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Facilitator Manual forHealthcare Non-Clinical Staff

Safety Training

“Protect YourselfProtect the Patients

Protect the Community”

April, 2018

Safety Facilitator Manual for Non-Clinical Staff

Acknowledgments

This manual is part of a generic training package developed in Atlanta at the Centers for Disease Control and Prevention (CDC), Division of Global HIV & TB (DGHT), International Laboratory Branch (ILB), Health Systems and Program Integration Team, funded by the President’s Emergency Plan for AIDS Relief (PEPFAR).

This manual was primarily developed using source materials from: World Health Organization (WHO)-Safe Injection Global Network (SIGN) Geneva and other WHO

programmes Making Medical Injections Safer (MMIS) materials produced for the United States Agency for

International Development (USAID)-funded MMIS programme from 2005 – 2012. Contractors included:o Initiatives, Inc., Boston, Massachusetts, USAo John Snow, Inc., Arlington, Virginia, USA and JSI Kenya and South Africa MMIS programmeso Chemonics International, Inc., Washington, DC, USAo URC, Chevy Chase, MD, USAo PATH, Training Health Workers in the Management of Sharps Waste. Version 1. Seattle:

PATH; 2005.

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Table of ContentsUpdate when doneFacilitator’s Introduction to the Course...................................................................ivFacilitator Tips........................................................................................................vi

Prepare the Facility Trainers/Safety Officers.................................................................................viFacilitator’s Familiarization and Training Preparation............................................viiFacilitator Resources.............................................................................................. xi

Introduce the Course to Participants.......................................................................1Welcome........................................................................................................................................ 1

Module 1: How is Disease Spread?..........................................................................3Facilitator Overview....................................................................................................................... 3What This Module Contains and Awareness Questions.................................................................3What is an Infectious Disease?.......................................................................................................4How a Disease Gets from an Infected Person to You.....................................................................4How Might You Be Infected?..........................................................................................................5Summary of Disease Risk................................................................................................................6Questions or Further Discussion....................................................................................................6

Module 2: Protect Yourself......................................................................................7Facilitator Overview....................................................................................................................... 7What This Module Contains and Awareness Questions.................................................................7How to Protect Yourself.................................................................................................................8Get Vaccinated.............................................................................................................................10Use Personal Protective Equipment.............................................................................................11PPE Awareness.............................................................................................................................11What is Personal Protective Equipment?.....................................................................................14Why and How to Put on (“Don”) Personal Protective Equipment................................................15Job Aid 2.1. Wear Available Personal Protective Equipment.......................................................19How to Clean and Take off (“Doff”) Personal Protective Equipment............................................20Practice Donning and Doffing PPE................................................................................................22Activity 2.1: We Are Too Short of Supplies; What Can We Do?....................................................23Wash Your Hands Properly and at the Right Time.......................................................................23Job Aid 2.2. Protect Yourself (and Your Family!) Wash Hands!....................................................24Activity 2.2: Remind Her to Wash Hands and Use PPE.................................................................25Use Post-Exposure Prophylaxis....................................................................................................26PEP: Part of Medical Evaluation...................................................................................................27Job Aid 2.3. First Aid + PEP for Exposure to Blood or Body Fluids................................................28PEP Steps to Take.........................................................................................................................29Activity 2.2: Practice PEP..............................................................................................................30Case Study: Why Me?...................................................................................................................31Summary......................................................................................................................................32

Module 3. Cleaning and Disinfecting......................................................................33Facilitator Overview.....................................................................................................................33What This Module Contains and Awareness Questions...............................................................33General Instructions for Disinfection...........................................................................................34

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Cleaning Instructions....................................................................................................................35General Instructions for Sterilizing in an Autoclave.....................................................................35General Laundry Instructions.......................................................................................................36Don’t Take Work Clothes Home...................................................................................................37Job Aid 3.1 How to Make Bleach Solutions..................................................................................38Job Aid 3.2 How to Make a Spill Kit..............................................................................................39Job Aid 3.3 How to Clean Up a Spill..............................................................................................40Types of Waste.............................................................................................................................41Table 3.1 Types of Medical Waste and Examples.........................................................................41Job Aid 3.4. Types of Medical Waste............................................................................................43Sharps are the Most Dangerous Waste........................................................................................44Key Points.....................................................................................................................................45Discussion.....................................................................................................................................46Practice........................................................................................................................................ 47

Module 4: Final Disposal of Medical Waste............................................................49Facilitator Overview.....................................................................................................................49What This Module Contains and Awareness Questions...............................................................49Handling and Storage...................................................................................................................50Transporting Medical Waste........................................................................................................52Final Disposal Methods................................................................................................................53Job Aid 4.1. Wear Your PPE When You Operate the Incinerator..................................................55General Directions on How to Use an Incinerator........................................................................56

Module 5: Summary..............................................................................................59

Appendix A: References.......................................................................................A-1Appendix B. Glossary........................................................................................... B-1

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Facilitator’s Introduction to the Course

Description ofthe course

This course provides key information on:

What you can do to stop the spread of disease Pre- and post-exposure prophylaxis Cleaning and disinfection and Ways to manage and dispose of waste properly.

Course goal For healthcare non-clinical staff, the goal is:

Protect yourself Protect the patient Protect the community

from the diseases caused by unsafe practices.

Who shouldtake thecourse?

This course was developed for all non-clinical healthcare workers who are exposed to infectious materials or chemicals in the workplace, such as:

porters maids, housekeepers, cleaners janitors laundry workers incinerator operators waste carriers drivers (including those who carry specimens or transport waste) staff who perform autopsies or prepare bodies for burial.

How to usethis manual

This course is not suitable for self-study. It should be led by a facilitator. Literacy may be an issue for this audience, so reading materials are not provided. Instead, the facilitator will lead discussions about current and improved practices using discussions, job aids, posters, demonstrations and practice.

The information in this manual should be adapted to country and facility needs, in accordance with national guidelines and facility standard operating procedures (SOPs).

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Objectives By the end of this course, participants should be able to:

Describe at a high level the ways diseases are spread Show the ways they can protect themselves at work Explain what to do if they are injured or splashed with an infectious material on

the job Demonstrate proper cleaning methods Demonstrate safe medical waste handling procedures

Practice all these things during the course using facility equipment and personal protective equipment (PPE) to encourage improved practices back on the job.

Use the posters and job aids provided during demonstrations and discussions.

Provide each participant with a set of job aids.

Additions,corrections,suggestions

Establish points of contact in your country and organizations so that you can receive suggestions for updates to this manual.

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Facilitator Tips

This is a “generic” manual, based in large part on safety concepts delivered in sub-Saharan Africa during the Making Medical Injections Safer (MMIS) project. This manual should be treated as a draft. It must be edited to follow your national plan and guidelines. Further adjustments will be needed at each facility to align with standard operating procedures.

Following approval at the national level, you can use it to hold a course for non-clinical staff (cleaners, drivers, incinerator operators, mortuary workers and so forth) in your country’s healthcare facilities.

