

Asset Management and Public Works

1. Drainage Services – Follow operational procedure “Handling, Storage and Disposal of Used Fluids and Solids that identifies “Sharps” as a potential hazard.

2. Land and Buildings

• Custodial Services – civic staff use “Procedure to Follow in the Case of Needle Stick Injury or Blood Exposure” and contracted staff are required, under contract, to follow safety program provisions under C.O.R. (Certificate of Recognition).

3. Mobile Equipment Services – existing policies and procedures under review.

4. Waste Management – Branch uses “Procedure to Follow in the Case of Needle Stick Injury or Blood Exposure” and procedure “Avoiding Sharps”. Continually work to improve Personal Protective Equipment.

Community Services

1. Parkland Services – conduct hazard assessments and use “Procedure to Follow in the Case of Needle Stick Injury or Blood Exposure”.

2. Recreation/Community Leisure Centres - Follow Infectious Control Resource Manual

3. Emergency Medical Services and Fire Rescue Services – Comprehensive Infection Control Program in place complete with dedicated Infection Control Officer.

Transportation and Streets

1. Roadways - use “Procedure to Follow in the Case of Needle Stick Injury or Blood Exposure” and Hypodermic Syringe Collection Procedure

2. Transit – Bus and LRT Inspectors follow “Guideline for the cleaning of Body Fluids on LRV Trains, Universal Precautions for Exposure to Potentially Infections Material, Handling Needles Safely and “Procedure to Follow in the Case of Needle Stick Injury or Blood Exposure” and receive information on immunizations for “Hepatitis B and Hepatitis B Vaccine”

Background

In the early 1990’s the federal government commenced hearings on issues related to the reduction of risk and prevention of exposure to infectious diseases in the line of duty for emergency response workers. In September 1994 a National Symposium on Risk Prevention of Infectious Diseases for Emergency Response Personnel was held in Ottawa. The consensus at this symposium was that a Notification Protocol following a potential infectious disease exposure “must be part of an overall occupational exposure management program”. The outcome of this symposium which included first responders from major Canadian agencies such as police, fire and emergency medical services was A National Consensus on Guidelines for Establishment of a Post-0Exposure Notification Protocol for Emergency Responders. (CCDR Vol 21-19; 15 October 1995).

These guidelines form the basis for the 1998 Alberta Emergency Services Post Exposure Notification Protocol developed by Alberta Health and Alberta Labour with extensive input from both ERD and EPS. A key component of this document is the role of the designated officer. It states that each Emergency Response organization will appoint a Designated Officer (DO) and describes the knowledge base expected of that DO and adds that education about occupational risks and how to use preventative measures is an important component of the DO role.

Both the Edmonton Police Service and Emergency Response Department have nurses designated as Infection Control Officers (ICO). These positions evolved from this Alberta Post Exposure Notification Protocol. The protocol recommends that each emergency response organization have a designated officer who is the key contact person in the organization for not only blood/body fluid exposures but also for direct contact with diseases such as meningoccocaemia and tuberculosis. The protocol outlines the content of the program which includes policies and procedures, appropriate personal protective equipment (PPE), education, pre exposure standards and education, immunization and post exposure follow-up.

To address this protocol in the large urban ERD and EPS the ICO position was created. A small part of the ICO responsibility is to be on 24/7 call to assist first responders through the occupational blood/body fluid exposure follow up process. Margaret McKenzie (ERD) and Diane Paltzat (EPS) are the DO’s for their respective groups. Their role is adapted from that outlined in the Alberta Protocol as initially assessing the exposure and facilitating the employee to the appropriate facility for treatment, liaising with the emergency physician regarding drug therapy, counsel on prevention of secondary spread and ensuring referral to an Infectious Disease physician when drug treatment has been started. The City of Edmonton Employee Health Services, as keepers of medical records on employees, receives the blood results to be put on the employees file; offers medical consultation from the Occupational physician if required and completes the 3 and 6 month follow up for employees.

Emergency Medical Services & Fire/Rescue

Policies and Protocols

In 1996 an Infection Control Manual was written which incorporates the Alberta document. In 1999 a protocol was developed with extensive consultation with Department of Emergency Medicine and Department of Infectious Diseases. A protocol was developed.

Changes within Capital Health, and reported inadequacy in the consultation process has caused a review of this protocol.

Attached please find the revised internal protocol as contained in the EMS and Fire/Rescue exposure packages. Appendix 1.

We also have a variety of SOP’s; SOG’s which refer to the use of the Personal Protective equipment provided by both departments. This equipment is extensive, available, based on the type of work done by each specialty and education on its use is continual.

