OSHA PROGRAM. MANUAL for Medical Facilities

Transcription

1 OSHA PROGRAM MANUAL for Medical Facilities About the Author Sheila Dunn, DA, MT (ASCP), holds a doctoral degree in clinical laboratory science from the Catholic University of America in Washington, DC. She has helped thousands of outpatient medical facilities comply with federal regulations such as CLIA and OSHA through her presentations at a nationwide seminar series. She has written more than 150 articles about regulatory issues and healthcare delivery systems and serves as an advisor to numerous companies. 11I HCPro, Inc. 75 Sylvan Street, Suite A-101 Danvers, MA Tel: 800/ Fax: 800/ HCPro, Inc. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.

2 OSHA Program Manual for Medical Facilities is published by HCPro, Inc. Copyright 2011 HCPro, Inc. All rights reserved. Printed in the United States of America ISBN: part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center (978/ ). Please notify us immediately if you have received an unauthorized copy. HCPro, Inc., provides information resources for the healthcare industry. HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Sheila Dunn, DA, MT (ASCP), Author David A. LaHoda, Managing Editor Elizabeth Petersen, Special Projects Editor Emily Sheahan, Editorial Director Mike Mirabello, Senior Graphic Artist Matt Sharpe, Production Manager Jean St. Pierre, Senior Director of Operations Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, Inc. 75 Sylvan Street, Suite A-101 Danvers, MA Telephone: 800/ or 781/ Fax: 800/ customerservice@hcpro.com Visit HCPro online at: and 09/

3 OSHA PROGRAM MANUAL Contents Front Pocket OSHA Poster 3165: IT S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self-Adhesive Labels CD-ROM (MS Word for Windows 2000) with Master Record Forms (Tab 11) from this Manual for Customization. Introduction Page Important Information About the Use of This Program... i How to Customize This Program... ii What Is Included in This Program... vi TAB 1: What Is OSHA? A Quick Look at OSHA States with OSHA-Approved Plans OSHA Consultative Services Division OSHA s Jurisdiction OSHA s General Duty Clause Employee or Employer? Employers Responsibility Under OSHA Overview of OSHA Standards OSHA Inspections Employee Complaints If an On-site OSHA Inspection Occurs During the Inspection What OSHA Inspectors May Ask Employees The Typical OSHA Inspection The Closing Conference OSHA Sanctions Whistleblower Protection Students and Volunteers ix

4 Contents TAB 2: OSHA Program Administration Injury and Illness Prevention Plan Flowchart... Reverse Side of TOC Injury and Illness Prevention Plan Management Leadership and Employee Involvement Key Contacts for the OSHA Program Manual Location of the OSHA Program Manual Duties of the OSHA Safety Officer Accident/Incident Investigation & Reporting Procedure Definition of an Accident and/or Incident When to Investigate an Accident and/or Incident How to Document an Accident and/or Incident Recording Accidents or Injuries for OSHA Correcting Unsafe Conditions Recordkeeping Requirements Workplace Hazard Analysis Practical Ideas for Involving Employees Organizing OSHA Compliance Duties Weekly Facility Review Checklist (Form 4-A) Monthly Facility Review Checklist (Form 4-B) Annual Facility Review Checklist (Form 5) Annual OSHA Program Manual (Exposure Control Plan) Review Form (Form 3) TAB 3: General Facility Safety Keeping Employees Safe Important Phone Numbers & Contacts Emergency Phone List Fire Safety Automatic Sprinkler Systems Fire Alarms Fire Procedures: Immediate Actions Building Evacuation Fire Extinguishers Purchase the Right Extinguisher How Many Fire Extinguishers to Have & Where to Put Them How to Use a Fire Extinguisher: The PASS Technique When to Extinguish Fires with a Portable Fire Extinguisher When NOT to Extinguish Fires and to Evacuate Fire Extinguisher Inspections Fire Extinguisher Maintenance Fire Risks During Surgery Fire Drills Fire Extinguisher Supplement... Supplement x

5 Contents Electrical Safety Physical Characteristics of a Safe Medical Facility Automated External Defibrillators Air Quality Mold Mold Remediation Aisles Emergency Lighting Employee Dress Code Exits, Means of Egress Exit Doors Exit Signs Floors Lighting ise Portable Space Heaters Restricted Access Areas Sinks Storage Systems Failure Evacuation Plan Evacuation Procedures Methods for Carrying Patients During an Evacuation Evacuation Floor Plan Example Evacuation Floor Plan Emergency Preparedness Supplies Emergency Action Procedures Bioterrorism: Suspicious Letters or Packages What Is a Suspicious Package? Bomb Threat If You Discover a Bomb or a Suspicious Item Explosion Civil Disturbance Earthquake If a Tremor Occurs when You Are Inside After the Tremor Is Over Severe Weather Flood Hurricane Severe Thunderstorm or Tornado Warning Tornado Safety Tips Severe Thunderstorm or Tornado Watch Toxic External Atmosphere Violence Violence Prevention Plan Introduction Overview of Violence Prevention Plan Components xi

