Medical Asepsis and the OSHA Standard

LEARNING OBJECTIVES	PROCEDURES
Microorganisms and Medical Asepsis
1. Define a microorganism and give examples of types of microorganisms. 2. Explain the difference between a nonpathogen and a pathogen. 3. Define medical asepsis. 4. List the six basic requirements for growth and multiplication of microorganisms. 5. Outline the infection process and cycle, including the following: Give examples of the means of entry of microorganisms into the body. Give examples of the means of transmission of microorganisms from one person to another. Give examples of the means of exit of microorganisms from the body. List and explain the protective mechanisms the body uses to prevent the entrance of microorganisms. 6. Explain the difference between resident flora and transient flora.	Handwashing.
7. State when each of the following is performed: handwashing, antiseptic handwashing, and alcohol-based hand rub. 8. Identify medical aseptic practices that should be followed in the medical office. 9. Explain how proper handwashing helps prevent the transmission of microorganisms.	Applying an alcohol-based hand rub.
10. List examples of when to wear clean disposable gloves.	Application and removal of clean disposable gloves.
OSHA Bloodborne Pathogens Standard
11. Explain the purpose of OSHA. 12. Describe the purpose of the Needlestick Safety and Prevention Act. 13. List and describe the elements that must be included in the OSHA exposure control plan. 14. Explain the purpose of each of the following OSHA requirements: labeling requirements and sharps injury log. 15. Define and give examples of each of the following: engineering controls, work practice controls, personal protective equipment, and housekeeping procedures. 16. Identify the guidelines for use of personal protective equipment.	Adhere to the OSHA Bloodborne Pathogens Standard.
Regulated Medical Waste
17. List examples of medical waste and explain how to discard each type of waste. 18. Explain how to handle and dispose of regulated medical waste.	Prepare regulated waste for pickup by an infectious waste service.
Bloodborne Diseases
19. Explain how hepatitis B and C are transmitted in the health care setting. 20. Describe postexposure prophylaxis for hepatitis B. 21. Explain what occurs when HIV gains entrance into the body.

Introduction to Medical Asepsis and the OSHA Standard

Medical asepsis and infection control are crucial in preventing the spread of disease. The medical assistant should always practice good medical aseptic techniques to provide a safe and healthy environment in the medical office. The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard is important for infection control. This standard is required by the federal government to reduce the exposure of health care employees to infectious diseases. This chapter presents a thorough discussion of medical asepsis, infection control, and the OSHA Bloodborne Pathogens Standard.

Microorganisms and Medical Asepsis

Microorganisms are tiny living plants or animals that cannot be seen with the naked eye, but instead must be viewed with the aid of a microscope. Common types of microorganisms include bacteria, viruses, protozoa, fungi, and animal parasites. Most microorganisms are harmless and do not cause disease. They are termed nonpathogens. Other microorganisms, known as pathogens, are harmful to the body and can cause disease.

In the medical office, practices must be employed to reduce the number and hinder the transmission of pathogenic microorganisms. These practices are known as medical asepsis. Medical asepsis means that an object or area is clean and free from infection. Nonpathogens would still be present on a clean or medically aseptic substance or surface, but all the pathogens would have been eliminated.

Growth Requirements for Microorganisms

For microorganisms to survive, certain growth requirements must be present in the environment, as follows:

1. Proper nutrition. Microorganisms that use inorganic or nonliving substances as sources of food are known as autotrophs. Microorganisms that use organic or living substances for food are known as heterotrophs.

2. Oxygen. Most microorganisms need oxygen to grow and multiply and are termed aerobes. Other microorganisms, known as anaerobes, grow best in the absence of oxygen.

3. Temperature. Each microorganism has a temperature at which it grows best, known as the optimum growth temperature. Most microorganisms grow best at 98.6° F (37° C), the human body temperature.

4. Darkness. Microorganisms grow best in darkness.

5. Moisture. Microorganisms need moisture for cell metabolism and to carry away wastes.

6. pH. Most microorganisms prefer a neutral pH. If the environment of the microorganisms becomes too acidic or too basic, they die.