Discussion has resumed with the Department of Emergency Medicine and the Department of Infectious Diseases not necessarily to change our protocol but to re acquaint both departments with our requirements and make any changes deemed necessary.

Number of Incidents 2000 – 2004

It is of note that of the 94 exposures to blood &/or body fluid reported from 2000 to 2004 inclusive, none were attributed to incidental needles or sharps in the community. All were associated with the provision of care in our normal business operation.

Attached please find Tables referring to numbers of exposures, types of exposures in EMS and where they occur. Appendix 2.

Fire/Rescue receives calls through Dispatch to pick up discarded needles in the community. These may be found in school grounds, city parks, hedges, etc.

Cursory reviews of that “Material Disposal” Code from CAD reveal needle/syringe pickup events as follows:

2003 – 110 events

2004 - 126 events

2005 – 10 events (up to February 28th)

No exposures were associated with any “Materials Disposal” events of this specificity.

Fire Prevention has a large role in the Safer Cities initiative related to Community needle disposal boxes. Fire Prevention checks on the number of needles in each box, empties them as necessary and prepares regular reports for the committee. Reference: Kate Gunn, Safer Cities Initiatives Coordinator, Visit edmonton.ca/SaferCities for their 2003 Annual Report

From June 2004 to April 2005 approximately 5500 needles have been collected from 11 boxes. No exposures have occurred as a result of this project.

Review of any incidents reported occurs at the monthly Fire/Rescue OH&S Committee meetings and the EMS Health & Support Services Committee meetings. Each incident is discussed and administrative, engineering or education controls changed or reinforced as deemed necessary.

Please contact Margaret McKenzie RN, BScN, CIC Emergency Response Infection Control Officer with any questions. (780) 944 5681.

SUPERINTENDENT/DISTRICT CHIEF Information

A. BLOOD or BODY FLUID EXPOSURE

TIME SENSITIVE – Requires IMMEDIATE Action

Blood &/or Body fluid exposures occur when:

• an employee has a needle stick

• cut by an object contaminated (or suspected to be contaminated) with blood &/or body fluid

• blood /body fluid comes in contact with mucous membrane (eyes, nose, mouth) or non intact skin.

The employee is to notify a supervisor immediately.

RECORD DETAILS of the exposure, including:

ERD Event #

Employees name; employee #; home phone number; DOB; Personal Health#

Source patients name; DOB; PH#

Any other relevant details

REPORT IMMEDIATELY to Infection Control Officer or Designate

CALL 944 5681 (24 hour PAGER # is recorded on message)

The Infection Control Officer will:

• assess the exposure

• counsel the employee

• communicate with the ER physician to ensure that source blood is collected if necessary

• arrange further consultation & follow up if required

For a KNOWN SOURCE exposure the employee is to:

• GO to EMERGENCY at the SAME HOSPITAL as the source (patient)

This facilitates follow up.

For an UNKNOWN SOURCE exposure (e.g: needle stick from sharps container), employee is to:

• GO to the NEAREST EMERGENCY Department

Employee is to take the Exposure Reporting Package to hospital and provide the Emergency staff with the Lab requisitions (yellow forms) in the package. These have information on them which facilitates effective follow up.

Note: Appropriate first aid should immediately be administered on scene as detailed in EXPOSED WORKER information of Exposure Reporting Package

The Emergency Physician or the Medical Officer of Health will be contacted by the ICO or designate if further assessment is required. If a consultation is required with Infectious Diseases, this may be arranged by either the Emergency Physician or the ICO.

Infection Control Officer will be notified of the results of the blood work by phone within 24 hours. ICO will then make arrangements with employee for the appropriate follow up.

Written results of the lab tests will be sent to the City of Edmonton Medical Services

Department for inclusion in employee’s file. Long-term follow up will be done by this

department or by employee’s own physician.

B. TUBERCULOSIS

Exposures to patients with suspected TB DO NOT REQUIRE IMMEDIATE NOTIFICATION

of the Infection Control Officer. Employees should notify their supervisor immediately.

Supervisor will record exposure details:

Employees: Name & payroll #; Event #

Source: Name; DOB; PH#; Address, etc

How the exposure occurred: Was the ERD member wearing Personal Protective Equipment?

Notify ICO of details: voice mail (944 5681)

e-mail: margaret.mckenzie@edmonton.ca

Subsequent follow up will be done by the Infection Control Officer or Designate.

If follow up is required it is NOT TIME SENSITIVE.