6 Contents Violence Prevention Plan; Part Violence Prevention Plan; Part More Sources for Prevention of Workplace Violence First Aid Crash Kit/Cart Components Drug-Free Workplace Program Service Animals Holiday Decorations Sample Checklist: Spot Check Your Facility s Holiday Decorations Safe Decorations and Displays Policy Slip, Trip, and Fall Prevention Contaminants on the Floor Poor Drainage: Pipes and Drains Indoor Walking Surface Irregularities Outdoor Walking Surface Irregularities Weather Conditions: Ice and Snow Inadequate Lighting Stairs and Handrails Stepstools and Ladders Tripping Hazards: Clutter, Including Loose Cords, Hoses, Wires, Medical Tubing Improper Use of Floor Mats and Runners TAB 4: Ergonomics in the Medical Workplace A Quick Look at Ergonomics Common Musculoskeletal Disorders Back Injuries Techniques to Reduce Injury Fatigue Repetitive Stress Injuries/Wrist Injuries Wrist and Hand Exercises Eye Strain Why Prevent CVS? Symptoms of CVS Other Suggestions for Relieving Eye Strain Selecting Equipment TAB 5: Bloodborne Pathogens Exposure Control Plan Exposure Control Plan Introduction Overview of Bloodborne Pathogens Standard Components A Quick Look at Occupational Exposure Industries Subject to the Bloodborne Pathogens Standard xii

7 Contents Key Provisions and Effective Dates Universal Precautions Other Potentially Infectious Materials (OPIM) Implementing Universal Precautions Bloodborne Pathogens Epidemiology of Bloodborne Pathogens Update on AIDS in the Workplace Transmission of Bloodborne Pathogens Exposure Determination Personnel Who Are Occupationally Exposed Exposure Prone Procedures Bloodborne Pathogens Exposure Determination List #1 (Form 8) Other Personnel Who Could Potentially Be Occupationally Exposed Bloodborne Pathogens Exposure Determination List #2 (Form 9) Employees Who Are t Occupationally Exposed Restricted Access Areas Engineering/Work Practice Controls Biohazard Labels Handwashing When to Wash Hands How to Wash Hands Artificial Nails Sharps Safety What to Look for in Safety Devices Sharps Evaluation Procedure Use of n-safe Sharps Phlebotomy Needles Sharps Containers Sharps Container Maintenance Sharps Container Disposal Procedure Biohazardous Waste (See Tab 8) Laundry Personal Protective Clothing & Equipment PPE Strategy Locations of PPE Gloves When to Wear Gloves How to Wear Gloves Latex Allergy Preventing Allergic Reactions Face Protection Body Protection Emergency Resuscitation Equipment When to Wear PPE Hepatitis B Vaccine Safety of the Hepatitis B Vaccine xiii

8 Contents Documenting Employee Hepatitis Vaccines Titering Employees after the Hepatitis B Vaccination How to Determine Employee Immunity Testing Employees Vaccinated before the Titer Requirement Types of Hepatitis B Tests Interpreting Hepatitis B Test Results New Employee Hepatitis B Virus Vaccination Flow Chart... Supplement Post-exposure Evaluation & Follow-up What Is an Exposure? What to Do after an Occupational Exposure Confidentiality of Post-exposure Procedures Employee Counseling/Precautions Occupational Exposure Management Resources Accident Report/Sharps Injury (Form 14) Post-exposure Checklist Post-exposure Medical Evaluation Declination Form (Form 18) Injection Safety Information for Providers Frequently Asked Questions: Injection Safety FAQs for Providers Overview Injection Procedures Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens... Supplement Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens (fingerstick, blood glucose sampling)... Supplement Bloodborne Pathogens Resources Bloodborne Pathogens Violations in Physician Practices TAB 6: TB/Infection Control Plan A Quick Look at TB TB Transmission Risk Factors for Developing Active TB TB Exposure Control Plan Policy Overview: How to Protect Staff from Contracting TB at Work TB Risk Assessment TB Risk Assessment Results Form (Form 21) Early Identification of Patients with Active TB Symptoms of TB Managing Patients with Suspected or Confirmed TB TB Isolation Procedures for Cough-Inducing & Aerosol-Generating Procedures xiv