If growth requirements are taken away from the environment of microorganisms, they are unable to survive. Eliminating these conditions is one way to reduce the growth and transmission of pathogens in the medical office.

Infection Process Cycle

For a pathogen to survive and produce disease, a continuous cycle must be followed; this is known as the infection process cycle (Figure 17-1). If the cycle is broken at any point, the pathogen dies. The medical assistant has a responsibility to help break this cycle in the medical office by practicing good techniques of medical asepsis. These techniques are discussed in the next section.

Protective Mechanisms of the Body

The body has protective mechanisms to help prevent the entrance of pathogens, and these help break the infection process cycle. Protective mechanisms of the body are as follows:

1. The skin is the body’s most important defense mechanism; it serves as a protective barrier against the entrance of microorganisms.

2. The mucous membranes of the body, which line the nose and throat and respiratory, gastrointestinal, and genital tracts, help protect the body from invasion by microorganisms.

3. Mucus and cilia in the nose and respiratory tract fight off pathogens. Mucus traps the smaller microorganisms that enter the body, and the hairlike cilia constantly beat toward the outside to remove them from the body.

4. Coughing and sneezing help force pathogens from the body.

5. Tears and sweat are secretions that aid in the removal of pathogens from the body.

6. Urine and vaginal secretions are acidic. Pathogens cannot grow in an acidic environment.

7. The stomach secretes hydrochloric acid, which helps in the process of digestion. This acidic environment discourages the growth of pathogens that enter the stomach.

Medical Asepsis in the Medical Office

Hand Hygiene

Hand hygiene refers to the process of cleansing or sanitizing the hands. Hand hygiene is considered the most important medical aseptic practice in the medical office for preventing the spread of infection. Specific techniques for sanitizing the hands in the medical office include the following:

• Handwashing with a detergent soap and water

• Handwashing with an antimicrobial soap and water

• Applying an alcohol-based hand rub

The Centers for Disease Control and Prevention (CDC) has issued new recommendations for hand hygiene in health care settings. The purpose of these guidelines is to promote improved hand hygiene practices and to reduce transmission of pathogenic microorganisms to patients and employees in health care settings. The CDC guidelines for hand hygiene as they apply to the medical office are outlined in Box 17-1. They are also discussed further in this section.

BOX 17-1

CDC Guidelines for Hand Hygiene in Health Care Settings

Wash Hands with a Detergent Soap or an Antimicrobial Soap

• When the hands are visibly soiled with dirt or body fluids (e.g., blood, feces, urine, respiratory secretions)

• Before eating

• After using the restroom

Apply an Alcohol-Based Hand Rub (or Wash Hands)

• Before having direct patient contact

• After contact with a patient’s intact skin (e.g., measuring pulse or blood pressure)

• Before applying and after removing gloves

• After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings as long as the hands are not visibly soiled

• When moving from a contaminated body site to a clean body site during patient care

• After contact with inanimate objects (e.g., medical equipment) when providing health care to a patient

General Recommendations

• Keep natural nail tips less than inch long. Avoid wearing artificial nails.

• Do not add soap to a partially empty liquid soap dispenser. The practice of “topping off” dispensers can lead to bacterial contamination of the soap. The correct procedure is either to dispose of an empty dispenser or to rinse an empty dispenser thoroughly and then refill it.

• Multiple-use cloth towels of the hanging or roll type are not recommended.

• Use hand lotions or creams to minimize the occurrence of dermatitis associated with frequent handwashing.

• Wear gloves if contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur.

• Change gloves during patient care if moving from a contaminated body site to a clean body site.

• Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient.

From Bonewit-West K: Clinical procedures for medical assistants, ed 8, St Louis, 2011, Saunders.