C. MENINGITIS

A significant exposure requires that the worker’s mucous membrane contact with the source patient’s respiratory, throat or nasal secretions. Health care workers are seldom at risk even when caring for infected patients as only intimate contact (mouth to mouth resuscitation and intubating or suctioning without wearing a mask) warrants prophylaxis (preventive medication).

If direct contact has occurred notify ICO immediately. Otherwise, record details and notify Infection Control Officer as above.

Complete Incident Investigation Data Collection Forms for all exposures and forward to the appropriate individuals – (Incident Reporting Packages in Station).

EXPOSED WORKER INFORMATION

A. BLOOD or BODY FLUID EXPOSURE

1. ASSESS:

• Was this a needle-stick, mucous membrane or non-intact skin exposure to any blood or body fluid?

• What type of fluid were you exposed to? Blood; saliva; saliva containing blood;

amniotic fluid etc.

• Check that your skin is intact: Look for nicks in the skin; hang nails; open rashes; abrasions; cracks or cuts in the skin.

2. IMMEDIATELY ADMINISTER APPROPRIATE FIRST AID:

remove blood/body fluid soaked clothing if the fluid has soaked through to the

skin and wash the area with soap and water or an antiseptic solution.

For percutaneous (needle-stick, cut or scratch ) exposure: force bleeding immediately at the site, then rinse & wash with water and soap or with an antiseptic solution.

e.g Betadine or Chlorhexidine swabs, Alcohol based hand rinse product

For mucosal exposure (eyes, or inside mouth/nose) flush the area thoroughly

Note: can use distilled water, IV solution, or saline solution

For cutaneous ( on skin) exposure, wash the exposed area thoroughly with soap and water or with an antiseptic solution or gel

Note: In the field, distilled water, IV or saline solution may be used for rinsing followed by thorough cleaning with the alcohol based hand gel

3. REPORT INCIDENT to SUPERVISOR IMMEDIATELY

4. SUPERVISOR NOTIFIES INFECTION CONTROL OFFICER (ICO)

or DESIGNATE for risk assessment to determine whether follow up procedures

( #5 & #6) are required.

CALL 944 5681 FOR THE ICO PAGER NUMBER (24 hours)

5. KNOWN SOURCE

• GO to EMERGENCY at the SAME HOSPITAL as the source (patient)

This facilitates follow up.

UNKNOWN SOURCE (e.g. needle stick from sharps container)

• GO to the NEAREST EMERGENCY Department.

6. Take the Exposure Reporting Package with you and provide the Emergency staff

with the Lab requisitions (yellow forms) in the package. These have information on

them which facilitates effective follow up.

7. The Emergency Physician or the Medical Officer of Health will be contacted by the

ICO or designate if further assessment is required. If a consultation is required with

Infectious Diseases, this may be arranged by either the Emergency Physician or the

ICO.

8. Infection Control Officer will be notified of the results of the blood work by

phone within 24 hours and will then make arrangements with you for the

appropriate follow up.

9. Written results of the lab tests will be sent to the City of Edmonton Medical Services Department for inclusion in your file. Long-term follow up will be done by this department or, if you wish, by your own physician.

B. TUBERCULOSIS

Exposures to patients with suspected TB DO NOT REQUIRE IMMEDIATE NOTIFICATION of the Infection Control Officer. Employees should notify their supervisor immediately.

Supervisor will record exposure details:

Employees: Name & payroll #; ERD Event #

Source: Name; DOB; PH#; Address, etc

How the exposure occurred: Was the ERD member wearing Personal Protective Equipment?

Notify ICO of details: voice mail (944 5681)

e-mail: margaret.mckenzie@edmonton.ca

Subsequent follow up will be done by the Infection Control Officer or Designate.

If follow up is required it is NOT time sensitive.

C. MENINGITIS

A significant exposure requires that the worker’s mucous membrane contact with the source patient’s respiratory, throat or nasal secretions. Health care workers are seldom at risk even when caring for infected patients as only intimate contact (mouth to mouth resuscitation and intubating or suctioning without wearing a mask) warrants prophylaxis (preventive medication).

If direct contact has occurred notify ICO immediately. Otherwise, record details and notify Infection Control Officer as above.

INFORMATION SHEET EMERGENCY RESPONDERS

EXPOSED TO BLOOD OR BODY FLUID (BBF)

Needle-sticks or other BBF exposures in the community can be a terrifying event. Overall, the risk of transmission of a blood-borne virus is very low. This information sheet will provide general information about the risks of transmission.