9 Contents Respiratory Protection for Healthcare Workers: N-95 Respirators Seal Checking N-95 Respirators Employee TB Skin Testing (TST) Baseline Employee TST: The Two-Step Skin Test Two-Step TST Interpretation Interpreting the TST False Positive/False Negative TB Tests Workers Who Have Had BCG Vaccination Periodic Retesting of Employees Recording TST Results TST Record (Form 22) TST Declination (Form 23) Evaluation & Management of Healthcare Employees Exposed to TB Employees with Symptoms of TB Employees Who Have Been Exposed to a Known TB Patient Positive Employee Skin Tests & Skin Test Conversions TB Exposure Log (Form 24) Decontaminating Patient Care Area and Equipment Employee Training Pandemic Influenza Plan Pre-pandemic Influenza Planning Once a Pandemic Is Announced OSHA Enforcement for H1N1 Influenza Identifying Very High and High Exposure Risks Dealing with N95 Respirator Shortages Prioritize Your Facility s Use of N95 Respirators Documentation Pandemic Influenza Resources MRSA Prevention and Control MRSA Transmission Patient Precautions Hand Hygiene Contact Precautions Environmental Cleaning Infected Employees MRSA Resources Pertussis and Worker Vaccination Supplement: Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care... S1-S10 TAB 7: The Hazard Communication Standard A Quick Look at HazCom Determining Which Chemicals Are Hazardous Routes of Exposure to Hazardous Substances Material Safety Data Sheets xv

10 Contents Examples of Substances Requiring MSDS Substances t Requiring MSDS MSDS Flowchart Determination Information Required on MSDS How to Get MSDS Where to Keep MSDS Classification of Hazardous Substances Flammable & Combustible Liquids Storage of Hazardous Substances Hazardous Chemicals with Permissible Exposure Limits (PEL) Labeling Hazardous Substances NFPA Label System Safety Tips for Working with Hazardous Substances Hazardous Chemical Waste Packaging & Disposal Medications Security & Disposal Security for Prescription Drugs Security for Controlled Substances Disposal of Prescription Drugs Disposal of Hazardous Drugs Medical Consultation & Injury Evaluation HazCom Recordkeeping TAB 8: Decontamination A Quick Look at Decontamination Routine Housekeeping Procedures Decontaminating Work Surfaces Sample Housekeeping Schedule (Form 7) Spill Containment Plan Spill Cleanup Procedures Spills That Contain Broken Glass or Sharp Objects Chemical Spill Clean-up Procedures Chemical Exposure to Skin Mercury Spills Cytotoxic Drug Spill Clean-up Decontamination of Medical Instruments & Equipment When to Sterilize Precleaning Instruments Prior to High-Level Disinfection or Sterilization Sterilization Quality Checks for Sterilization High-Level Disinfecting Using Glutaraldehyde Glutaraldehyde Spills Sterilant Safety...Supplement xvi

11 Contents Sources for Chemical Air Monitoring Testing the Potency of Glutaraldehyde Disposing of Glutaraldehyde Cleaning Transvaginal and Transrectal Ultrasound Probes Disinfect Transvaginal and Transrectal Probes After Each Use Cleaning Ultrasound Transducers Decontaminating Vaginal Specula Keeping Employees Safe During Instrument Disinfection Decontaminating Semi-critical Patient Care Equipment Decontaminating n-critical Patient Care Equipment Decontaminating Personal Protective Equipment (PPE) Eyewashes Number & Placement of Eyewash Stations Eyewash Maintenance Waste Disposal Biomedical Waste Disposal Hazardous Waste Disposal Waste Handling & Storage TAB 9: Specialty Services About This Section Working Safely with Cytotoxic Drugs NIOSH Hazardous Drug List for Healthcare Effects of CD Exposure on Health Safe Work Practices Clothing Drug Preparation & Administration Sample List of Drugs that Should be Handled as Hazardous...Supplement Selecting Biological Safety Cabinets (BSC) Cleaning the Drug Preparation Area Caring for Patients Receiving CDs Waste Disposal Spill Clean-up Suggested Spill Kit Components CD Receiving CD Storage CD Transport Employee Training Employee Medical Surveillance Employee Exposure Gas Cylinder Safety Electrosurgical Safety (Laser, LEEPs) Safe Work Practices Surgical Safety General PPE Indications for Surgery Surgical Gowns xvii

12 Contents Surgical Gloves Face and Eye Protection Headwear Shoe Covers Surgical Drapes Safe Sharp Strategies for the Surgical Setting Scalpels Suture Needles Transferring Sharps Safely How to Use the Neutral Zone Tips for Minimally Invasive Surgeries Safety Techniques for Operating on Patients Infected with Known Bloodborne Pathogens Preventing Surgical Fires Laboratory Safety Laboratory Specimen Transport Radiation Safety Regulation of the Medical Use of Nuclear By-products The ALARA Principle Radiation Safety Guidelines for Personnel Radiation Safety Policies for the Facility Ionizing Radiation Exposure Limits Special Precautions for Pregnant Workers Low-level Radioactive Waste Disposal NRC tification, Reports, and Record NRC Resources and Publications Working Safely with Cryogenic Liquids Precautions for Handling Liquid Nitrogen Storing Liquid Nitrogen Personal Protective Equipment Liquid Nitrogen Disposal Steps to Take if There Is Accidental Exposure First Aid (cryogenic burns) First Aid (anoxia) Safe Vaccine Handling and Storage Waste Anesthetic Gases Where Exposures Occur Preventing Exposures Controls Medical Surveillance Recordkeeping More Information TAB 10: Employee Training A Quick Look at the Employee Training Program Training Format xviii