Resident and Transient Flora

Microorganisms on the hands are classified into the following categories: resident flora and transient flora. Resident flora (also known as normal flora) normally resides and grows in the epidermis and deeper layers of the skin known as the dermis. Resident flora is generally harmless and nonpathogenic. Because resident flora is attached to the deeper skin layers, it is difficult to remove from the skin.

Transient flora lives and grows on the superficial skin layers, or epidermis. It is picked up on the hands in the course of daily activities. In the medical office, this may include contact with an infected patient, contaminated equipment, or contaminated surfaces. Transient flora is often pathogenic, but because it is attached loosely to the skin, it can be removed easily with proper handwashing or by applying an alcohol-based hand rub.

Putting It All into Practice

My Name is Jennifer Hawk, and I work for a large group of physicians in a multispecialty clinic. I work in both the front and back areas of the office. I really enjoy experiencing all of these areas of the office, and I definitely never get bored.

The most interesting experience I have had as a practicing medical assistant is seeing the impact that I make in patients’ lives. They rely on you and look to you first for help in their health care situation. You are most often the first person they come into contact with in the office, and they look to you for understanding and empathy. Especially patients who come to your office on a regular basis see you as a kind of family member. They appreciate a familiar face and a smile. Most often, you are the individual giving patients instructions concerning testing they will be having done or medication they will be taking. Patients truly do count on your knowledge and assistance throughout their course of care. I was genuinely surprised at what an impact I could have on others.

Handwashing

Handwashing refers to washing the hands with a detergent soap and water. Detergent soap (commonly known as plain soap) contains agents that help break down and emulsify dirt and oil present on the skin. Soap is used to sanitize the hands through the physical removal of dirt and transient flora. It is important to use adequate friction during handwashing to ensure the removal of all transient flora. The CDC recommends that the hands be rubbed together for at least 15 seconds, making sure to cover all surfaces and to focus on the fingertips and fingernails. Procedure 17-1 outlines the handwashing procedure.

Procedure 17-1 Handwashing

1. Procedural Step. Remove your watch or push it up on the forearm so that the wrist is clear. Avoid wearing rings. If you wear rings, remove all except a plain wedding band and put them in a safe place.

Principle. Microorganisms can lodge in the crevices and grooves of rings.

2. Procedural Step. Stand at the sink, making sure clothing does not touch the sink.

Principle. The sink is considered contaminated, and if the uniform touches the sink, it may pick up microorganisms and transfer them.

3. Procedural Step. Turn on the faucets, using a paper towel.

Principle. The faucets are considered contaminated because they harbor microorganisms.

4. Procedural Step. Adjust the water temperature. The water should be warm to make the best suds.

Principle. Water that is too hot or too cold tends to dry the skin, causing chapping and cracking and making it easy for pathogens to enter the body or be transferred to patients.

5. Procedural Step. Discard the paper towel in the waste container.

Principle. The paper towel is considered contaminated after touching the faucets.

6. Procedural Step. Wet the hands and forearms thoroughly with water. The hands should be held lower than the elbows at all times. Do not touch the inside of the sink because it is also contaminated.

Principle. When you hold the hands lower than the elbows, bacteria and debris are carried away from the arms and body and into the sink.

7. Procedural Step. Apply soap to the hands. Apply 1 teaspoon of liquid soap (approximately the size of a nickel) to the palm of one hand.

8. Procedural Step. Wash the palms and backs of the hands with 10 circular motions. Use friction along with the circular motions to wash the palm and back of each hand.

Principle. Friction helps to dislodge and remove microorganisms from the hands.

9. Procedural Step. Wash the fingers with 10 circular motions while focusing on the fingertips and fingernails. Interlace the fingers and thumbs, and use friction and circular motions while rubbing the fingers back and forth.

Principle. This kind of movement helps remove microorganisms and debris that have accumulated between the fingers.

Interlace the fingers and thumbs, and use friction.

10. Procedural Step. Rinse well, making sure to hold the hands lower than the elbows.

Principle. Running water helps to rinse away dirt and microorganisms.

Rinse well, holding the hands lower than the elbows.

