Eye Splash Prevention Becoming Problem #1 For Infection Control - PowerPoint Presentation

1. Eye Splash PreventionBecoming Problem #1 For Infection ControlMelanie A Burton BSN RN CNOR MLSO

2. ObjectivesDescribe Eye-Related Infection RisksReview Prevailing Eyewear StandardsObtain New Clinical Data to Inform DecisionsDiscuss Reusable Eyewear Use HazardsObtain Risk-Reduction RecommendationsEnable Improved Best-Practice Processes

3. Key StakeholdersHealthcare staff that come into contact with bodily fluids, aerosol droplets, other potentially contaminated fluids…..As well as those who track contact incidents

4. The UpshotInfectious Pathogens Transfer Via ConjunctivaMany Exposures Avoidable, UnnecessaryProtocols, Products Make a Big Difference

5. Risk ModesBlood Borne Pathogen (BBP) Transmission Routes Include Mucous Membranes of the EyeSmall Amount Can Produce InfectionSplash, Aerosol, Contact Contamination Risks

6. Risk SettingDirect & Indirect ExposureWith & Without Apparent “Event”Known & Unknown Sources

7. What Can Happen?ConjunctivitisEye HerpesErythema/eye burnInfectionVirus/fluIllnessEven death

8. BackgroundMost clinicians make an effort to avoid needle stick injuries and contamination to their handsLess attention paid to potential of infection of eye splash exposureChemicals used during chemotherapy have been shown to burn the eyeInfectious pathogens, such as HIV, hepatitis B or C and viruses, can transfer through the mucous membranes of the eye

9. Direct Contact“73% of OR nurses and clinicians have, at some point in time, received direct contamination of the eye during the course of clinical care.”

10. Contamination SourcesOpen wound splash IV careTouching contaminated source

11. It Just Takes One Touch……Touching reusable PPE components during the course of care heightens the risk of contamination.

12. FDA MAUDE Events170 separate events were found using the general search term “eye splash” in the FDA MAUDE database

13. Unknown EventsStaff unaware of splash in 40% of instances leading to eyewear contamination during vascular procedures British Journal of Radiology

14. Unawareness LevelSurgeon performing lesion surgery unaware of splash 86% of the time…i.e., almost alwaysJournal of Plastic, Reconstructive & Aesthetic Surgery

15. Spit in the EYEA nurse contracted Hepatitis B via saliva in her eyeMedical Journal of Australia

16. Needle Stick…and a SplashTwo ICU doctors exposed to HIV removing a chest drain; one stuck by needle, the other splashed in eyeOccupational Medicine

17. Splash TransmissionTransmission of hepatitis C virus by blood splash into the conjunctiva; multiple cases, one involving a hemodialysis nurse American Journal of Infection Control

18. Aerosol TransmissionTrans ocular transmission of seasonal influenza attenuated virus aerosolsJournal of Infectious Diseases

19. Risk RealityRisk of Eye-Related Infection UnderratedReal Consequences, Possibly Life-ThreateningMost Healthcare Settings Put Staff at Risk

20. Review Prevailing Eyewear StandardsNo eyewear wornEyewear provided by Wearer, recommended by facilityEyewear provided by facilityPolicies and Procedures written regarding eyewearUniversal Protocols

21. OSHAFor the first time since 1990, the U. S. Occupational Safety and Health Administration is raising the monetary penalties for workplace violations, effective August 1, 2016.Maximum penalties will Increase 78%$7,000 maximum fine per violation climbing to $12,675Willful and repeat violation raising to $126,749Fines will be annually adjusted to keep pace with inflation

22. Eyewear ValueProtective Eyewear UndervaluedRegulatory Ambiguity PrevailsProduct use, Rx Failures Result

23. Regulatory AmbiguityNIOSH/CDC – Where workers “may be” at riskOSHA – When splashes, spray, spatter, droplets “may be” generated…and contamination can be “reasonably anticipated”WHO – Where splashes “may” occurAORN – When splashing or spraying is “likely,” if contamination “reasonable can be anticipated”AST – When splash injury “could occur”

24. Obtain New Clinical Data to Inform DecisionsEvaluate Current PracticesEvaluate Reusable verses Disposable

25. Research ObjectivesAssess True Risk LevelsInform Protocol DevelopmentReduce Infection Rates & RiskFurther Best Practices