13 Contents Checklist for an Effective Safety Training Session Interactive Safety Training Exercises General Safety Fire Safety Bloodborne Pathogens Safety Chemical Safety TB Safety Annual Employee Retraining Bloodborne Pathogens Annual Training Contents Respiratory Protection Annual Training Contents Hazard Communication Annual Training Contents New Employee Orientation New Employee OSHA Orientation Checklist (Form 26) Sample Tests with Answer Keys OSHA Yearly Retraining: Sample Essay Test Questions (Form 28) OSHA Yearly Retraining: Sample Essay Test Answer Key OSHA Yearly Retraining: Sample Multiple Choice Test Questions (Form 29) OSHA Yearly Retraining: Sample Multiple Choice Test Answer Key OSHA Yearly Retraining: Sample True/False Test Questions (Form 30) OSHA Yearly Retraining: Sample True/False Test Answer Key Documenting Employee Training Annual Safety Training Record (Form 27) TAB 11: Master Record Forms General Equipment and Facility Records Safety Report...Form 1 Autoclave Log...Form 2 Eyewash Station Weekly Check Log...Form 2-A Annual OSHA Program (Exposure Control Plan) Review...Form 3 Weekly Facility Review Checklist...Form 4-A Monthly Facility Review Checklist...Form 4-B Annual Facility Review Checklist...Form 5 Fire Drill Evaluation Form...Form 5-A Employee Fire Drill Participation Sign-up Sheet...Form 5-B Risk Assessment for Workplace Violence...Form 6 Housekeeping Schedule...Form 7 Emergency Telephone List...Form 7-A Healthcare Facility Slip, Trip, and Fall Hazard Checklist...Form 7-B Bloodborne Pathogens Records Bloodborne Pathogens Exposure Determination List #1...Form 8 Bloodborne Pathogens Exposure Determination List #2...Form 9 Bloodborne Pathogens PPE Compliance Checklist...Form 9-A Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records...Form 9-B Safety Needle/Syringe Evaluation...Form 10 Phlebotomy Device Evaluation...Form 11 Generic Safety Device Evaluation...Form 12 xix

14 Contents Sharps Disposal Container Locations...Form 12-A Sharps Evaluation Results...Form 13 Exposure Prevention Checklist...Form 13-A Bloodborne Pathogens Employee Medical Records Accident Report/Sharps Injury...Form 14 Sharps Injury Log...Form 14-A HBV Vaccination Declination Form...Form 15 HBV Employee Vaccination Form...Form 16 Post-exposure Checklist...Form 17 Post-exposure Medical Evaluation Declination Form...Form 18 Source Patient Testing Consent Form...Form 18-A Hazard Communication Records Hazardous Substances List...Form 19 Sample MSDS Request Letter...Form 20 TB/Infection Control Records TB Risk Assessment Results Form...Form 21 TST Record...Form 22 TST Declination Form...Form 23 TB Exposure Log...Form 24 Influenza Vaccine Log...Form 25 Influenza Vaccine Declination Form (Seasonal and H1N1)...Form 25-A Checklist for Infection Prevention for Outpatient Settings...Form 25-B Training Records New Employee OSHA Orientation Checklist...Form 26 Annual Employee Training Record...Form 27 OSHA Yearly Retraining (Sample Essay Test)...Form 28 OSHA Yearly Retraining (Sample Multiple Choice Test)...Form 29 OSHA Yearly Retraining (Sample True/False Test)...Form 30 Respiratory Protection Training Record...Form 31 Checklist for Decreasing Surgical Fire Risks...Form 32 TAB 12: OSHA Regulations & Key Contacts OSHA Regulations Bloodborne Pathogens Standard Amended Bloodborne Pathogens Standard (Sharps Safety) Hazard Communication Standard Exit Routes, Emergency Action Plans, and Fire Prevention Plans Ionizing Radiation Table of Other OSHA Standards for Outpatient Medical Facilities Additional OSHA Resources Healthcare Worker Vaccination Recommendations (Revised 2011) Suggested Work Restrictions for Employees Key Contacts State OSHA Consultative Services Directory Directory of States with Approved OSHA Plans Acronyms used in the OSHA Program Manual xx