Risk of Infection

The average risk of HIV infection due to all types of percutaneous exposures to HIV-infected blood is 0.3%. That is, 99.7% of emergency responders who are exposed to HIV will not be infected, even if treatment is not provided. Risk factors for transmission include: (1) a deep injury, (2) visible blood on the device causing the injury, (3) a device previously placed in the source patient’s artery or vein (e.g.. a needle) or (4) the source patient is acute/early or end-stage AIDS.

The risk after mucous membrane and skin exposure to HIV-infected blood is estimated to be 0.1% and less than 0.1%, respectively.

Most exposures in the Capital Health Region involve source patients of unknown status who will prove to be HIV-negative when tested. The risk of HIV is almost zero in this situation.

The risk of Hepatitis B transmission from a chronic carrier (positive HBsAg) ranges from 10-30%. Fortunately, most emergency responders should have received Hepatitis B vaccine and are immune. For those who are not immune, Hepatitis B Immune Globulin is available to provide immediate protection; vaccination will be also be commenced to provide future protection.

The risk of Hepatitis C transmission is 2-3% in recent studies.

Hepatitis C is by far the most common blood-borne virus in our community. Unfortunately, nothing is currently available to reduce the risk of transmission of Hepatitis C. Immune Globulin has been used previously but does not provide protection and is not recommended.

Thus, the risk of transmission of a blood-borne virus following a Needle-stick from a patient having such a ‘virus is approximately 30% for Hepatitis B, 3% for Hepatitis C and 0.3% for HIV.

Symptoms of Disease

Some individuals infected with HIV or hepatitis experience a viral syndrome within a few weeks of exposure. Fever is frequent and symptoms may include headache, nausea, decreased appetite, and sore throat. Enlarged lymph nodes and rash may accompany the symptoms. Abdominal pain and jaundice may also occur with hepatitis. If you develop such symptoms within the first few weeks following exposure to blood or body fluid, do not panic. There are a variety of infections that can cause similar symptoms. You should contact your Family Doctor for assessment.

Precautions to Prevent Secondary Spread

Individuals who have had a significant exposure to blood or body fluids infected with HIV, Hepatitis B or Hepatitis C should use a condom when engaging in sexual intercourse and should refrain from open-mouth kissing until testing at 6 months post-exposure confirms lack of seroconversion Sharing of shaving instruments and toothbrushes should be avoided. Individuals should also refrain from any type of blood, tissue or organ donation. Breast feeding or becoming pregnant should also be avoided.

These recommendations are very conservative but are appropriate for emergency responders with definite exposure to a blood-borne virus. If the source patient is of unknown status or known to be negative but you are awaiting follow-up serology, it is difficult to provide definitive advice. Knowing that your risk of acquiring a blood-borne virus is very low, you and your partner will have to decide how much risk you are prepared to take while waiting for your follow-up blood tests.

If you have questions or would like to talk further about your exposure and risks, counseling is readily available.

Contact the Infection Control Officer at 944 5681

POST_EXPOSURE PROPHYLAXIS AGAINST HIV

(Preventive medication treatment)

Two (2) Drug Protocol

The drugs in this packet are offered to you because you have had an exposure to blood or other material which may contain Human Immunodeficiency Virus (HIV), the virus which causes AIDS. It is believed that your risk of becoming infected with HIV as a result of this exposure, which is already less than 1%, can be reduced even more by taking these drugs. The following guidelines will help you to take these drugs in the most effective manner and to recognize side effects which may occur. The drugs which you are being given are Zidovudine (AZT; Retrovir) and Lamivudine (3TC), however, there is a combination pill available.

1. Begin taking these drugs immediately.

2. Contact your Infection Control Officer.

3. Continue taking both drugs until you discuss your situation with the ICO or

your Doctor.

A full course following definite exposure to HIV is 4/weeks, however, if

information from the source patient and serological testing make it unlikely that you

have been exposed to HIV, the anti-retroviral drugs will be discontinued. You may

only get a 24/48 hour supply of drugs from the emergency physician to start

immediately until the source blood results are available.

4. Take these drugs according to the following schedule:

Zidovudine (AZT): Two (2) capsules (100 mg each) three (3) times a day.

(total 6/day). Side effects may be decreased if you take AZT with food.

Lamivudine (3TC): One (1) capsule (150 mg each) twice a day (total of 2/day).

3TC may be taken with food.

5. Following is a list of the most common side effects:

If you experience any of these, contact the Infection Control Officer or your doctor. In some cases you can keep taking the drugs. If more serious side effects occur, another regimen may be substituted.