11. Procedural Step. Wash the wrists and forearms, using friction along with circular motions.

(NOTE: The hands are washed first because they are the most contaminated; microorganisms and dirt are washed away and do not spread to the wrists and forearms.)

Wash wrists and forearms using friction.

12. Procedural Step. Clean the fingernails with a manicure stick. The fingernails should be cleaned at least once daily, preferably during initial handwashing (i.e., handwashing performed just after arriving at the medical office to begin your day).

Principle. Dirt and microorganisms collect underneath the fingernails.

13. Procedural Step. Rinse the arms and hands.

Principle. The running water rinses away the dirt and microorganisms.

14. Procedural Step. Repeat the handwashing procedure. For initial handwashing or when the hands come into contact with blood or other potentially infectious materials, the handwashing procedure should be repeated to ensure removal of all pathogens.

15. Procedural Step. Dry the hands gently and thoroughly, and discard the paper towel.

Principle. Gently drying the hands prevents them from becoming chapped. Microorganisms can lodge in the crevices of chapped hands. Ensure that the hands are dried completely, because wet skin also may cause chapping.

16. Procedural Step. Turn off the water, using a paper towel, and discard the paper towel in a waste container.

Principle. The faucet is considered contaminated, whereas the hands are medically aseptic or clean.

17. Procedural Step. Do not touch the sink with the bare hands.

Principle. The hands are now medically aseptic, and the sink is considered contaminated.

The CDC hand hygiene guidelines recommend that handwashing be performed when the hands are visibly soiled with dirt or body fluids, before eating, and after using the restroom (see Box 17-1). If the hands are not visibly soiled, the CDC recommends that an alcohol-based hand rub, rather than handwashing, be used to sanitize the hands. This is because repeated handwashing tends to dry out the hands, leading to irritation, chapping, and dermatitis.

Washing the hands with an antimicrobial soap is termed antiseptic handwashing. Antimicrobial soaps contain an antiseptic, which is an agent that functions to kill or inhibit the growth of microorganisms (Figure 17-2, A). Antiseptic handwashing sanitizes the hands through the mechanical scrubbing action and through the action of the antiseptic. Proper handwashing with an antimicrobial soap removes all soil and transient flora from the hands. Most antimicrobial soaps also deposit an antibacterial film on the skin that discourages bacterial growth. Antiseptic handwashing should be performed by the medical assistant before assisting with minor office surgery. Examples of antiseptics contained in antimicrobial soaps include triclosan, chlorhexidine, hexachlorophene, iodine, and chloroxylenol.

Alcohol-Based Hand Rubs

CDC guidelines recommend the use of an alcohol-based hand rub for sanitizing the hands when they are not visibly soiled (see Box 17-1). Alcohol-based hand rubs, also known as hand sanitizers, consist of 60% to 90% alcohol (ethanol or isopropanol) and come in the forms of gels, lotions, and foams (Figure 17-2, B). Studies have shown that hand rubs are more effective than traditional soap and water handwashing in removing transient flora and reducing bacterial counts on the hands. The advantages that alcohol-based hand rubs offer over traditional handwashing are as follows:

• Alcohol-based hand rubs are usually more accessible than sinks.

• They do not require rinsing; water or hand drying with a towel is not needed.

• Less time is required to perform hand hygiene. It takes 20 to 30 seconds to sanitize the hands with an alcohol-based hand rub compared with 1 to 2 minutes to perform proper handwashing.

• They are less damaging to the skin, resulting in less dryness and irritation. Most alcohol-based hand rubs contain emollients, which help prevent the skin of the hands from overdrying. As the alcohol dries, protective fats and oils remain on the hands.

Alcohol-based hand rubs have disadvantages. They are more expensive than plain soap. They also cause a brief stinging sensation if they are applied to broken skin, such as a cut or abrasion on the hand. Procedure 17-2 describes the proper steps for performing an alcohol-based hand rub.

Procedure 17-2 Applying an Alcohol-Based Hand Rub