26. Study MethodsDisposable & Reusable Eyewear Tested30-Day Data Collection PeriodResults Analyzed and ReportedMost of the cases (nearly 75%) from which eyewear was worn and tested did NOT involve power tools

27. Testing ProcessPieces Cultured in OR SuiteEntire Product Surface SwabbedSwabs Individually Bagged, Sent to LabSamples Cultured

28. Nearly HALF (approximately 45%) of all pieces tested cultured positive for contamination post use, whether staff was aware of the contamination or notContamination Rate

29. Nearly ALL (95%) of the reusable pieces tested positive for contamination post use, whereas about one-third of the disposable pieces tested positiveReusable Contamination

30. Reusable Bioburden

31. Findings RecapNearly HALF (45%) of all pieces tested cultured positive for contamination post use, whether one was aware of contamination or notNearly ALL (95%) of the REUSABLE pieces were contaminated post useMost (75%) of REUSABLE pieces STILL tested positive POST decontamination

32. Pathogens43.9% Coagulation Negative Staph.36.1% Gram Positive Cocci10.6% Bacillus spp.5.6% Diphtheroids3.5% Micrococcus

33. Translated RiskContamination Occurs Often Without Healthcare Worker KnowledgeHealthcare Workers Regularly and Unnecessarily Exposed to Infection Risk

34. Protective EyewearProtocols Need StrengtheningIncrease Compliance of Eyewear UseVariety of Product - Types, Designs, Materials Fits, Constructions

35. The Role of EyewearEyewear…If Properly Selected, Used, and Disposed of…Can Prevent InfectionEyewear…If NOT Properly Selected, Used, Disposed of, or Decontaminated…Can increase Cross – Contamination and Infection Risk

36. ReusablesReusable Eyewear or Eyewear with Reusable Components May Increase Infection RiskProduct Design & Construction FactorsInability to Entirely or Effectively DisinfectMore Likely to Carry Ongoing Bioburden

37. DisposablesDisposable Eyewear May Reduce RiskMust Be Readily Available and PrescribedMust Deliver Sufficient CoverageCannot be Reused Between CasesIdeally of Smooth Construction

38. Infection ProtocolsAll Protocols Should be Re-EvaluatedConditions for Eyewear Use, Access in ParticularReusable Eyewear Disinfection MethodsFurther Guidance Should Be Sought

39. Eye Splash CostEye Splash Recipient away from workLab costs for donor and recipientMedication CostsLong Term Care

40. HAI CostsOn a per-case basis, average infection care costs can range from $10,000 to $25,000.

41. Risk ReductionBest-Practice Policies, Procedures and Education Improved Protective Eyewear ComplianceIncreased Compliance-Enhancing Product UseQuality Disposable Products Reduce RiskImproved Reusable Disinfection Protocols Cut RiskImproved Clarity in Standards and Guidelines

42. Clinical FactsOcular Contamination Can Be DeadlyContamination Occurs Often, More Often Than Reported, and Often Goes UnnoticedProtective Eyewear Missing in Circumstances In Which Ocular Contamination May OccurReusable Protective Eyewear May Spread RiskDisposable Protective Eyewear May Reduce Risk

43. Bibliography1. Aisien A, Ujah I. Risk of blood splashes to masks and goggles during cesarean section. Medical Science Monitor : February 2006; 12(2): CR 94-972. Alani A, Modi C, Aimedghio S, Mackie I. The risks of splash injury when using power tools during orthopaedic surgery: a prospective study. Acta Orthopaedic Belgica: October 2008; 74 (5): 678-6823. Alayi Y, Alayi E. Prevalence of ocular injury and the use of protective eye wear among dental personnel in a teaching hospital, Nigerian Quarterly Journal of Hospital Medicine. April-June 2008; 18 (2): 83-864. American Society of Health System Pharmacists5. AORN 2017 Guidelines for Perioperative Practice 113-1146. Ando y, Iwaski T, Terao K, Nishimura H, Tamura S. Conjunctivitis following accidental exposure to influenza B virus/Shandong/7/97. Journal of Infection 2001; 42:223:47. AST Recommended Standards of Practice for Use of EYE Protection During Invasive Surgical Procedures, Association of Surgical Technologists8. Batty L, Holland-Elliot K, Rosenfeld D. Investigation of eye splash and needlestick incidents from an HIV positive donor on an intensive care unit using root cause analysis. Occupational Medicine (London) March 2003; 53 (2); 147-1509. Bischoff WE, Reid T, Russel GB, Peters TR. Transoccular entry of seasonal influenza –attenuated virus aerosols and the efficacy of n95 respirators, surgical masks and eye protections in humans. Journal of Infectious Disease, 15 July 2011: 204 (2): 193-199

