PLEASE NOTE: This online, read-only version of the Policy & Procedure is the OFFICIAL copy. 3/24/06 9:30 AM
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Subject: TUBERCULOSIS (TB) EXPOSURE CONTROL PLAN
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Effective Date: March, 2006Supersedes: July 2004
Approved By:Environment of Care Committee
Infection Control Committee
Medical Executive Committee
Author: Susan Davidson, M.D.
Maureen Spencer, M.Ed., R.N
Jeanine Shaughnessy, AP RN MSN
Eileen O’Donnell, RN BSN
Jane Kelly, RN BSN CRNA
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Responsibility
Employee Health, Infection Control, Human Resources, Vice Presidents, Directors, Department Managers, Coordinators, Facilities, Environment of Care Committee, and All employees who have patient contact.
Program Administration
New England Baptist Hospital (NEBH) maintains, reviews and updates the Exposure Control Plan (ECP) at least annually, and whenever necessary to reflect new or modified tasks, procedures and Facilities control that affect occupational exposure. The ECP is also updated to reflect new or revised employee positions with occupational exposure. The managers under the direction of Infection Control Coordinator will do this review. The Environment of Care Committee and the Infection Control Committee then review the plan.
A.Access to Plan
Employees and/or OSHA or NIOSH representatives may view the Exposure Control Plan in the NEBH Safety Manual located in every department of the hospital.
B.Employee Exposure Determination/Fit Testing
- All employees with job classifications, which have or may have occupational exposure to TB, are listed in the TB Category Employee list below. These employees are required to be tested/screened yearly (See Appendix A) according to Human Resource Policy #119. All employees are tested/screened on hire.
- Infection Control will identify employees who are required to wear respirators as part of their work functions. This identification will be based on job title, activities evaluation of exposures and relevant OSHA standards. This identification may be affected by changes in job process or standards and will be updated when such changes occur. Job Categories with * will have a medical evaluation and be fit-tested for an N-95 mask during their orientation period. Fit-testing for * Job Categories will be performed annually thereafter and on an as needed basis if there is any change in health status (eg, new onset or change in baseline cardiac or respiratory symptoms), difficulty wearing a respirator (eg, skin irritation, cardiac or respiratory symptoms, anxiety, claustrophobia); or major change in facial anatomy.
- Personnel in other Ancillary Departments, including but not limited to, Laboratory, Radiology, IV Therapy, Security, PT/OT, Case Management and Surgical Services staff will be medically evaluated for respirator use and fit-tested on an as needed bases.
TB CATEGORY EMPLOYEES
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PLEASE NOTE: This online, read-only version of the Policy & Procedure is the OFFICIAL copy. 3/24/06 9:30 AM
Patient Care Service
*Ambulatory Services
*Hospitalist
*ICU
*J4E, J4W
*J5E, J5W
*Nurse Manager (ACU, ICU only)
*Nursing Coordinator
*Registered Nurse (ACU, ICU only)
*Respiratory Therapist
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PLEASE NOTE: This online, read-only version of the Policy & Procedure is the OFFICIAL copy. 3/24/06 9:30 AM
C.Tasks and Procedures
1.Employees in the following job classifications have occupational exposure because of the nature of their jobs (i.e., direct patient contact): They are listed as TB category employees.
- NEBH Medical Associates,
- Patient Care Services including all department personnel listed
- Orthopedic personnel
2.Employees in the following job classifications may have exposure to TB when they are performing the listed tasks and procedures
JOB TITLE/DEPARTMENTTASKS/PROCEDURES
AdministrationEnter room of patient
AdmittingEnter room to interview
AmenitiesGreet/direct patients at front desk
Case ManagementEnter room to interview/plan care
Central TransportEnter room/transport of patients
Clinical FacilitiesEnter room to repair equipment
DietaryEnter room to interview patient
EEGEnter room to perform testing
Environmental ServicesEnter room to clean
Facilities/FacilitiesEnter room to maintain air handling,
plumbing, or equipment
LaboratoryEnter room to draw blood and/or perform other
laboratory procedures requiring close patient contact
Media ProductionEnter room to photograph/video patient
Non-invasive CardiovascularEnter room for cardiovascular services
PathologistPerforms autopsy
Pastoral CareEnter room to provide pastoral services
PharmacyEnter room to provide information
regarding medication
RadiologyEnter rooms and/or provides services
in radiology suite
Rehabilitation ServicesEnter room to provide rehab services
ResearchEnter room to interview patient regarding
research protocol
SecurityEnter room to provide security services
Spine CenterEnter room to provide services
TelecommunicationsDirect contact with patients at front desk
D.Employee Notification of TB Hazard
New England Baptist Hospital uses the following procedures to assure that all employees with job tasks that offer potential for occupational exposure are informed of the hazard and take proper precautions against exposure to TB.