15 OSHA Program Manual for Medical Facilities a. Post signs at entrances with instructions to patients with symptoms of respiratory infection to: i. Cover their mouths/noses when coughing or sneezing ii. Use and dispose of tissues iii. Perform hand hygiene after hands have been in contact with respiratory secretions b. Provide tissues and no-touch receptacles for disposal of tissues c. Provide resources for performing hand hygiene in or near waiting areas d. Offer masks to coughing patients and other symptomatic persons upon entry to the facility e. Provide space and encourage persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care 2. Educate HCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection. Additional Considerations The majority of ambulatory care settings are not designed to implement all of the isolation practices and other Transmission-Based Precautions (e.g., Airborne Precautions for patients with suspected tuberculosis, measles or chicken pox) that are recommended for hospital settings. netheless, specific syndromes involving diagnostic uncertainty (e.g., diarrhea, febrile respiratory illness, febrile rash) are routinely encountered in ambulatory settings and deserve appropriate triage. Facilities should develop and implement systems for early detection and management of potentially infectious patients at initial points of entry to the facility. To the extent possible, this includes prompt placement of such patients into a single-patient room and a systematic approach to transfer when appropriate. When arranging for patient transfer, facilities should inform the transporting agency and the accepting facility of the suspected infection type. Additional information related to Transmission-Based Precautions (contact precautions, droplet precautions and airborne precautions) can be found in the 2007 Guideline for Isolation Precautions (available at: Recommendations regarding management of multidrug-resistant organisms can be found in the Guideline for the Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 available at: Checklist As a companion to the infection prevention guide for outpatient settings the CDC has developed a checklist to use with the guidance document. You can find the checklist in Tab 11, Form 25-B. A customizable Word version of the checklist on the CD accompanying the OSHA Program Manual (new purchasers) or on the OSHA Program Manual update page (current users) at 6-S-7

16 OSHA Program Manual for Medical Facilities The checklist consists of two sections, used to assess the following: Policies and procedures for safe care Personnel adherence through direct observation There are 12 areas of focus in the policies section and eight areas in the personnel and patient care observations section. Some sections of the checklist may not apply to all facilities, but if there are applicable sections that receive a answer: Correct the involved practice Appropriately educate healthcare personnel Determine why the correct practice was not being performed When using the checklist, you must also consider risks posed to patients by deficient practices. For example, unsafe injection practices can result in transmission of infection and should be halted immediately, according to the checklist. Identification of such lapses warrants immediate consultation with the state or local health department and appropriate notification and testing of potentially affected patients. Conclusions The recommendations described represent the absolute minimum infection prevention expec ta - tions for safe care in outpatient (ambulatory care) settings. This guidance is not all-encompassing. Facilities and HCP are encouraged to refer to the original source documents, which provide more detailed guidance and references for the information included in this document. Source Documents All evidence-based recommendations for prevention of healthcare-associated infections from CDC/HICPAC can be found at the following site: Guidelines available at this webpage include: General 2008 Guideline for Disinfection, and Sterilization in Healthcare Facilities Guidelines for Environmental Infection Control in Healthcare Facilities 6-S-8

17 OSHA Program Manual for Medical Facilities Guideline for Hand Hygiene in Healthcare Settings Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Guideline for the Prevention of Surgical Site Infection, Guidelines for the Prevention of Intravascular Catheter-Related Infections, Drug-resistant Organisms Management of Multi-drug Resistant Organisms in Healthcare Settings, Healthcare Personnel Influenza Vaccination of Health-Care Personnel, Guideline for Infection Control in Healthcare Personnel Specialized Settings Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients available at: Guidelines for Infection Control in Dental Health-Care Settings 2003 available at: Key Links for Additional Information CDC Website on Healthcare-associated infections: CDC Website on Hand Hygiene in Healthcare facilities: CDC Website on Injection Safety: CDC Website on Influenza: 6-S-9

18 OSHA Program Manual for Medical Facilities Burning eyes and conjunctivitis Hives Rash contact and/or allergic dermatitis Headaches Nausea Staining of the hands (brownish or tan) Before using glutaraldehyde, be sure employees follow these policies and procedures: 1. Have an MSDS on file and be sure all employees who use glutaraldehyde know the safety precautions to take. 2. Place a warning label that states the name of the chemical on the soaking container. 3. Rinse and clean instruments to be disinfected prior to soaking. This removes bacteria and viruses in device lubricants. 4. Those who rinse instruments must protect themselves from splashes and sprays by wearing gowns, gloves, and face protection. 5. Use in a well-ventilated area, with at least 10 air changes per hour. Cover the soaking container at all times when not inserting or removing objects. 6. After precleaning, rinsing, and drying instruments, precisely follow the manufacturer s instructions for high-level disinfection. 7. Carefully place precleaned instruments in the disinfectant, making sure they are totally immersed. Use a strainer basket if instruments have sharp edges. Adhere to the manufacturer s instructions for dilution and immersion time. 8. Wearing heavy-duty utility gloves, remove instruments from the solution. Rinse with water. Then, visually inspect prior to stocking for reuse or storage. Be vigilant about cleaning areas of the instruments that have serrations and crevices. Store in a clean, dry area. 9. Change solutions at intervals recommended by the manufacturer. See p Glutaraldehyde Spills All glutaraldehyde spills have the potential to create vapor concentrations that exceed recommended exposure limits, according to OSHA s Best Practices for the Safe Use of Glutaraldehyde in Health Care. Employers must create a suitable plan for handling glutaraldehyde spills. The plan should consider the physical characteristics of the area where glutaraldehyde is used (e.g., type and effectiveness of ventilation, room size, and temperature) as well as the quantity and concentration of the solution. Cleanup equipment and personal protective equipment (i.e., eye, hand, body, and respiratory protection) should be readily available. 8-12