Zidovudine: Most people have no side effects, but nausea, headache and fatigue are fairly common, especially during the first week or two. Nausea may be decreased by taking Zidovudine with food or an anti-nauseant such as Gravol. You may take small amounts of Tylenol, Aspirin or Ibuprofen for headache. These symptoms usually subside with time. Zidovudine also causes anemia and a low white blood cell count which will be monitored. A blood test will be performed to check for these after about two weeks of taking Zidovudine. Other side effects are rare but have included rash, agitation/insomnia, and rarely, pancreatitis.

6. Check with your doctor or pharmacist before taking any other medications to be sure they do not interact with AZT or 3TC.

IMPORTANT: You should be aware that we have relatively limited information about the effects of anti-retroviral drugs (aside from AZT) in the healthy Emergency Care Worker. As their use in this situation is new we have no information about possible long-term toxicity. The benefits of using these drugs to reduce transmission of HIV in the workplace must be weighed against the known risks and our incomplete knowledge of long-term effects.

Risk of Infection

The average risk of HIV infection following a needle-stick with HIV-infected blood

0.3%. That is, 99.7% of emergency responders who are exposed to HIV will not be infected, even if no drugs are taken. Features which increase transmission risk include:

(1) a deep injury, (2) visible blood on the device causing the injury, (3) a device previously placed in the source patient’s artery or vein (e.g.. a needle) or (4) the source patient acute/early or end stage AIDS.

The risk after mucous membrane or skin exposure to HIV infected blood is estimated to be 0.1% and less than 0.1%, respectively.

The risk of Hepatitis B transmission from a chronic carrier (positive HBsAg) ranges from 10-30%. Most emergency responders have received Hepatitis B vaccine and are immune. The risk of V Hepatitis C transmission is 2-10% (2-3% in recent studies). Hepatitis C is by far the most common blood-borne virus in our community.

Symptoms of Disease

Some individuals infected with HIV experience a viral syndrome within a few weeks of exposure. Fever is frequent and symptoms may include headache, nausea, decrease appetite, and sore throat. Enlarged lymph nodes and rash may accompany the symptoms. Similar clinical presentations are commonly due to other agents and are not cause panic. If you develop such symptoms, you should seek the opinion of the Infection Control Officer and/or your own doctor.

Precautions to Prevent Secondary Spread

Individuals who have had a significant exposure to blood or body fluids infected with HIV/ Hepatitis B or Hepatitis C are advised to use a condom when engaging in sexual intercourse and should refrain from open-mouth kissing until testing at 6 months post-exposure confirms lack of seroconversion. Sharing of shaving instruments and toothbrushes should be avoided. Individuals should also refrain from any type of blood, tissue or organ donation. Breast feeding or becoming pregnant should also be avoided.

If you have questions or would like to talk further about your exposure and risks, please call your Infection Control Officer 944 5681

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Plan Outline

• A corporate-wide education program to reduce the risk of needle stick injury to city employees is an initiative for 2005 under the City’s Occupational Health and Safety Business Plan.

• Employees find discarded needles in parks, streets, public buildings and during waste collection activities. While infection from a needle puncture has not been the cause of reported loss time among civic workers, the emotional health impact on workers who are stuck is high.

• The Safer Cities Initiative has developed a focused program to reduce the number of needles on Edmonton streets. The expertise and resources of the Safer Cities initiative will be applied to reduce the risk of needle sticks among city employees.

• Targeting City staff who come into contact with needle debris will better equip these staff to deal with needles. These staff could also serve as ambassadors to the community for safe needle disposal. The staff to whom this plan will be targeted include:

- Waste collectors (garbage and recycling), Employees at the Materials Recovery Facility (recycling plant) and Eco Station employees

- River Valley Rangers, other Community Services staff working in playgrounds and recreation programs, Recreation Facilities and Parkland Services staff

- Land and Buildings staff who provide maintenance services

- (Edmonton Police Service and ERD are not part of this initiative’s target audience but will be consulted as experts in the development of workshop materials)

• Workshops tailored to meet the needs of the department or branch will incorporate any existing procedures or unique circumstances.

• A series of articles will appear in City Link, fact sheets will be distributed to all directors and supervisors and a modified version of the Safe Needle Disposal Toolkit will be created for distribution at the workshops and on e-city.

• Other target audiences include the EFCL and 144 community leagues; community organizations such as Edmonton Neighbourhood Watch and Block Parents: and other parent groups that may want to address the issue of needles in their neighbourhood.

• Other related initiatives such as the Edmonton Police Service’s Needle Injury Prevention Program aimed at school children will be rolled together in a media relations program to avoid confusion among the public. These events will also be leveraged to increase awareness among city employees.

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