- Nursing personnel will post signs at patient room doorway – so they are visible to all entering the anteroom.
Airborne Precautions Sign.
- Post Airborne Precautions sign in other service areas where procedures or services are being performed on an individual with suspected/confirmed infectious TB.
Service area personnel (e.g., Radiology, Operating Room) will post these signs.
3.Post Warning labels, which say “Contaminated Air – Respiratory Protection Required”, on all systems carrying air that may contain aerosolized M. Tuberculosis.
- On exhaust ducts and areas where occupational exposure to TB is expected.
- At all points where ducts are accessed prior to HEPA filter,
- At fans and
- At the discharge outlets of non-HEPA filtered direct discharge systems.
Facilities personnel will post these labels.
- Inform all outside contractors
The Director of Facilities or his designee will inform all outside contractors who provide temporary or contract employees who may incur occupational exposure. This allows the contractor to institute precautions to protect his/her employees. These contractors are informed of the TB hazard and the facility’s procedures for protecting them from exposure.
E.Exposure Incident Reporting
- NEBH will inform employees of exposure to a newly diagnosed TB patient.
2.All employees must immediatelyreport a knownexposure incident in or out of hospital to the Employee Health Department/Infection Control Department.
3.NEBH is responsible for investigating, evaluating and documenting the circumstances surrounding the exposure incident, and for instituting changes to prevent similar occurrences. The procedures used to investigate/evaluate exposure incidents at NEBH are located in the Infection Control Manual under Tuberculosis in the Employee Health Policy.
4.When a suspected case of TB is diagnosed in the hospital and this case has not been on Airborne Precautions, the risk of transmission to the exposed individual will be determined by the Epidemiologist, ID physician, Infection Control Coordinator.
- The Infection Control Coordinator will inform the appropriate Nurse Manager of the exposure source. The Nurse Manager will compile a list of exposed employees according to risk categories and submit it to the Infection Control Practitioner.
- The Infection Control Coordinator will contact ancillary department managers to compile a list of exposed employees according to risk categories.
- The Infection Control Coordinator will submit all lists to Employee Health. Employee Health will proceed with evaluation of employees.
F.Medical Follow-up
Refer to Infection Control Manual Employee Health Policy under Tuberculosis.
The evaluation tool given to the employee is in Appendix B.
G.Identification of Individuals with Suspected or Confirmed Infectious TB
1.If there is no other medical explanation,NEBH employees will suspect infectious TB and initiate Airborne precautionsin an individual with the following symptoms
a.A history of TB with an active respiratory process, i.e., abnormal chest x-ray, cough, etc., OR
b.A persistent cough lasting 3 or more weeks
AND 2 or more signs and symptoms of active infectious TB:
Bloody sputum
Night sweats
Weight loss
Fever
Anorexia
Upper lobe cavitating lesion on chest x-ray
Horse voice
Chest pain OR
c. A positive AFB smear OR
d. A positive culture for Mycobacterium tuberculosis.
If a question arises regarding TB infection status, the Infection Control Coordinator, Nursing Coordinator or the ID physician may be consulted.
- All employees will receive education about the signs and symptoms of infectious TB in orientation andyearly in Annual Review.
- NEBH utilizes the following procedures for early detection of individuals with suspected/confirmed infectious TB.
a.Assessment – Prior to Admission
The attending physician will assess patients for infectious pulmonary TB before scheduling admission, outpatient, radiological, laboratory or cardiopulmonary procedures.
