Patient and Employee Safety

Mary Kay Hobby

The importance of effective workplace safety cannot be understated. The safety of employees affects morale, attendance, and workmen’s compensation. Well-written policies and procedures play an imperative role in patient and employee safety. Policies help clarify and reinforce the standards expected of employees. Federal, state, and local organizations’ and agencies’ guidelines assure the occupational health and safety of the technologist and patients who visit the sleep center. The Occupational Safety and Health Administration (OSHA) is a division of the US Department of Labor. OSHA provides regulatory standards for workplace safety. These standards are intended to protect employers, employees, and patients in and around the work environment. Personal and environmental hazards that the sleep technologist may be subjected to should be addressed in the department policy and procedures manual. A Quality Improvement Plan is a formal documented action plan that targets areas of practice within an organization that will be the focus of safety and outcomes to obtain the highest quality of patient care. Quality assurance measures are then evaluated quarterly to track the effectiveness of the plan. The plan is adjusted appropriately to ensure that quality goals are being met. The American Academy of Sleep Medicine requires sleep centers to perform a safety risk analysis at a minimum every 5 years to identify and make a plan to lessen the risk of events such as falls, medical emergencies, or harassment allegations (1).

PERSONAL SAFETY/CHEMICALS

An aspect of personal safety in the sleep disorder clinic that may be neglected is a frequent exposure to fumes/odors from cleaning solutions and adhesive materials. Chemical exposure for health care workers is a possible threat at any sleep disorders center. Causes may include improperly used or maintained disinfectant solutions or sterilizing agents. OSHA requires manufacturers to provide safety information on chemical products in a uniform format to ensure safety and proper handling of the chemical products that are utilized in the workplace (2). Staff meetings discussing the hazards of chemicals and solutions used and, quick and easy access to safety data sheets (SDSs) are ways to educate workers about the potential dangers surrounding these compounds.

The SDS is not meant for consumers but is for employees who may be occupationally exposed to hazardous products or chemicals while in the working environment. The SDS is designed to provide workers with the proper procedures for handling, storing, and working with a particular substance. Basic supplies the sleep technologist uses during patient hookup procedures or cleaning equipment that require an SDS include the following:

Electroencephalography (EEG) conductive paste or cream
Disinfectant/cleaner concentrate
Germicidal deodorizing cleaner
Abrasive skin prep gel
Adhesive to secure electrodes
Alcohol prep pads
Diaphoretic skin prep

The OSHA Quick Card identifies the required format for SDS (3).

Section 1, Identification includes product identifier; manufacturer or distributor name, address, phone number; emergency phone number; recommended use; restrictions on use.

Section 2, Hazard(s) identification includes all hazards regarding the chemical; required label elements.

Section 3, Composition/information on ingredients includes information on chemical ingredients; trade secret claims.

Section 4, First aid measures include important symptoms/effects, acute, delayed; required treatment.

Section 5, Firefighting measures list suitable extinguishing techniques, equipment; chemical hazards from fire.

Section 6, Accidental release measures list emergency procedures; protective equipment; proper methods of containment and cleanup.

Section 7, Handling and storage lists precautions for safe handling and storage, including incompatibilities.

Section 8, Exposure controls/personal protection lists OSHA’s Permissible Exposure Limits; American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Values; and any other exposure limit used or recommended by the chemical manufacturer, importer, or employer preparing the SDS where available as well as appropriate engineering controls; personal protective equipment (PPE).

Section 9, Physical and chemical properties list the chemical’s characteristics.

Section 10, Stability and reactivity lists chemical stability and the possibility of hazardous reactions.

Section 11, Toxicologic information includes routes of exposure; related symptoms, acute and chronic effects; numerical measures of toxicity.

Section 12, Ecologic information

Section 13, Disposal considerations

Section 14, Transport information

Section 15, Regulatory information

Section 16, Other information, includes the date of preparation or last revision.

It is crucial to the safety of sleep technologists to have access to a SDS manual containing information concerning each chemical used in the sleep center. This reference should be available for employees at all times.