You will tailor the training at each facility to create a “realistic” training session. To do this, conduct a familiarization visit if you are not well acquainted with the facility where training will be held. Determine existing conditions at the healthcare facility, the availability of supplies needed for safe operations, the staffing. A detailed familiarization checklist is provided next section of this manual. You will be determining and keeping notes of what you find:

if vaccinations are available to the non-clinical staff at no cost what PPE is available at the facility, which will also require obtaining a set of PPE for practice

donning and doffing with the staff their protocol for post-exposure prophylaxis (PEP) how they use their cleaning products and how they segregate waste: colors of bags and bins in use, including details on final disposition of

waste at the facility.

Prepare the Facility Trainers/Safety Officers

Safety is not a subject that can be taught once then forgotten. Refresher training will be needed. New staff will need to be trained. For sustainability, a facility manager should designate one or more facility trainers. This person(s) should participate in the training session for non-clinical staff. If the facility has a safety officer or biosafety officer or an infection control officer, these people should also participate.

As facilitator, it will be part of your role to involve the trainers/officers in:

Conducting a familiarization in this facility Tailoring the training to prepare (simply choose the subjects you will cover: make a list of those

in an agenda) Showing how to add to the materials to keep it up-to-date. For example, if the facility is able in

the future to procure additional PPE that was not available for this training, the facility trainer could demonstrate how to use it in a future refresher training session and add that information to the facilitator manual

Passing the materials on to the facility trainers/officers along with a modified version of the facilitator manual prepared for this facility.

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Make the training informal. For example, sit at a table with the staff rather than standing at a whiteboard:

o Ask the staff questions about their current practices.o Talk through and discuss the job aids, videos and posters with the staff. o Include demonstrations and practical exercises using the PPE available at that facility. o Practice segregating waste and talk about the waste stream from this facility.

Facilitator’s Familiarization and Training Preparation

Each facility will have its own equipment, materials and local directives or procedures. Therefore, before you provide training in a facility:

determine what equipment, materials and documents the facility has determine what management directs the staff to do ask if there are training records.

You can then tailor the training to that facility. Do this to avoid confusing the staff by suggesting things they have never been told to do or do not have the equipment to do.

Begin by reading the facility Safety SOPs that pertain to healthcare non-clinical staff. Record what SOPs are available and if they are complete or if some key points are missing.

Next, interview people at this facility who are very familiar with non-clinical staff activities and work situations. Talk to the safety or biosafety officer or an infection control officer.Record the results beginning next page.

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Familiarization Checklist: Non-Clinical Staff Operations

Facility Name:

Date:

Question Yes No N/A or Not Sure + Comments1. Have the non-clinical staff been formally

trained to use facility SOPs rather than receiving on-the-job advice from another worker?

2. Have the non-clinical staff been vaccinated in this facility?a. Is vaccination at no cost to them?b. If so, who would they talk to at this facility

to get vaccinated?c. What vaccinations are available to them?

3. Do some of the non-clinical staff enter patient rooms to clean the room or actually touch patients?a. If so, what PPE is available to them?b. Is the PPE at no cost to them?c. Is a respirator fit testing available to these

workers, especially if they come in contact with TB patients?

d. Note: If PPE is supplied, collect one complete set for your training demonstration and practice.

4. Is there clean running water at this facility for handwashing?a. If not, is there hand gel?b. If clean water is not readily available, what

workarounds do they use at the facility for hand hygiene, washing after they are splashed and so forth?

5. What is the post-exposure prophylaxis (PEP) policy or procedures in this facility?a. Who should staff go to if they are injured?b. Who should they talk to if the identified

person is not available? And who next?

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Question Yes No N/A or Not Sure + Comments6. What cleaning supplies are available?

a. Is bleach or another disinfecting solution readily available?

b. Do non-clinical staffs make up bleach solutions and hand gel or does someone else do this? Or is hand gel purchased?

c. How often are bleach or other disinfecting solutions made up?

7. Does this facility use disposable supplies (needles and syringes, gowns, masks, gloves) or do they use supplies that must be cleaned and reused?a. Do the non-clinical staffs do the cleaning,

disinfecting and sterilizing (autoclave) of reusable supplies or does someone else do this?

b. Note: If possible, observe staff cleaning and sterilizing.

8. How does this facility collect waste?a. What color bags do they use for infectious

and general (non-infectious) waste?b. Do they also have colored bins? Are they

the same color as the bags?c. Have the non-clinical staffs been formally

trained on how to use the bags?d. What kind of sharps containers do they use

here?

9. What is the procedure in the facility for dealing with used sharps and sharps containers?”

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Question Yes No N/A or Not Sure + Comments10. How does this facility conduct final waste

disposal?a. Do they have an incinerator? If so, who

works the incinerator?b. Have incinerator operator(s) been trained

in incinerator and PPE use?c. What PPE do they use?

If no incinerator, how is the waste decontaminated and disposed?a. If waste (including full sharps containers) is

stored prior to transport to a different facility for incineration, is there a secured area or locked room for the storage?

b. Are there records of waste shipments (with dates) showing what was loaded on the transport vehicle?

11. What training equipment and materials are available at this site?a. Are you able to print job aids here?b. Are you able to show videos?c. Are you able to use Power Point slides?d. Is there an area to provide training?

Facility Notes:

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Facilitator Resources

In addition to job aids in this manual, the job aids listed below are available as Facilitator Resources. Review the available job aids and videos available for this course. You may use them based on what is available to non-clinical staff.

Job Aids Related VideoHow is Infection Spread? NoneWhen to Wash or Clean Your Hands When to Wash or Clean Your HandsEssential Hand Hygiene Supplies NoneWash Your Hands Wash Your HandsGlove Use Information Leaflet (WHO) NoneDon Gloves Don GlovesDon a Mask NoneNone Fit TestDon Respirator Don RespiratorUser Seal Check User Seal CheckDoff Gloves Doff GlovesDoff, Reuse and Dispose of a Respirator Doff, Reuse and Dispose of a RespiratorHandwashing Bleach Solution (CDC) NoneSummary of Don and Doff PPE (CDC) NoneHow to Clean Up a Large Spill with Bleach How to Clean Up a Large Spill with BleachSegregate Waste Segregate Waste

Facilitator Resource graphics are also available for class discussions.

Decide what course content you will present based on the situation at this facility. For example, no need to discuss incinerators if they don’t have one.

Select the job aids you will use. If possible, have a packet of job aids made up for each participant.

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Notes

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Introduce the Course to Participants

Welcome

Introductions Facilitator: Introduce yourself. Then say:

“Please introduce yourselves.Tell us your name and describe your job, what you do here at the facility.”

Describe thecourse

Explain the purpose of the course:

“The purpose of this course is to learn and practice ways to:

Protect yourself Protect the patients Protect your community”

Describe the objectives of the course

Tell participants:

“By the end of this course, you should be able to:

Describe at a high level how disease is spread. Show how to protect yourself using the personal protective equipment provided

at this facility. Explain what to do if you are injured or splashed with infectious material or

chemicals on the job. Demonstrate safe cleaning methods and medical waste handling procedures.”