When TB is suspected, physicians will inform admitting and other appropriate department(s) before admission/testing is undertaken.
Any procedure, which is not an emergency, should be delayed until the patient is no longer
infectious.
b.Assessment – Interdisciplinary
All patients will be assessed for symptoms of TB as part of the initial assessment. The assessment will include the signs and symptoms of infectious TB previously listed (in G.1.). If patient reveals signs and symptoms, refer questions to physician, Infection Control Practitioner or Infectious Disease Physician regarding the institution of Airborne precautions.
H.Procedures to Isolate and Manage Care
1.The following procedures are used to isolate individuals with Suspected or Confirmed infectious TB.
- Physician or Nursing staff will institute Airborne Precautions and:
Place Airborne Precaution sign outside the door
Patient will be placed in one of the designated negative pressure isolation rooms (room 519, 539 or ICU – Room 8)
- Both doors (the anteroom door and patient room door) are to be CLOSED except when entering or leaving the room. The room must be accessed through the anteroom.
- Doors are to be KEPT CLOSED for 4 hours after a patient leaves a negative pressure room. The room may be entered with an N95 Mask. The negative air pressure unit must stay in the room for the entire four hours after discharge.
- When room is not a negative pressure room such as OR or Radiology, the doors will be kept closed for 4 hours after patient leaves the room. Post the Airborne Precaution sign on the door.
- Patients required to leave the room for tests will be required to wear a surgical mask.
- When a negative pressure room is not immediately available:
The patient is given a surgical mask
The patient is placed in an area away from other patients.
The patient is instructed to cover all coughs and sneezes with a tissue and discard it into a small red bag.
Staff will obtain N-95 masks from General Stores and use these masks
Every effort will be made to place the patient in a negative pressure room as soon as possible. In no case will the delay exceed 5 hours.
Approved negative pressure rooms for Airborne Infection Isolation (AII) are:
Room 519
Room 539
ICU – Room 8
h.Visitor will be restricted to immediate family/significant other. They will be given NIOSH approved (N-95) masks, but fit testing will not be required.
2.Nursing staff will notify the Infection Control Coordinator and/or Nursing Coordinator of Airborne Precaution Patient(s).
- The Infection Control Coordinator or Nursing Coordinator will notify Facilities so that verification of room negative air pressure and labeling of air systems will be done.
- NEBH uses the following procedures to minimize the time an individual with suspected or confirmed infectious TB remains outside of an Airborne Precaution room or area.
The nursing floor will notify the receiving department of patient’s precaution status.
Diagnostic or therapeutic (Radiology or Operating Room) testing which requires the patient to leave the room will be scheduled only when absolutely necessary. Procedures will be scheduled at the end of the day and when fewer patients and personnel are in the area, whenever possible.
The patient will be promptly returned to his/her room as soon as procedure is finished.
- NEBH uses the following procedures to minimize employee exposure to tuberculosis:
- Respiratory Protection
- Employees will wear a NIOSH approved (N95) mask or Powered Air Purifying Respirator (PAPR), which has been properly fitted, while in the Airborne Precautionroom.
- Initial Fit Testing
Medical clearance is necessary before fit testing for Respirator use (See Appendix E)
Managers will determine the employees in each department to be screened
Listing of personnel who have been fitted is maintained by Employee Health Department. A written recommendation regarding the employee’s ability to use a respirator will be forwarded to the employee and his/her manager by the Employee Health Department. Annually, thereafter, fit testing is done by unit based representatives. Each department will keep a list of personnel who have been fit tested.
Fit testing will take place prior to respirator use (See Appendix F)
The Employee Health Providers, Respiratory Therapists, and Occupational Medicine do fit testing and designated personnel on each unit.
- N95 masks may be used for one (1) day or for one use then discarded. Mask must be discarded if it becomes wet, soiled or otherwise judged unusable.
- Fit check – To assure that a tight seal is obtained each time a mask is used, a fit check will be done.
3M Respirator
Cup both hands around respirator, cover as much as possible. Take care not to disturb position of respirator.
Exhale – If air leaks around edges and nose piece of respirator, readjust and repeat procedure.