19 OSHA Program Manual for Medical Facilities Whether a spill can be cleaned up safely without the use of neutralizing chemicals and/or a respirator will depend on the factors listed in the previous section. When vapor con cen - tra tions are unknown, air-supplied, atmosphere-supplying respirators are appropriate. OSHA s Best Practices divides glutaraldehyde spills into two categories: drips/splashes and large spills. Drips/splashes can be cleaned up by in-house personnel using the procedures listed on page 8-5. Large spills require either specially trained in-house personnel or hazmat professionals to take the following steps: Evacuate the area until the spill is cleaned up and declared safe. If responders are fit-tested for respirator use, don respirators. Contain the spill with spill pillows and booms if needed. Neutralize the spill with a commercial neutralizer or appropriate chemical agents such as sodium bisulfite or glycine. After removal of the spill, thoroughly rinse area and clean up supplies with water. Dispose of rinse water, disposable supplies, and absorbent mediums according to applicable regulations and the procedures outlined in the facility spill control plan. Sources for Chemical Air Monitoring Assay Technology 1070 East Meadow Circle Palo Alto, CA 800/ AirScan Environmental Technologies 291 Route 22, Suite 12 Lebanon, NJ / Healthcare Environments Montgomery Road, Suite 283 Cincinnati, OH / Testing the Potency of Glutaraldehyde OSHA does not address check strips to verify the potency. Follow manufacturer s instructions for the frequency of checking solutions, or routinely test solution for strength each day of use (or more frequently) using the appropriate chemical indicator and document the results of this testing. Discard the solution if the chemical indicator shows the concentration is less than the minimum effective concentration. Disposing of Glutaraldehyde According to both OSHA and the U.S. Environmental Protection Agency, glutaraldehyde solutions may be disposed of as ordinary domestic waste at the end of their use life. Wearing protective garments and face protection, carefully pour the used soaking solution down the drain and flush thoroughly with water. At concentrations of less than 10 ppm in water, glutaraldehyde is readily degraded by sewage systems. If your facility is on a septic system, do not discard used glutaraldehyde down the drain. Rinse empty quart and gallon containers before discarding. Do not reuse containers. 8-13

20 TAB 11: MASTER RECORD FORMS Contents General Equipment and Facility Records Form 1 Form 2 Form 2-A Form 3 Safety Report..... Use to document employee complaints; staff meeting minutes. Autoclave Log..... Use weekly or as indicated to record performance of biological indicator tests. Eyewash Station Weekly Check Log... Use weekly to record performance of emergency eyewash stations. Annual OSHA Program Manual Review... Use annually to document that this manual was reviewed and updated. Form 4-A Weekly Facility Review Checklist... Use weekly (optional form). Form 4-B Form 5 Form 5-A Form 5-B Form 6 Form 7 Monthly Facility Review Checklist... Use monthly (optional form). Annual Facility Review Checklist... Use annually. Fire Drill Evaluation Form... Use at least once per year. Employee Fire Drill Participation Sign-up Sheet... Use at least once per year. Risk Assessment for Workplace Violence Use initially and as needed. Housekeeping Schedule..... Use initially. Form 7-A Emergency Telephone List..... Use initially and as needed. Form 7-B Healthcare Facility Slip, Trip, and Fall Hazard Checklist...Use as needed. Bloodborne Pathogens Records Form 8 Form 9 Form 9-A Form 9-B Bloodborne Pathogens Exposure Determination List #1... Use initially and whenever new clinical staff is added. Bloodborne Pathogens Exposure Determination List # Use initially and whenever new clinical staff is added. Bloodborne Pathogens PPE Compliance Checklist..... Use initially and whenever new clinical staff is added. Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records. Use initially and whenever new clinical staff is added.

21 Contents Form 10 Form 11 Form 12 Safety Needle/Syringe Evaluation... Use initially and whenever new safety devices are under consideration. Phlebotomy Device Evaluation... Use initially and whenever new safety devices are under consideration. Generic Safety Device Evaluation... Use initially and whenever new safety devices are under consideration. Form 12-A Sharps Disposal Container Locations... Use periodically to monitor compliance for sharps disposal container locations. Form 13 Sharps Evaluation Results Form... Use initially and whenever new safety devices are under consideration. Form 13-A Exposure Prevention Checklist Use periodically to monitor compliance for sharps disposal container locations Bloodborne Pathogens Employee Medical Records Form 14 Form 15 Form 16 Form 17 Form 18 Accident Report/Sharps Injury Log... Use when an employee injury occurs, including sharps injuries and other bloodborne pathogens exposures. HBV Vaccination Declination Form... Use when an employee is given the hepatitis B vaccine or declines this vaccine. HBV Employee Vaccination Form...Use when an employee is given the hepatitis B vaccine or declines this vaccine. Post-exposure Checklist....Use to document that all required actions were taken after a sharps injury or employee exposure to bloodborne pathogens. Post-exposure Medical Evaluation Use to document a particular employee refusing post- Declination Form... exposure testing and treatment. Form 18-A Source Patient Testing Consent Form.. Use to obtain consent from a source patient after an exposure incident such as a needlestick. Hazard Communication Records Form 19 Form 20 Hazardous Substances List.... Use initially to list all hazardous chemicals in your facility and when a new hazardous chemical is introduced. MSDS Request Letter..... Use when a new hazardous chemical is intro duced to document attempts to procure an MSDS. TB/Infection Control Records Form 21 Form 22 Form 23 Form 24 TB Risk Assessment Results Form... Use annually. TST Record Use as indicated, based on your facility s risk assessment. TST Declination Form Use when an employee declines receiving a TB skin test. TB Exposure Log Use as indicated when employees are exposed to a known TB patient.