Describe howparticipantswill learn

Explain to participants:

“We will discuss and practice how to be safe on the job. I am new here so you will need to tell me how you do your jobs now.

We will practice using the equipment and resources in this facility. All opinions and ideas are valued. Please speak up during discussions for the

good of your own health and your family’s health. This is a safe time to add to your knowledge and learn from each other.”

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Facilitator Notes

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Module 1: How is Disease Spread?

Facilitator Overview

Duration 20 minutes

Learningobjective

At the end of this module, participants will be able to describe at a high level how infectious disease is spread.

Materials job aids, posters; facility’s SOPs

What This Module Contains and Awareness Questions

Describe the module to participants

Tell participants:

“I want to talk about what causes disease and how disease is spread. An infectious disease is an illness that can be passed from person to person or objects to person. In a healthcare facility, diseases are easily passed from person to person. I’m going to start by asking you some questions to see what you think about it.”

Q1 “Do you think you have to touch a sick person to get an infectious disease? Or can you get it from their blood, saliva, or waste?”

Yes, can get it from blood, saliva, waste, coughing, etc.

Q2 “Are there some diseases that you cannot catch from another person?”

Some diseases start in a person’s body but cannot be spread to another person: heart disease, cancer

Q3 “Do you know if there are any things you can do to stop from getting an infectious disease here at work? Or if we are around it, will we get it for sure?”

If we protect ourselves from the cough, the blood, saliva, feces of a person who is ill, we may keep healthy.

.

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What is an Infectious Disease?

Discussion “At work, you come in contact with patients or visitors who are or may be infected: They may be ill and admitted to hospital. They may be recently ill but recovering in hospital or released or coming back to

see their doctor. They may have come to your facility after an accident. They may feel healthy but be in a clinic or hospital for routine care. They may be visitors who believe they are healthy.”

How a Disease Gets from an Infected Person to You

Discussion “A disease often lives in a certain part of the body. It will come out of the infected body to infect other people.

Can you think of a disease that lives in the lungs and comes out when the patient coughs?”

Influenza (“Flu”) and Tuberculosis (“TB”) infections live in the lungs. When a person with flu or TB coughs or sneezes, tiny particles are released in the air. This spreads the disease to others.

“Can you think of a disease that lives in the blood?”

Bloodborne infections such as rubella or syphilis can infect an unborn child. Other bloodborne agents, such as HIV and Hepatitis B are sexually spread or

spread when a healthy person with a break in their skin contacts infected blood.

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How Might You Be Infected?

Discussion Lead a discussion about the following:

Direct contact by two ways:o Skin-to-skin contact, for example touching or kissing and sexual intercourse

or contact with blood or body fluids, such as vomit, urine, feceso A spray of small particles produced by sneezing, coughing, or even talking

Indirect contact by the transfer of an infectious agent on objects.”

Tell participants:

“Disease or illness can be spread in many ways. We will just talk about how you can be infected with a disease while at work.”

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Summary of Disease Risk

Discussion Lead a discussion about the following:

“Diseases are caused by very small germs called bacteria and viruses. The germs are tiny and cannot be seen except with a laboratory microscope. Some people who come to the hospital are ill: they have a harmful bacteria or

virus in their body. Make sure you don’t get a disease from the patients or pass diseases to the

patients or to your coworkers.”

Tell participants:

“In this course, we will talk about ways you can protect yourself from disease here at work.”

Ask participants the following questions:

Q1 “If your hands look clean, can there still be bacteria or virus germs?”

Yes. They are tiny. You can’t see them with your eyes, only with a microscope.

Q2 “Name some places where germs can live.”

Anywhere: Underneath your fingernails or on hands (hands are a favorite place of germs!) In bathrooms, toilets, sinks, drains, waste bins On trolleys, mops, dustpans, door knobs In the breakroom or eating facilities that you and other staff use On staff uniforms, boots, coats

Q3 “How can germs get on or in you at work?”

When you are doing daily chores, such as cleaning the wards, toilets, sinks or medical waste bins

If you are cut by a sharp object such as a needle or broken glass By not washing your hands, especially after you touch waste, doorknobs, other

people

Questions or Further Discussion

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Module 2: Protect Yourself


Duration 45 minutes (additional time if you use the role play and activities)

Learningobjectives

At the end of this session, participants will be able to: Explain the things staff can do to keep healthy at work (vaccinations,

personal protective equipment [PPE], hand washing). Demonstrate how to properly don and doff personal protective

equipment. Describe ways to keep from infecting their family with diseases from work. Describe the steps to follow if they are injured by anything sharp.

Materials Flipchart pages (blank) with titles NO and YES Facilitator resource graphics Job Aids, posters, videos tape Facility PEP poster (or facilitator’s PEP poster) Spray bottle



Tell participants:

“In this module, we will talk about ways you can protect yourself and your family.I’m going to start by asking you some questions.”

Q1 “Why do we say, ‘your family’?”

If you become ill at work, you might spread the disease to your family, or If you are seriously ill and not able to work, this will affect your family because

they will not have the money you make from your job.

Q2 “Have you ever worn special clothing or equipment at work to protect yourself?”

Any PPE: Gloves, mask, boots, goggles, etc.

Q3 “Tell me some good times in your work day to wash or clean your hands.”

1. Before touching a patient2. If I am splashed with body fluid or something dirty3. After touching a patient4. After touching anything in the patient’s room5. Before eating6. Before and after using the toilet7. After removing PPE

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Q4 “Do you even touch a patient or clean a patient’s room while the patient is there?”

This will just depend on the worker

How to Protect Yourself

Facilitator Suggestions:

Many participants may not know the significance of these graphics or be able to discuss the problem. Instead of explaining each one, tell them you will revisit with them as you come to a part of the course where you are discussing the problems or good practices.

Don’t write on a flipchart; instead, use the resource graphics provided. You may have additional graphics of your own. You may have to draw some of the pictures or ask someone in the class who is a good artist to draw.

Use two flipchart pages: one NO and one YES (or a split flipchart page to NO and YES) Use the large graphics provided (facilitator resource packet with this course). Some

graphics should show problems/issues and some should show good practices. Tape the graphic to the flipchart as class discusses. Things they should not do or dangers on the NO page. Things they should do or good practices on the YES page. You might ask a participant to assist. For example, hand them the graphics to tape to

flipchart paper.

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Questions Ask participants the following questions:

1. “There are steps you can take to avoid being infected with certain diseases. Can you think of some?”

Get vaccinated Use personal protective equipment (PPE) at work Wash hands regularly

2. “What are some ways you can avoid bringing germs from work to your family?”

Do not take protective clothing home (gloves, aprons, long boots that have hospital germs on them)

Do not wash your work clothes with other family clothing Before you leave work, wash your hands Bathe and change clothes as soon as you get home

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Get Vaccinated

Facilitator: Conduct the Facilitator Familiarization and Preparation on page vi of this manual. Determine in advance what immunizations are available at this facility for non-clinical staff and if

there is a charge for this. Determine who staff should talk to for vaccinations.

o Invite that person to come in to say hello to the training participants.o If possible, he/she could ask them to come by and give times to come.