44. 10. Birnie A, Thomas K, Varma S Should eye protection be worn during dermatological surgery: prospective observational study. Department of Dermatology, Queen’s Medical Centre, Nottingham, UK British Journal of Dermatology; June 2007;156(6): 1258-126211. Bouria D, Wirthlin R, Bouria N, Gupta A, Stanescu-Segall D, Schwartz S, Axer-Siegel R. Risk for Eye Splash Injury During Administration of Introcular Injections: A Study of Retina Specialists and Fellows, Retina June 2007; 27 (5); 609-61212. CDC Basic Infection Control and Prevention Plan for Outpatient Oncology Settings13. CDC Severe Acute Respiratory Syndrome FAQ’s14, Centers for Disease Control and Prevention. Fatal Cercopithecine Herpes virus 1 (B Virus) Infection Following Mucoctanous Exposure and Interim Recommendations for Worker Protection. MMWR Morbity Mortality Weekly 19988:47:1073-1076615. Collins D, Rice J, Nicholoson P, Barry K. Quantification of facial contamination with blood during orthopaedic procedures. Journal of Hospital Infection. 2000 May; 45(1); 73-7516. Davidson I, Crisp A, Hinwood D, Whitaker S, Gregson R. Eye Splashes during Invasive vascular procedures. British Journal of Radiology. January 1995; 68: 39-4117. Davies C, Khan M, Ghauri A, Ranaboldo C. Blood and Body Fluid Splashes During Surgery – The Need for Eye Protection and Masks. Annals Royal College of Surgery, England. 2007. November; 89(8): 770-77218. De Silva R, Mall A, Panieri E, Stupart D, Kahn D. Risk of blood splashes to eye during surgery. South African-Journal of Surgery, February 2009; 47 (1)19. Eberle J, Havermann J, Gurtler L G. HIV-1 Infection Transmitted by serum droplets into the eye: a casse report. AIDS, 28 January 2000; 14, (2); 20620. Fetal Laboratory Acquired Infection with an Attenuated Yersinia pestis Strain. Chicago, Illinois, 2009 CDC MMWR 2011:201-30521. Giachino A, Profitt A, Taine W. Contamination of the conjunctiva of the orthopaedic surgeon. J.B.JS., 70A, 126-127, 198822. Giachino A, Profitt A. Expected contamination of the orthopaedic surgeon’s conjunctiva. Canadian Journal of Surgery, 1988, 31 (1) 51-5223. Gioannini P, Sinicco A, Cariti G, Lucchini A, Paggi G, Giachino O. HIV infection acquired by a nurse. European Journal of Epidemiology. March 1988; 4(1) 119-120