INFECTION CONTROL

Infection control should be an integral part of the health care facility’s objectives. It is the responsibility of each member of the health care team to ensure the use of proper techniques to eliminate the spread of infection (2). Cooperation from the organization’s administration, medical staff, and other health care personnel is necessary to maintain infection control standards. The following elements are necessary to attain appropriate infection control:

Coordination with other departments
Medical evaluations
Health and safety education
Immunization programs
Management of job-related illnesses and exposure to infectious diseases, including policies for work restrictions for infected or exposed personnel
Counseling services for personnel on infection risks related to employment
Maintenance and confidentiality of personnel health records (2)

According to the Centers for Disease Control and Prevention and OSHA, the use of “universal precautions” or “standard precautions” refers to an infection control system that assumes any direct contact with a patient, particularly with body fluids, has the potential for transmitting disease (4). Health care personnel are at risk for occupational exposure to blood-borne pathogens, including hepatitis B virus, hepatitis C virus, and HIV. Standard precautions are designed to reduce the risk of transmission of blood-borne pathogens and to reduce the risk of transmission of pathogens from moist body substances. Standard precautions apply to blood, secretions, excretions except sweat, and all other body fluids of patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. It is important to note that bodily fluids can be considered contaminated whether or not they contain visible blood, nonintact skin, or mucous membranes (5). Exposures occur through needle sticks or abrasions caused by contaminated sharp objects. Infection may occur through contact with mucous membranes of the eyes and mouth, skin, or the patient’s blood (6). Contact with any bodily fluid, regardless of quantity, is considered to be a potential source of infectious agents (5). Using appropriate barriers such as gloves, goggles, or gowns when contact with blood is expected can prevent many exposures. Remove gloves promptly after use and wash hands immediately to avoid the transfer of microorganisms (5). If exposure occurs, wash needlestick injuries and cuts with soap and water, flush splashes to the nose, mouth, or skin with water, and irrigate the eyes (6). Prompt reporting of exposures to the department that handles such
situations is essential, so that proper treatment can be initiated.

Handwashing must occur after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and any time contamination has occurred, to avoid transfer of microorganisms to other patients or environments (5). Handwashing is also essential before eating and after using the bathroom.

It is important for technologists to handle used patient care equipment in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other patients and environments. Adequate procedures should be in place and followed for routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces (7).

Cleaning and disinfecting reusable equipment in the sleep center is a safety standard that cannot be compromised. It is the responsibility of every staff member to prevent the spread of infection with proper handwashing and effective cleaning of reusable equipment. Consider utilizing central processing for sterilizing reusable patient care equipment. Some facilities opt for disposable equipment to minimize the cost of disinfecting agents and staff time. Electrodes, masks, and even respiratory inductance plethysmography belts come in a disposable variety.

OSHA defines decontamination as the use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal. Sterilization is the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores (8).

In 1968, Spaulding (9) devised an approach to disinfect and sterilize patient care items or equipment that is still used today. This approach classifies medical equipment into categories according to a degree of risk of infection involved in the use of the items. Spaulding (9) describes these categories as critical, semicritical, and noncritical. Positive airway pressure (PAP) masks and airflow sensors fall into the category of semicritical, meaning that they come in contact with mucous membranes or skin that is not intact (9). Semicritical items require high-level disinfection, in a separate cleaning area, with wet pasteurization or a chemical disinfectant (9). Today most accrediting bodies recommend single use PAP masks, tubing, humidifiers and headgear. If these items are cleaned there must be a method in place to track the number of times each item has been disinfected, and they must be discarded after they have been cleaned the maximum number of times indicated by the manufacturer. Reprocessing guidelines differ by manufacturer, by specific interface within manufacturers, and sometimes even for different parts of a CPAP mask-so this can be daunting to track and manage.