Why do it? Tell participants:

“Get vaccinated to avoid infection. Then keep up with your vaccinations to reduce your risk of being infected with bloodborne diseases.”

Find out Ask participants:

“Do you know if you have had the Hepatitis B and Tetanus vaccines?”


“Find out from your healthcare provider or in this facility if you have had all vaccination doses.

If records are with healthcare provider, take your records to the facility where you work.

The nurse will record what vaccinations you need or file your records. This is important. If you are stuck with something sharp, the nurse will know if you are already protected against Hepatitis B and Tetanus if it is in your records.

If necessary, the nurse will arrange for you to be vaccinated – immediately if possible. If not, the nurse will tell you when to come back.

Get vaccinated as soon as possible: you are protecting yourself and your family by avoiding infections that would make you unable to work.”

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Use Personal Protective Equipment

Facilitator: Conduct the Facilitator Assessment and Preparation on page 3 of this manual. Collect in advance at least one set of PPE non-clinical staff use in this facility. If there is no PPE for non-clinical staff, speak in advance of the training to the supervisor/manager to see if they can procure some for the non-clinical staff.

PPE Awareness

Directions Tell participants:

“Let’s talk about what you wear at work to protect yourself.

I will read some questions. To answer, just say what you are doing now at work. It is fine to respond, “I am not sure but I think…” If someone says an answer and you disagree, you can give your own answer. We will learn about these things throughout the course then talk about these

questions again at the end of the course. I will keep notes, just to make sure we cover everything you need to know.”

Facilitator: Keep notes here of class answers and discussion. Make sure to note areas of confusion and disagreement. Don’t try to give all the answers now. Clear up the areas of confusion or disagreement during the course. Invite the class to revise at end of the manual (Summary).

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Questions Ask participants about their workday and how they protect themselves.

1. “Does anyone here work in the laundry? Do you wear any protective clothing? If so, what and when do you wear it? Please describe.”

2. “Does anyone here collect waste and trash? Do you wear protective clothing? If so, what and when do you wear it? Please describe.”

3. “Has anyone here sometimes cleaned up after a patient was ill? Do you wear protective clothing for this? Please describe what and when.”

4. “Does anyone here clean up a patient’s blood or vomit? Do you wear protective clothing for this? Please describe what and when.”

5. “Does anyone here incinerate waste? Do you wear protective clothing? What and when? Please describe.”

6. “Does anyone here transport waste from this facility to another for final disposal? Or do you transport blood and other specimens? Do you wear protective clothing? Please describe what and when.”

7. “Does anyone work in the morgue? What protective clothing do you wear, if any? Please describe what and when.”

8. “Does anyone here transport specimens, such as tubes of blood, from one place to another? Do you wear protective clothing? What and when?”

9. “Anyone else? What kind of work do you do? Do you wear any protective clothing or equipment? What and when?”

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Facilitator Notes

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What is Personal Protective Equipment?


1. “What are some examples of personal protective equipment you can wear to protect yourself?”

Apron Mask or respirator Heavy boots Heavy gloves Goggles

2. “Why and when do you use PPE?”

Wear protective equipment to help prevent infections Wear personal protective equipment at work when you are cleaning or any task

(laundry, preparing a body for burial where you may be splashed or encounter sharps)

Wear when handling healthcare waste Wear when disposing of healthcare waste (burying, burning)

3. “Do you have to clean protective gear? If so, how do you do it?”

Take off gloves first: they are usually the most soiled. Wipe down any splashes of blood or body fluids with 10% bleach. Wash at the end of work day with soap and water Wash boots inside and out and dry well at least once per month

4. “Where do you store your protective gear at work when you are not wearing it?”

Based on their situation, but should be stored at health facility at the end of the work day

Do not take home to clean or store!

Protective gear samples

Show participants samples of protective gear that is available to them at this facility.Ask participants the following question: “Have you worn this PPE before?”

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Why and How to Put on (“Don”) Personal Protective Equipment

How to don PPE

Explain that donning PPE includes the following:

Wear clothes that cover the arms and legs. Apron: Wear an apron if you have contact with infectious body fluids. Tie in back.

The apron prevents contact with infectious body fluids that may soak through if you are cleaning spills.

Respirator: Coughs, sneezes, broken containers and splashes create tiny particles in the air. These tiny particles cannot be seen. A respirator protects your nose and mouth from contact with blood or droplets of infectious body fluids.

Use a mask if no respirator. Cover your feet: boots, shoe covers Heavy duty gloves for general cleaning or clean-up of spills Cover your hair In some cases where splashing, use goggles or a face shield.

Show the job aids on this and videos.

Ask for a volunteer to come up so you can show how to put on PPE.Don’t don it yourself or you will have trouble explaining how to doff.

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Masks Explain the following:

“Some masks are fastened with ties, others with elastic. If the mask has ties, place the mask over your mouth, nose and chin.

Fit the flexible nose piece to the form of your nose bridge. Tie the upper set at the back of your head and the lower set at the base of your neck.

If a mask has elastic head bands, separate the two bands, hold the mask in one hand and the bands in the other. Place and hold the mask over your nose, mouth, and chin, then stretch the bands over your head and secure them comfortably, one band on the upper back of your head, the other below the ears at the base of the neck. Adjust the mask to fit. You don’t want to be touching the mask during use, so take a few seconds to make sure it is secure on your head and fits snuggly around your face with no gaps.” See job aid.

Aerosolsdemonstration

Ask the class to close their eyes.

Use a spray bottle to spray perfume (or anything with a smell, but not harmful) into the air. Ask what they smell. Remind that some diseases are spread by these small droplets in the air, from people coughing, sneezing or even talking.

Explain examples of diseases spread by droplets: Tuberculosis (TB) SARS (Severe Acute Respiratory Syndrome) Coronavirus Influenza Hantavirus

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Respirator Tell the class there is special equipment to protect from small droplets in the air:

“A respirator is a special covering for your nose and mouth. A respirator that fits you properly seals to your face. As you breathe, your breath comes through the respirator. The respirator filters the air, so only clean air can come in.

If you are around patients who have tuberculosis, influenza or other diseases spread by coughing and sneezing, it is good to use a respirator.

There is a special “fit test” to make sure the respirator you will use fits your face. If you have a beard, the respirator may not fit properly.

Every time you use the respirator, you have to put it on properly. Otherwise, contaminated air can come in.”

See several job aids and videos on respirator use if these are available to non-clinical staff.

Heavy boots Explain the following:

“Boots or overboots must be worn over street shoes when infectious waste is on the floor. Common rubber boots are recommended.

The sides of the boots should be at least 30 cm (12 inches) high and have textured soles. Store your boots in a covered shelf or in a plastic sack between each use.”

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Heavy gloves Explain the following:

“Wear heavy gloves to clean spills, launder reusable protective clothing and patient bedding, handle disposable waste and assist with autopsies and burial preparations.

The gloves should reach well above the wrist, about 30 cm (12 inches) up the arm.