22 Contents Form 25 Influenza Vaccine Log Use annually to vaccinate all employees. Form 25-A Influenza Vaccine Declination Form... Use when an employee declines this vaccine. Form 25-B Checklist for Infection Prevention for Use initially and at least annually thereafter. Outpatient Settings... Training Records Form 26 Form 27 Form 28 Form 29 Form 30 Form 31 Form 32 New Employee OSHA Use to document initial OSHA training when new staff Orientation Checklist... members are added. Annual Employee Training Record... Use annually. OSHA Yearly Retraining (Sample Essay Test)..... Use annually. OSHA Yearly Retraining (Sample Multiple Choice Test)..... Use annually. OSHA Yearly Retraining (Sample True/False Test)..... Use annually. Respirator Protection Training Record... Use annually. Checklist for Decreasing Surgical Fire Risks... Use annually.

23 OSHA Program Manual for Medical Facilities CHECKLIST FOR INFECTION PREVENTION FOR OUTPATIENT SETTINGS Section I. Administrative Policies and Facility Practices 1. Facility Policies Written infection prevention policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards (te: Policies and procedures should be appropriate for the services provided by the facility and should extend beyond OSHA bloodborne pathogen training.) Infection prevention policies and procedures are reassessed at least annually or according to state or federal requirements Supplies necessary for adherence to Standard Precautions are readily available (te: This includes hand hygiene products, personal protective equipment, and injection equipment.) 2. General Infection Prevention Education and Training Healthcare personnel (HCP) receive job-specific training on infection prevention policies and procedures upon hire and at least annually or according to state or federal requirements (te: This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility.) Competency and compliance with job-specific infection prevention policies and procedures are documented both upon hire and through annual evaluations/assessments 3. Occupational Health HCP are trained on the OSHA Bloodborne Pathogens standard upon hire and at least annually The facility maintains a log of needlesticks, sharps injuries, and other employee exposure events Following an exposure event, post-exposure evaluation and follow-up, including prophylaxis as appropriate, are available at no cost to employees and are supervised by a licensed healthcare professional Hepatitis B vaccination is available at no cost to all employees who are at risk of occupational exposure Post-vaccination screening for protective levels of hepatitis B surface antibody is conducted after third vaccine dose is administered Practice Performed All HCP are offered annual influenza vaccination at no cost All HCP who have potential for exposure to tuberculosis (TB) are screened for TB upon hire and annually (if negative) If answer is, document plan for remediation Form 25-B

24 OSHA Program Manual for Medical Facilities (Infection Prevention Checklist, page 2 of 8) The facility has a respiratory protection program that details required worksite-specific procedures and elements for required respirator use Respiratory fit testing is provided at least annually to appropriate HCP Facility has written protocols for managing/preventing jobrelated and community-acquired infections or important exposures in HCP, including notification of appropriate infection prevention and occupational health personnel when applicable 4. Surveillance and Disease Reporting An updated list of diseases reportable to the public health authority is readily available to all personnel The facility can demonstrate compliance with mandatory reporting requirements for notifiable diseases, healthcareassociated infections, and for potential outbreaks 5. Hand Hygiene The facility provides supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) and ensures that they are readily accessible to HCP in patient care areas HCP are educated regarding appropriate indications for hand washing with soap and water versus hand rubbing with alcoholbased hand rub (te: Soap and water should be used when bare hands are visibly soiled [e.g., blood, body fluids] or after caring for a patient with known or suspected infectious diarrhea [e.g., Clostridium difficile or norovirus]. In all other situations, alcoholbased hand rub may be used.) The facility periodically monitors and records adherence to hand hygiene and provides feedback to personnel regarding their performance 6. Personal Protective Equipment (PPE) The facility has sufficient and appropriate PPE available and readily accessible to HCP HCP receive training on proper selection and use of PPE 7. Injection Safety Medication purchasing decisions at the facility reflect selec tion of vial sizes that most appropriately fit the procedure needs of the facility and limit need for sharing of multi-dose vials Injections are required to be prepared using aseptic tech nique in a clean area free from contamination or contact with blood, body fluids, or contaminated equipment Facility has policies and procedures to track HCP access to controlled substances to prevent narcotics theft/diversion Form 25-B