EEG electrodes and other sensors generally fall into the noncritical category (9). These items come in contact with skin but not with mucous membranes. Most non-critical reusable items may be disinfected where they are used and do not need to be transported to a central processing area. There is generally little risk of transmitting infectious agents to patients by means of noncritical items. A high-level disinfectant wipe should be used to clean most noncritical items (Table 28-1) (10).

PAP Mask Cleaning

According to the Spaulding criteria for medical device classification (9), PAP masks are considered semicritical medical equipment. Semicritical items contact mucous membranes or nonintact skin. Cleaning and disinfection requirements should adhere to those approved by the Food and Drug Administration (FDA) for each individual mask in order to ensure elimination of tuberculosis spores. Semicritical items minimally require high-level disinfection containing a tuberculocidal disinfectant. Glutaraldehyde, hydrogen peroxide, ortho-phthalaldehyde, and peracetic acid with hydrogen peroxide are FDA-approved semicritical method(s) of disinfection (i.e., Control III Elite, Cavicide, Sanizide Plus, and CIDEX OPA). Follow specific manufacturer’s recommendations. Consider using a timer to remind you when the equipment can be removed from the disinfecting agent to avoid excessive wear.

Sleep centers have also found pasteurizing to be a cost-effective way to clean and disinfect equipment. Pasteurization is a form of cleaning/high-level disinfecting of health care equipment using water temperatures of 160° to 170° F (71° to 77° C). This eliminates or reduces the use of expensive toxic chemicals and saves labor costs of staff handwashing supplies. Guidelines on sterilization processes vary from state to state and, in some cases, from facility to facility.

The sleep center may have a maintenance agreement with a mask manufacturer that allows the patient to take home the mask that was used in the sleep center during the titration study. The manufacturer then replaces that mask for the sleep center. Small replacement fees may apply.

Patient Room, Electrode, and Sensor Cleaning

Work surfaces, bed rails, EEG electrodes, thermal airflow sensors, head straps, snore microphones, and belts are considered noncritical medical equipment. Noncritical items come in contact with intact skin but not mucous membranes. In addition, surfaces in patient rooms and work surfaces must be decontaminated to avoid
transmission of infection. A low-level disinfectant such as isopropyl alcohol (70% to 90%), sodium hypochlorite (5.25% to 6.15%) diluted with water at 1:500, or a germicidal (i.e., Control III, Sani-Cloth HB wipe, Super Sani-Cloth wipe, and Sani-Cloth Plus) wipe may be used to decontaminate noncritical items (10).

Table 28-1 Disinfecting Chart

	Noncritical Spaulding Category	Semicritical Spaulding Category	Cleaning
EEG electrodes	X		Rinse with warm water. Soak in general disinfectant according to manufacturer’s directions after each patient use. Wipe lead wires using a cloth soaked in a solution of low-level disinfectant or wipe with a disinfectant towelette. Air dry prior to plugging into head box.
Snap electrodes	X		Wipe using a cloth soaked in a solution of low-level disinfectant or wipe with a disinfectant towelette.
Airflow sensors		X	Disposable airflow sensors are preferred. Wipe using a cloth with a high-level disinfecting agent or towelette that is not corrosive to metal or plastic. Air dry.
Belts	X		Disposable belts are preferred. Straps may be safely soaked in low-level disinfectant solution. Air dry.
			The wire-set may be wiped with disinfecting cloth or towelette. Do not immerse in liquid.
Body position sensor	X		Wipe using a cloth with a low-level disinfecting agent or towelette that is not corrosive to metal or plastic. Do not immerse in liquid. Air dry.
Snore microphone	X		Wipe using a cloth with a disinfecting agent or towelette that is not corrosive to metal or plastic. Do not immerse in liquid. Air dry.
SpO₂ sensor	X		Disposable sensors are preferred. Remove disposable adhesive from permanent sensors and discard; wipe with a low-level disinfecting agent or towelette that is not corrosive to metal or plastic. Do not immerse in liquid. Air dry.
Headgear	X		Should not be re-used. Single patient use headgear is preferred.
CPAP masks		X	Single-patient use CPAP masks are preferred. If re-used soak in a high-level disinfectant according to disinfectant manufacturer’s guidelines or pasteurize. Rinse and dry thoroughly.
Linen	X		Blanket, sheets, and pillowcases must be washed between patients. Contaminated linens should be placed in impermeable bags.
Rutala, W. A., & Weber, D. J. (2008). MPH and the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Disinfection and Sterilization in Healthcare Facilities. Centers for Disease Control, ©US Department of Health and Human Services. Retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdf

Proper handling and cleaning of sensors will prolong their durability and longevity. All equipment and sensors, masks, and belts coming into contact with the patient are considered contaminated. The sleep center must maintain a separation of “clean” and “dirty” equipment by keeping clean and dirty equipment in distinct areas designated as clean and dirty, respectively. All dirty equipment must be cleaned and disinfected after each use according to manufacturer guidelines. Single-use items must be discarded after each use.

Reusable equipment must be completely disassembled and thoroughly washed using an approved cleaning solution. OSHA requires staff to wear PPE such as gloves and goggles while cleaning equipment to reduce exposure to hazardous chemicals. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and processed appropriately (11). Personnel are more likely to comply with an infection
control program if they understand the rules and the importance of such rules. Personnel education is the key element of an effective infection control program.

MEDICAL WASTE

Medical waste generated by health care providers can pose a risk of disease transmission if not managed properly. Hazardous waste and discarded chemicals that are toxic, flammable, or corrosive can cause fires, explosions, and pollution of air, water, and land. Knowing how to identify and properly dispose of medical and other hazardous waste is critical. Hazardous waste is a serious safety and health problem that continues to endanger human and animal life and environmental quality (12). Unless hazardous waste is properly treated, stored, or disposed, it will continue to do great harm to all living things that come into contact with it now or in the future.

Because of the seriousness of the safety and health hazards related to hazardous waste operations, OSHA has issued regulations to protect workers and help them handle hazardous wastes safely and effectively (13).

Medical “sharps” is the term used to describe any needle or sharp object including glass. If not cared for properly, sharps have the ability to cause puncture wounds and/or lacerations that may create a point of entry for infectious agents. Infectious agents are any organisms that cause disease or an adverse health impact to humans (2). Take care to prevent injuries when using needles and other sharp devices before, during, and after procedures, when cleaning used devices, and when disposing of used needles. Never recap used needles. Place used disposable syringes and needles and other sharp items in appropriate puncture-resistant containers and dispose of as regulated medical waste. Patient disposal of syringes, such as syringes used for insulin injection, should be monitored to prevent needles in the patient room. Sharps or products contaminated with blood or body fluids that are disposed of in the health care setting should be placed in properly identified and labeled containers to be sent to the waste treatment center for decontamination.

PROPER LIFTING TECHNIQUES

Back injuries account for nearly 25% of occupational injuries. Not only are these injuries costly to the Worker’s Compensation program, but they also leave the worker prone to recurrent injury. Attention to posture, conditioning, and body mechanics are essential to maintaining a healthy back while on the job. Body mechanics refers to the way we use our body to accomplish a task (Table 28-2). Eighty percent of Americans will experience back pain some time in their lives. Of these, 90% are due to strain of back muscles, ligaments, or soft tissue. These conditions generally heal completely, but often recur if prevention strategies are not used (14). The National Institute of Occupational Safety and Health (NIOSH) has researched and developed a lifting equation taking into account such things as weight of the object lifted, distance of the hands above the floor, angle of the distance of the object from the core of the body at the beginning or end of the lift, and twisting of the legs, shoulders, or torso in assessing physical stress with unassisted two-handed lifting.

Table 28-2 Body Mechanics to Promote Back Injury Prevention

Do		Do Not
Bending	Stoop with bent knees	Bend at the back
Reaching	Use step stool	Stretch overhead
Pulling or pushing	Use entire body	Use arms only
Lifting	Stand close to object	Reach
	Bend at knees and hips	Bend or twist at the waist