If thick rubber gloves are not available, use heavy duty or dishwashing kitchen gloves.

Disinfect gloves after work tasks or after contact with infectious body fluids and contaminated material.

If gloves are not available, use plastic bags to cover the hands.”

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Job Aid 2.1. Wear Available Personal Protective Equipment

Wearing PPE reduces your risk from injury from sharps, germs, exposure to blood or body fluids, splashes, inhalation of tiny particles and harmful medical waste burning products such as sparks from the incinerator. You will need extra protective gear to prevent burns if you operate an incinerator.COVER AS MUCH SKIN AS POSSIBLE! For example, do not wear open-toed shoes.

Cleaning

Clothes that cover the arms and legs

Apron Mask Heavy duty boots Heavy duty gloves

Incinerating

Clothes that cover the arms and legs

Apron Mask Hard hat if possible Safety goggles Heavy duty, heat resistant boots. Heavy duty, heat resistant gloves

PATH, “Training Health Workers in the Management of Sharps Waste”. Version 1. Seattle: PATH; 2005.

19


How to Clean and Take off (“Doff”) Personal Protective Equipment

Discussion Tell participants:

“To remove PPE safely, think about equipment parts that are probably “clean” and parts that may be “contaminated and dirty” from your work.

Questions Ask participants the following question:

1. “After you finish working, what parts of your PPE may be contaminated?”

The outside front of your apron The outside front of your mask Your gloves Your boots

2. “Are there other parts that will probably be clean?”

Inside the gloves Inside and back of the apron or apron ties The ties, elastic, or ear pieces of the mask

Clean and disinfect PPE as you remove it

Explain to participants the following process for cleaning, disinfecting and doffing PPE:

“The areas that are considered “clean” are the parts you can touch when you are doffing PPE. These include:

Inside the gloves Inside and back of the apron or apron ties The ties, elastic, or ear pieces of the mask”

Disinfect and remove your heavy gloves

“Wash your heavy glove hands in soap and water. Dry with a paper towel.

Dip your heavy gloved hands in 1% bleach solution for one minute if you have been in contact with waste.

Do not try to wash thin examination gloves! They are too easy to tear or damage.”

20


Disinfect and remove your boots

“The soles of rubber boots are difficult to clean because they are textured. Disinfect them carefully and make sure to reach all surfaces of the textured soles.

o Use a sprayer containing a 10% bleach solution to spray boots or

o Hold the foot over a pan or basin and ask another healthcare worker to pour a 10% bleach solution over the boots or

o Step into a shallow pan containing 10% bleach solution and wipe boots on a bleach-drenched cloth.

o Avoid touching the boots with bare or gloved hands. Use a boot remover to take off the rubber boots.

o Store boots safely until next use. For example, store them in a plastic sack or on a covered shelf.”

Disinfect and remove your apron

“Disinfect the front of your apron: Spray or wipe it with 10% bleach solution.

Unfasten the apron ties with the ungloved hands. Slip hands underneath the apron and peel away or lift over your head.

Put the apron in a laundry container or hang it for reuse (if it will be reused).”

21


How to remove yourmask “The front of the mask is considered contaminated. Don’t touch it. Remove by

handling only the ties or elastic bands starting with the bottom then top tie or band. Lift the mask away from the face.

If the mask is disposable, discard it into the designated waste receptacle.

If the mask is reusable, send to laundry.”

How to remove your respirator

“If you receive training for respirator use, you will be shown how to don and doff it.”

Dress instreet clothes

Explain to participants the following process for removing the inner layer of clothes and dress in street clothes:

“If personal shower facilities are available, shower before dressing in street clothes.

If skin has contact with soiled material, follow guidelines for accidental exposure.

Put on street clothes to go home.

Do not wear or take PPE home! You may spread disease to your family and the community if you do this.”

Practice Donning and Doffing PPE

Class practice Now have each person come up to don and doff. Gloves are usually the first to doff (the most contaminated).

Ask the class to help if the person practicing gets confused.

22


Activity 2.1: We Are Too Short of Supplies; What Can We Do?

Facilitator: Read this story aloud to participants. Use names that are realistic for the country.

In the last few days, a number of patients are coming in with fevers and bleeding. The Chief Medical Officer suspects a serious infectious disease outbreak. Staff are being asked to use personal protective equipment more carefully than usual.

The hospital is short of supplies such as gloves and masks. In the supply closet, there are many supplies but they are being saved for H1N1 influenza outbreaks.

Activity study questions

Q1 “Should these supplies be saved? Do you need to buy your own supplies? Or reuse supplies? What would you do?”

Raise this question with a supervisor. Someone should check to see if you can use the supplies since there is a current danger.

Personal protective supplies that are stored for a long time may not be good any more.

Q2 “Has a similar situation every happened to you? What was done? What could have been done differently?”

<Based on personal experience>

Wash Your Hands Properly and at the Right Time

Wash your hands properly

Tell participants:

“Handwashing is the simplest and most important way to prevent the spread of diseases.

Protect yourself, your coworkers and your family by washing your hands with soap and clean water.”

Question See job aids for handwashing, essential hand hygiene supplies and hand cleaning with gel.

Ask participants the following question:

“When should you wash your hands?”

23


Whenever hands are soiled After handling medical waste or completion of duties even if you wore gloves

(wash hands with gloves on; remove gloves; wash hands again) Before eating Before and after using the toilet Before leaving for home

Job Aid 2.2. Protect Yourself (and Your Family!) Wash Hands!

24


Activity 2.2: Remind Her to Wash Hands and Use PPE

Introducerole play

Explain to participants: “Let’s practice what we have learned!”

Ask for volunteers for a role play: two cleaners at the end of their shift. One knows about PPE and hand washing. The other is a new employee who has not been trained.


“Nadja (use realistic names for the country), a cleaner, is exposing herself to harm. You are trying to help her to adopt a new approach to protecting herself.

Nadja has not been trained in how to collect infectious waste. One of her bags is open. Blood-soaked gauze from surgery falls out. She begins to pick up the bloody gauze with her ungloved hand and calls her co-worker, Tora, to help her. He goes to get a mop to help clean up but does not touch the waste.

They finish the clean up. Tora sees that Nadja does not wash her hands. Soon after, they go to lunch.”

Player 1, Tora

You have been trained to protect yourself and your coworkers. Talk to your colleague Nadja about the safe way to work.

Explain to her the need to use protective gear. Explain why to do this. Also, talk to her about washing hands.

Player 2, Nadja

You have not been to PPE training. You have always used bare hands. Your gloves are too tight and make your hands hot. You never use them.

Ask why you have to do these things. Tell your colleague you have never been sick and have been working at the hospital for over a year.

25


Debriefrole play

Debrief the role play: Ask participants the following questions:

Q1 “What was the message in the role play?”

Change your own behavior to be safe. Help to change people’s behavior. Help your coworkers.

Q2 “Would you be able to talk to another worker about this? What would you say?”

Will depend on the person but be polite.

“Say it now to the person next to you…”

Use Post-Exposure Prophylaxis

Facilitator: Determine during familiarization this facility’s process for PEP. They may have some variation of the national guidelines.