45. 24. Helwig R. Western equine encephalomyelitis following accidental inoculation with chick embryo virus. JAMA 1940; 113:7; 291-29225. Hosoglu S, Celen M K, Akalin S, Geyik M F, Soyoral Y, Kara I H. Transmission of hepatitis C by blood splash into conjunctiva in a nurse. American Journal of Infection Control. December 2003: 502-50426. Ippolito G, Pura V, Pertrosilla N, De Carli, G Micheloni G, Magliano E, Simultaneous Infection with HIV and Hepatitis C Virus Following Occupational Conjunctival Blood Exposure, Letter to Editor, JAMA 1 July 1998; 280 (1)27. Lange, Victor R. CRC. Eyewear contamination levels in the operating room: Infection risk; American Journal of Infection Control 2013; 1-2128. Lewis F, Chernak E, Goldman E, et al, Ocular vaccinia infection in laboratory worker in Philadelphia 2004. Emerging infectious Disease January 2006; 12: 134-13729. Maharaj D, Lawton B, Garrett S. Poor compliance with standard precautions against infections during minor gynaecological procedures. Australian New Zealand Journal of Obstetrics and Gynecology. June 2012; 52 (3): 262-26530. Maxcy, K. The Transmission of Infection Through the Eye. Journal AMA March 1 191931, McWilliams R, Blanshard K. The risk of blood splash contamination during angiography. Clinical Radiology. January 1994; 49 (1): 59-6032. National Health and Medical Research Council, Australian Commission on Safety and Quality in Healthcare. Clinical Educators Guide for the Prevention and Control of Infection in Health Care 201033. Newton S. Handling Chemo Safely: Your Concern, too. Modern Medicine, May 1, 200234. NIOSH Alert – Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Health Care Setting 200435. Oncology Nursing Society Chemotherapy and Bjiotherapy Guidelines and Recommendations for Practice (2009) p 74-7536. OSHA Technical Manual, Section VI: Chapter 2. Controlling Occupational Exposure to Hazardous Drugs. National Study Commission on Cytotoxic Exposure37. Pedrosa P, Cardoa T. Viral Infections in workers in hospital and research laboratory settings: a comparative review of infections modes and respective biosafety aspects. International Journal of Infectious Disease, 2011; 15: 366-37638. Petrosillo N, Puro V, Jagger J, Ippolito G. The risks of occupational exposure and infection by human immunodeficiency virus, hepatitis B virus, and hepatitis C virus in the dialysis setting. American Journal of Infection Control, 1995 Oct; 23 (5): 278-85

46. 39. Pitto R, Caruso G. Criteri di Prevenzione Della Trasmissione Del Virus Dell Immumodeflecienza Acquisita Nella Practica Chirurgica Ortopedica. Giornale Italiano Di Ortopedia E Traumatologia, Supplemento Comunicazioni, Novembre 199140. Pitto R, Caruso G. La Contaminazione Congliuntivale in Chirurgia Ortopedica Gionale Itallano Di Ortopedia E Traumatologia, Supplemento Comunicazioni, Novembre 1991 41. Polovich M. Safe Handling of Hazardous Drugs. OJIN 2004. Vol 9, No 3. Too www.bu.cdc.gov/agent/smallpox/vaccination/slinevalClinical. Evaluatio tool for Smallpox Vaccine Adverse Reactions, Ophthalmologic Reaction/Eye Splash or Other Potential Exposure to Vaccinia Virus42. Ramos M F. Prevention of work related injuries, a look at eye protection use and suggested prevention strategies. Journal of Ophthalmic Nursing and Technology. May-June 1999; 18 (3): 117-11943. Reiss-Levy E, Wilson C, Hedges M, McCoughan G. Acute fulminating hepatitis B following a spit in the eye by a hepatitis B antigen negative carrier. Medical Journal of Austria 1994; 160: 524-52544. Rosen H R. Acquisition of hepatitis C by conjunctival splash. American Journal of Infection Control. 1997 June: 25 (3) 242-24745. Seto W, Tsanf D, Tsung R, Ching T, Ho L, Peiris J. Effectiveness of precautions against driplets and contact in prevention of nosocomial infection of severe acute respitatory syndrome (SARS) Lancet, 2003 May; 361: 15199-152046. Sharma J, Gupta A, Malhotra M, Arora R. Facial and body blood contamination in major gynecologic surgeries. Journal of Obstretrics and Gynecological Research. December 2003; 29 (6) 402-40547. Sharma N, Singh D, Sobti A et al. Course and outcome of accidental sodium hydroxide ocular injury. American Journal of Ophthalmology, October 2012: 154 (4): 740-74948. Sheybani F, Naderi H, Mostafavi I, Khosravi N, Bojdi A. Naked Eyes: Occupational exposure to infectious materials by splashes at a teriary hospital. Journal of Environmental and Occupational Science. May 30, 201349. Tehrani H, Juma A, Lambe G, James M. The risk of eye splash in burn surgery. Burns, June 2009; 35(4): 587-58950. Tichenor J, Miller R, Wolf E. Risk of eye splash in obstetric procedures. American Journal Perinatology. September 1994; 11(5) 359-36151. World Health Organization (WHO) Check List – Strategy to protect health workers from infection with bloodborne viruses52. Wines M, Lamb A, Argyropoulous AN, Caviezel A, Gannicliffe C, Tolley D. Blood splash injury: an underestimated risk in endourology. Journal of Endourology, June 2008; 22(6): 1183-1187

47. Questions