25 OSHA Program Manual for Medical Facilities (Infection Prevention Checklist, page 3 of 8) 8. Respiratory Hygiene/Cough Etiquette The facility has policies and procedures to contain respir atory secretions in persons who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing through the duration of the visit. Policies include: Posting signs at entrances (with instructions to patients with symptoms of respiratory infection to cover their mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions). Providing tissues and no-touch receptacles for disposal of tissues. Providing resources for performing hand hygiene in or near waiting areas. Offering face masks to coughing patients and other symptomatic persons upon entry to the facility. Providing space and encouraging persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care. The facility educates HCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection. 9. Environmental Cleaning Facility has written policies and procedures for routine cleaning and disinfection of environmental services, including identification of responsible personnel Environmental services staff receive job-specific training and competency validation at hire and when procedures/ policies change Training and equipment are available to ensure that HCP wear appropriate PPE to preclude exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection) Cleaning procedures are periodically monitored and assessed to ensure that they are consistently and correctly performed The facility has a policy/procedure for decontamination of spills of blood or other body fluids 10. Reprocessing of Reusable Instruments and Devices Facility has policies and procedures to ensure that reusable medical devices are cleaned and reprocessed appropriately prior to use on another patient (te: This includes clear delineation of responsibility among HCP.) Policies, procedures, and manufacturer reprocessing instructions for reusable medical devices used in the facility are available in the reprocessing area(s) Form 25-B

26 OSHA Program Manual for Medical Facilities (Infection Prevention Checklist, page 4 of 8) HCP responsible for reprocessing reusable medical devices are appropriately trained and competencies are regularly documented (at least annually and when new equipment is introduced) Training and equipment are available to ensure that HCP wear appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection) (te: The exact type of PPE depends on infectious or chemical agent and anticipated type of exposure.) The above basic information allows for a general assessment of policies and procedures related to reprocessing of reusable medical devices. Ambulatory facilities that are providing on-site sterilization or high-level disinfection of reusable medical equipment should refer to the more detailed checklists related to sterilization and high-level disinfection in separate sections of this document devoted to those issues. Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior to use (see Sterilization Section). Semi-critical items (e.g., endoscopes for upper endoscopy and colonoscopy, vaginal probes) are objects that contact mucous membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse (see High-level Disinfection Section). n-critical items (e.g., blood pressure cuffs) are objects that may come in contact with intact skin but not mucous membranes and should undergo cleaning and low- or intermediate-level disinfection depending on the nature and degree of contamination. Single-use devices (SUD) are labeled by the manufacturer for a single use and do not have reprocessing instructions. They may not be reprocessed for reuse except by entities that have complied with FDA regulatory requirements and have received FDA clearance to reprocess specific SUDs. te: Pre-cleaning must always be performed prior to sterilization and/or disinfection. 11. Sterilization of Reusable Instruments and Devices All reusable critical instruments and devices are sterilized prior to reuse Routine maintenance for sterilization equipment is per formed according to manufacturer instruction (confirm maintenance records are available) Policies and procedures are in place outlining facility re sponse (i.e., recall of device and risk assessment) in the event of a reprocessing error/failure 12. High-Level Disinfection of Reusable Instruments and Devices All reusable semi-critical items receive at least high-level disinfection prior to reuse The facility has a system in place to identify which instrument (e.g., endoscope) was used on a patient via a log for each procedure Routine maintenance for high-level disinfection equipment is performed according to manufacturer instruction; confirm maintenance records are available Practice Performed If answer is, document plan for remediation Source: Adapted with permission from the CDC s Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care. Form 25-B

27 OSHA Program Manual for Medical Facilities (Infection Prevention Checklist, page 5 of 8) Section II. Personnel and Patient-care Observations 1. Hand hygiene performed correctly: Before contact with the patient or their immediate care environment (even if gloves are worn) Before exiting the patient s care area after touching the patient or the patient s immediate environment (even if gloves are worn) Before performing an aseptic task (e.g., insertion of IV or preparing an injection) (even if gloves are worn) After contact with blood, body fluids, or contaminated surfaces (even if gloves are worn) When hands move from a contaminated body site to a clean body site during patient care (even if gloves are worn) 2. PPE is correctly used: PPE is removed and discarded prior to leaving the patient s room or care area Practice Performed Hand hygiene is performed immediately after removal of PPE Gloves: HCP wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated equipment HCP do not wear the same pair of gloves for the care of more than one patient HCP do not wash gloves for the purpose of reuse Gowns: HCP wear gowns to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated HCP do not wear the same gown for the care of more than one patient Facial protection: HCP wear mouth, nose, and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids HCP wear a face mask (e.g., surgical mask) when placing a catheter or injecting material into the epidural or subdural space (e.g., during myelogram, epidural, or spinal anesthesia) 3. Injection safety Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and cartridge devices such as insulin pens) The rubber septum on a medication vial is disinfected with alcohol prior to piercing Medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient If answer is, document plan for remediation Form 25-B