Questions Introduce the topic by asking a few questions. “What should you do when you are injured on the job?” Ask participants the following questions:

Q1 When I say “sharps”, what do I mean? Give me some examples.

A syringe/needle Broken glass Razor blades A scalpel Anything that can break the skin

Q2 Have you ever had a needlestick injury or been splashed with blood or body fluids in your face or on your skin? What did you do?

Will depend on the person: right answer is to describe PEP in this facility

Q3 Have you heard of PEP? What is it? Why do it?

PEP = what to do if you have a sharps injury or are splashed with blood, body fluids, etc.

Doing something right may prevent infection by bloodborne diseases. You do this to try to avoid infection by HIV, Hepatitis B and other blood diseases.

Go over the steps in this facility.

26


PEP: Part of Medical Evaluation

Explain:

“Medical evaluation is a three-step process that applies to all healthcare workers, whether injured or ill.

See a clinician if you have an incident or injury. Tell a supervisor if you are ill. Some facilities issue staff ID cards to identify that you are around pathogens. Have on file at your facility contact and emergency contact information”

27


Job Aid 2.3. First Aid + PEP for Exposure to Blood or Body Fluids

Think beforehand: “Who will I tell if I am stuck with a sharp or splashed with blood of body fluid?”

Do not wait! Stop what you are doing. Take these actions immediately when you are injured by sharps or get splashed with blood or body fluids.

If you can’t find soap or hand gel, don’t waste time looking. Go to your supervisor or a nurse. Tell them what happened and ask for their help.

Post-exposure prophylaxis


“What should you do (PEP)?”

Follow your SOPs! Don’t squeeze a sharps injury. If you can wash or clean the injury or splash, do that first. Notify someone right away.

“What if it happens on a Friday? Can you go home and just wait until Monday or next time you come in?”

Tell someone right away: your supervisor, a nurse. Ask for help. Do not wait the weekend!

28


PEP Steps to Take

Skin is brokenfrom sharpsinjury

Use the facility SOPs or country job aids to get the exact steps.

Explain the steps to participants:

Step Do this…1 Wash using soap and water or mild disinfectant. If no clean water is

available, clean the site with gel or other hand-cleaning solution that you use for hand-cleaning at your site. Do not use bleach or other strong cleaners.

2 Report the injury right away to your PEP representative, your supervisor, a manager or a nurse for confidential evaluation.

3 Take all of the recommended medication.

4 Attend all follow up appointments.

Explain what not to do:

Do not squeeze the site. Do not use strong solutions such as bleach or iodine on the injury. It could make the

injury worse.

Splashes onskin or in eyeor mouth

Explain the steps to participants:

Step Do this…1 For splashes on the skin, wash or clean the area right away.

For a splash in your eye, rinse with clean water many times. Blink and move your eyeball. Look up and down and from side to side to rinse all parts of the eye.

For a splash in your mouth, spit out the blood or body fluid. Rinse your mouth with clean water and spit several times.

2 Report the injury right away to your PEP representative, your supervisor, a manager or a nurse for confidential evaluation.(some countries break out evaluation of the healthcare worker and the source as separate steps)

3 Take recommended medication.

4 Attend all follow up appointments.

29


Activity 2.2: Practice PEP

Facilitator: Have on hand in advance whatever the participants use to clean hands on the job. Put up the PEP poster that comes with this course.

Activity directions

Explain the directions to participants:

1. Divide into teams of three:

Have one participant be the injured or splashed healthcare worker. Have another who will function as the supervisor and have the job aid to

remind of the steps Have a third to also have the job aid to observe and give feedback at the end

of the practice.

2. Practice what to do for each kind of situation: stick, splashes on skin, in eye, in mouth.

Tell yoursupervisor

Tell participants:

“During review of the PEP steps, we said every time: Tell your supervisor (or a manager, a nurse).”

Questions Ask participants the following questions (all answers except the last are based on facility SOPs):

Q1 “What is the name of the person you will talk to if you get a needle stick or sharps injury?” [Try to get that person in to meet the class].

Q2 “How can this person be reached? Where will you go?”

Q3 “If this person is not available, who else could you talk to? [Try to get that person in to meet the class].”

Q4 “What is the policy on sharps injury reporting or incident reporting (such as splashes)?”

Q5 “If the PEP supervisor or manager is not available and the nurses are busy, can you politely wait until next day?”

No! Find someone right away.

30


Case Study: Why Me?

Facilitator: Read this story aloud to participants. Use names that are realistic for the country.

In January, 2008, Smyth, a maid at Provincial Hospital, was removing soiled linens from a bed in one of the wards at the end of her shift. She was stuck by a needle left behind in the sheets. Smyth was upset and told her supervisor. The supervisor said to go for a PEP kit in the pharmacy but it was late. Smyth’s shift was over and she needed to go get her children.

In March, Smyth developed loss of appetite, vomiting, pain in the joints. Examination of Smyth’s blood showed she had Hepatitis B. Smyth was very ill and could not work so she lost her job.

Smyth now lives with chronic pain. The costs of treatment are very high.

Case study questions

Ask participants the following questions [use a common name in your country instead of Smyth]:

Q1 “What should Smyth have done differently?”

She should have been vaccinated for Hepatitis B before this even happened: when a new employee.

When the injury happened, she should have reported and been counseled to determine if she needed PEP. Even after the injury, she could get an HVB vaccination and immunoglobulin.

Q2 “Do you know anyone this has happened to? Someone that was injured but didn’t go for PEP? What were the reasons? What could have been done differently?”

<Based on personal experience>

31


Summary

Discussion Show photos of unsafe activities by non-clinical staff: failing to wash hands, failing to use PEP


Q1 “What do you see in the pictures? Is there danger? Who is in danger? Why?”

Probe for signs of potential danger:

Protective gear not used? Sharps among medical waste?

Q2 “What can you do in each case to make work safer?”

32


Module 3. Cleaning and Disinfecting Facilitator Overview

Duration 30 minutes (add more time for activities)

Learningobjectives

At the end of this session, you will be able to: Explain when to use 1% and when to use 10% bleach solutions Explain where to use and not use bleach solutions Demonstrate how to clean PPE Demonstrate how to make bleach solutions

Materials Facilitator resource graphics Posters, tape, job aids, videos

Facilitator: Conduct the Facilitator Assessment and Preparation on page vi of this manual. Determine what cleaning supplies and practices are used in this facility.



Tell participants:

“Let’s talk about cleaning and disinfecting. Surfaces can be contaminated without visible signs of viruses, bacteria or parasites. You know they are so small, you can’t see them with your eyes. For example, hepatitis B virus can survive on surfaces at room temperature for at least a week. The virus is ready to go into any breaks in your skin.”

Q1 “There are many kinds of spills. Can you name some spills you have had to clean up?”

Will depend on the worker, his/her job and the facility

Q2 “Do you have different cleaners and instructions on how to clean different spills? Tell me about what you do.”