- An Air Mate/Hepa 12 powered air respirator (PAPR) will be worn by anyone with a beard, anyone who fails fit testing with N95 mask, employees designated by medical clearance or any other personnel not fit tested with N95 mask (See Appendix C). There are four (4) portable respirators located in the Respiratory Therapy Department.
- Combining Tasks – Combine as many tasks as possible into one entry while continuing all necessary care andcontact with the patient.
- NEBH uses the following procedures, to minimize the number of workers entering Airborne Precaution rooms.
Primary nurse assigned to patient will answer requests by patient, when possible.
Nursing will bring food trays into patient rooms.
Dieticians, admitting clerks, case managers; etc. will do telephone interviews, whenever this is appropriate.
- NEBH utilizes the following procedures to delay transport or relocation within the facility until the individual is considered noninfectious.
Provide services in the patient’s room whenever feasible; for example, portable x-ray.
- NEBH will place a regular surgical mask on a patient with suspected or confirmed infectious TB when it is necessary to transport or relocate the individual.
- Communication of Airborne Precaution status to Central Transport by telephone and computer is done to assure transport TO and FROM a procedure in a timely fashion.
- Services that cannot be rendered in the patient’s room and are not elective, such as surgery or radiology procedures will be provided at a time when the least amount of patients and personnel are in the area; example, late in the day. The physician or primary nurse will prearrange these services with the receiving department.
- High-Hazard Procedures
Elective high-hazard procedures and surgery are delayed, when possible, until the patient is noninfectious
High-hazard procedures (where TB may be aerosolized) when performed on TB patients require special precautions to prevent-and minimize occupational exposure to infectious TB. The following high-hazard procedures are performed at this facility in an AFB isolation room, PACU, OR or ICU:
BronchoscopyIncentive Spirometry
SuctioningIntubation
Trach CareChest PT
Sputum collection
I.Facilities Controls Maintenance Schedules and Records
The maintenance schedule for ventilation in Airborne Precaution rooms is as follows:
- Daily – Negative pressure areas are qualitatively demonstrated by using smoke trails when room is being used for TB patient.
- Quarterly – preventive maintenance to assure negative pressure is maintained.
- After construction/renovation which involves modification of air ducts in negative pressure rooms
Facilities will inform Nurse Manager and Infection Control Coordinator if an air handling problem is discovered.
Facilities will provide reports of ventilation maintenance to Infection Control Committee.
J.Information and Training
Education will be provided to all personnel during:
1.Initial orientation
2.Annually at Safety review and
3.Whenever changes such as modification of task/procedures or initiation of new tasks/procedures which affect the employee’s occupational exposure
Content of Training will include:
- Explanation of the content of federalstandard
- Location of copy of regulatory text
- Epidemiology of TB including multi-drug resistant TB
- Potential for exposure at NEBH
- Signs and symptoms of TB
- Difference between TB infection and TB disease
- Possibility of re-infection
- Health conditions which increase employee risk, HIV, steroid therapy, immunosuppression, etc.
- Respiratory protection program
- Tasks that involve exposure
- Respirator information
- Medical surveillance program
- Procedure to follow for exposure
- Procedure to follow if employee develops TB
Training records will be maintained for 3 years in Human Resource Department.
K.Recordkeeping
Employee health will maintain a confidential record for each employee with TB exposure for 30 years. Record will include:
Name
SS#
Job classification
Copy of results of exam, testing, follow-up procedures.
Employee Health will maintain records of medical determination of respiratory fitness in the employee’s health record. All records will be maintained the length of employment plus thirty years.
L.Compliance Monitoring
It is the policy of NEBH that all employees and medical staff members will comply with the protective measures outlined in the TB Exposure Control Plan.
1.Department Manager Responsibility will:
a. Ensure that each new or transferred employee will have:
Orientation to TB Exposure Control Plan including Airborne Precautions
Instruction in the use of appropriate personal protective equipment (PPE)
Medical screening and fit testing for NIOSH approved (N-95) masks or PAPR prior to entering the room of a TB patient OR
Instruction in the use of Air Mate Hepa 12 powered air respirator for bearded personnel.
b. Review annually the exposure category of each job classification in the department.
c. Assess employee compliance in conjunction with the employee performance appraisal.