Will depend on the worker, his/her job and the facility

33


General Instructions for Disinfection

“Let’s think about spills: What has been spilled? Where is the spill? How big is the spill? Is there a cleaning procedure to follow in this facility?”

Disinfectioninstructions

Review the general instructions for disinfection:

“Fresh bleach solutions are strong: mix bleach solutions every day. The solutions should smell strongly of bleach.

If you use household bleach, mix 1% for general cleaning and hand cleaning and 10% for spills

Do not immediately wipe up a spill: let towels soaked with bleach sit on it to kill germs.

Bleach can be used on hard surfaces such as tile or concrete. It can be sprayed for large coverage but wear PPE to protect your eyes and breathing! Bleach corrodes metal, such as stainless steel so do not use it there.

If you use powdered bleach, follow the directions for mixing Do not rinse your bare hands (no gloves) in bleach. If you rinse your gloved hands

in 1% bleach, then rinse with clean water.”

Clean work surfaces according to your national guidelines or SOPs.

• “Make 10% bleach and water cleaning solution daily.• Make 1% bleach cleaning solution daily.• Use disposable towels for cleanups if possible.• Wear rubber gloves, boots, an apron and a mask when in contact with blood and

body fluids, including when handling of linen. Remember that contamination is invisible.

• Clean and disinfect contaminated environmental surfaces or objects as soon as possible using standard hospital detergents/disinfectants

• Clean floors and horizontal work surfaces (such as countertops) at least once a day with clean water, detergent and 1% bleach

• Do not spray or fog occupied or unoccupied clinical areas with disinfectant. This potentially dangerous practice has no proven disease-control benefit.”

34


Cleaning Instructions

Cleaninginstructions

Review the following cleaning instructions:

Use PPE when handling waste. Handle contaminated items as little as possible. Put contaminated materials in approved containers. Decontaminate infectious waste before disposal to reduce risk to staff and

patients, public health and the environment:o Soak with bleach solutiono Clean trolleys and vehicles used to transport waste with 1% bleacho Autoclave

General Instructions for Sterilizing in an Autoclave

Sterilizing in an autoclaveinstructions

Tell participants:

“You must be trained to work the autoclave. In an autoclave, water is boiled. The steam enters the items to be cleaned and sterilized. High temperatures of 121-134°C are held for 20 to 50 minutes during the sterilization process. The moist heat destroys the proteins of the germs.”

Review the following general instructions:

Use containers and special bags made for autoclaving Do not overfill containers Do not tighten lids Label contents

These materials can be decontaminated or sterilized in an

autoclave

These materials should notbe autoclaved

Waste material Surgical instruments Glassware Plastic tubes and pipette tips Solutions and water

Items packed in waterproof wrappings (steam must be able to penetrate the material being autoclaved)

Items (such as some plastics) that will melt

Paper or other products that would be damaged by the steam

Chemicals (for example, bleach)

35


Loading andunloading anautoclave

Review the following about loading and unloading an autoclave:

Load Unload Load material to allow steam to

penetrate Autoclave washed items and waste

separately

Wear the recommended PPEAllow the autoclave to completely

finish cycleStand clear of door when opening to

allow the steam to escapeCarefully remove the items, especially

hot liquids

Verify theautoclave run

Explain the following:

“When the autoclave has run then cooled, make sure the autoclave reached the correct temperature and pressure for the correct amount of time.

Use autoclave tape or a steam indicator that changes color or physical form when exposed to steam, temperature, or both.

Use a biological test containing spores of a heat-resistant bacterium. The spores will germinate if the autoclave does not reach the right temperature.

Use temperature and pressure gauges on the outside of the autoclave. A printout may be available to confirm conditions were met.”

General Laundry Instructions

Laundry instructions


Wear personal protective equipment when you gather contaminated laundry. Handle contaminated laundry as little as possible. Place soiled linen in clearly labelled, leak-proof bags or buckets at the site of

use. Disinfect the container surfaces before transporting directly to the laundry

area. Launder promptly with water and detergent. For low-temperature laundering, wash linen with detergent or soap and water,

rinse and then soak in 1% bleach for approximately 30 minutes. Dry linen according to routine standards and procedures.

36


Don’t Take Work Clothes Home

“DO NOT take your uniform or lab coat, aprons, shoes, tall boots and used gloves home to launder! Consider everything you wear in the hospital to be contaminated. When you take it home, you bring the contamination with it, to your family. Instead:

Bring spare clean clothes to wear home after work. For work clothes/uniforms: rinse and bleach as described in the general instructions if you

have no soap. If work clothes and uniforms are not sent to the laundry at your facility, just use a tub and

1% bleach.”

37


Job Aid 3.1 How to Make Bleach Solutions

“You will need a 10% bleach solution for spills and a 1% bleach solution for cleaning. Make up fresh bleach solutions every day: fresh bleach is strong bleach. Remember to make enough for both the facility and transport of waste if used. There are different strengths of bleach. Have someone tell you how much bleach and water to

use to make the solutions.”

“For spills, use the 10% bleach.

These directions are for household bleach. If you use a different product at your facility, use the manufacturers instructions.

The larger the spill, the longer you should leave 10% bleach on it.

To prepare a 10% bleach solution, take a 1 litre empty bottle that has been marked with 100 ml (= 1 part).

Pour in bleach to reach the 100 ml level. Pour in water to reach to top mark (900mls = 9

parts). Label the container.

For general cleaning or wiping down surfaces at the end of the day, use a 1% bleach solution (1 part bleach to 99 parts water).”

These directions are for household bleach. If you use a different product at your facility, use the manufacturers instructions.

To prepare a 1% bleach solution, take a 1 litre empty bottle.

Pour in bleach to reach the 10 ml level. Pour in water to reach to top mark (990mls = 99

parts). Label the container.

38


Job Aid 3.2 How to Make a Spill Kit

Gather these materials and keep together as a kit in a locked area for large spill emergencies:

1 or 2 five gallon bucket(s) Broom (disposable or one that can be taken apart to autoclave) Dustpan with a long handle (one you don’t have to stoop over to use) 2 or 3 pairs of heavy duty gloves (in various sizes) such as used in the kitchen Several pairs of thin examination gloves (in various sizes) Shoe covers or plastic bags for feet or heavy rubber boots Absorbent paper or cloth towels Disinfectant (10% bleach or other used at your facility) Spray bottle or pump sprayer Large forceps or tongs for picking up needles or infectious material Faceshield/goggles/mask Rubber apron and protective clothing such as a gown Spill sign Biohazard bags Sharps container

39


Job Aid 3.3 How to Clean Up a Spill

Never leave spills unattended! For a small spill, wipe with a paper towel soaked in 10% bleach. For a larger spill of infectious or potentially infectious material, follow these steps (see job aid and video):

Step Do this…1 Wear gloves and protective clothing, including face and eye protection.

2 Carefully wash any skin splashed with blood.

3 Remove any large broken glass first.Cover the spill with cloth or paper towels to contain it.

4 Pour a 10% bleach solution or other disinfectant over the cloth or paper towels and the surrounding area. Start at the outer edge of the towels. Move in a ring around the spill area. Work toward the centre.

5 Wait 15 minutes or as long as possible, depending on the location of the spill. Clear away the towels and bleach. Dispose of contaminated materials. If there is small broken glass or other sharps, use a dustpan or a piece of stiff cardboard to collect the material. Put waste and sharps into a leakproof container that cannot be punctured for disposal.

6 Clean and disinfect the area of the spill (if necessary, repeat steps 3 - 6).

7 After disinfection, inform your supervisor or other authority that the site has now been decontaminated.

World Health Organization, Laboratory Biosafety Manual, 3rd Edition, 2004, page 95 and

HIV Rapid Testing/Current Laboratory Practice Series Participant Manual,

Module 6, pp 8-9,

40


Types of Waste


Tell participants the three types of medical waste. Ask participants to give you examples of each. Table 3.1 next page provides more information to share with the class.


• “Not every kind of medical waste is infectious, that is, able to cause disease.• Most medical waste is not-infectious.• The rest of the medical waste can cause great harm.• Sharps waste is the most dangerous: Healthcare workers, doctors and nurses, should place

sharps in a puncture-proof, leakproof sharps container.”

Table 3.1 Types of Medical Waste and Examples

Explain to participants to segregate medical waste immediately according to the type of waste.

Type of Waste ExamplesNon-infectious (general) waste: Medical waste that does not spread disease.

Office paper, boxes, packaging material, office supplies, drink containers, hand towels, glass, plastic bottles, food

Infectious (dangerous) waste: Examples of each:

Medical waste that has been in contact with human blood or body fluids: this waste has the ability to spread disease

Used gauze, cotton, dressings, laboratory cultures, IV fluid lines, blood bags, gloves, anatomical waste, syringes

Chemical or pharmaceutical waste Outdated or waste laboratory chemicals, expired drugs, contaminated drugs, aerosol cans, pressurized cylinders

Medical waste that contains mercury or gases

Broken thermometers

Sharps waste can puncture the skin. Needles, infusion sets, scalpels, knives, blades, lancets, broken glass

41


How to separateeach type ofmedical waste

Job Aid 3.4 on the next page/poster shows the three types of medical waste. Each type is separated (segregated) from the other types.

Explain the following to participants:

“Segregate waste when it is first picked up then handle safely. Collect all solid, non-sharp, infectious waste in leak-proof waste bags and

covered bins.”

Discuss the bag or bin colors used in this facility.

Discuss importance of not using different bag colors randomly (mixing waste; accidental exposures)

42


Job Aid 3.4. Types of Medical Waste

Non-Infectious Waste Infectious Waste Sharps Waste

Send to landfill (bury) Autoclave (sterilize) then send to landfill (bury). If not, incinerate (burn).

Always sterilize (autoclave) equipment (scalpel); incinerate (burn)

safety boxes/sharps containers.

43


Sharps are the Most Dangerous Waste

Sharps containers

Tell participants:

“We are told to put sharps waste in a sharps container immediately after use to prevent injury.”

Ask participants the following:

Q1 “Why do we need to talk about the sharps container? Aren’t those things the concern of the healthcare worker using them?”

A sharps container is a way to control needles and sharps to prevent needlestick injury to healthcare workers, including non-clinical staff.

You may come in contact with sharps when you are cleaning, removing full sharps containers for temporary storage, preparing containers for transport or incinerating the containers.

Your facility should have a plan on how to handle sharps containers: who closes a ¾ full box and removes it to storage, how often containers are sent for incineration or how often you incinerate on site.

How to use asharps container


“A sharps container is a puncture- and leak-resistant container used only for disposal of sharps, such as:o Syringes with needleso Infusion setso Scalpelso Bladeso Broken glass

Never overfill sharps containers.

Don’t try to close a sharps container if there are needles and syringes sticking out. Instead, notify a supervisor.”

Ask participants the following:

Q1 “What is your experience with how sharps waste and sharps containers are handled? Do all the doctors and nurses follow the rules of sharps disposal every time?”

Do not make assumptions that everything is perfectly segregated. Be careful at all times of stray needles and infectious waste.

Q2 “How would you clean up if you spilled a container of used needles?”

Pour 10% bleach solution over needles; allow to sit for at least 15 minutes.

44


Do not clean up sharps with bare hands. Put on heavy gloves. Use a dustpan and broom to sweep up needles. Or use tongs or a similar tool. Never

touch the needles, even with gloves on! Empty into a sharps container. Tap the broom on the ground to make sure no needles are stuck there. Mop the area with 10% bleach solution. Soak the broom in 10% bleach solution.

Question: waste mistake

Tell participants:

“Segregating medical waste is important, but remember this: Never try to correct errors if you see something in the wrong waste bag or bin or box.”

If you see waste that was not disposed of properly, what would be the safe thing to do?

NEVER put your hand in a sharps container or infectious waste bin to remove items after improper disposal!

NEVER place one bag inside a bag of a different color! That will cause confusion and possible injury.

If non-infectious and infectious medical wastes are accidentally mixed, treat the mixture as infectious medical waste. Make sure it is in an infectious waste bag.”

Key Points

Tell participants:

“There are three kinds of healthcare waste: non-infectious, infectious and sharps. Each type of medical waste is collected in a different way, in a different colored bag or box.

Handling waste in a safe way is your critical role: protect yourself and other healthcare workers. Keep patients and the community safe!”

45


Discussion

Questions Ask participants the following:

Q1 “What to do if you don’t have black, yellow and red bags or cans or boxes?”

Your facility must choose one color bag and bin for infectious and non-infectious waste.

Always use those colors. Sharps need their own special container that must not leak and has firm walls and

bottom.

Q2 “What do you do if your facility has an incinerator but it is not working or the incinerator operator is out?”

Store waste bags in a secured area that has been set aside for infectious waste and sharps containers.

Storage should not be more than two weeks. If the equipment isn’t working, managers should make arrangements to transport

the waste or burn in a secure area.

Q3 “What do you do if the autoclave is not working?”

Soak items to be disinfected in 10% bleach for 30 minutes.

Q4 “What do you do if there is a hole (with leakage) in the infectious waste bag?”

DO NOT remove WASTE FROM the LEAKING BAG TO another BAG . Just put the whole leaking bag inside a new infectious waste bag.

If the bag is almost full, close it and send for final disposal in your facility or transport to another facility.

46


Practice

Facilitator instructions

Before class, collect a number of items that should be identified as infectious, non-infectious, sharps. Use safe examples. For example, use catsup or paint to simulate blood. Use dry spaghetti to simulate sharps.

Use the proper facility containers. For bloody linens or even just used linens from a patient, wrap the linens up,

keeping the bloody portion inside. Use a special laundry bag for infectious linens if this facility uses.

Give each participant some items to segregate. Review the “answers” with the class by asking if each item was segregated correctly.

Waste Not Infectious

Infectious Sharps Container

Comments

Banana peel XGauze that looks clean on the floor

X Contaminated

Dry bandages from patient dressing

X Contaminated

Unused needle and syringe from damaged package

X May have been contaminated

Wrapper from needle and syringe

X May have been contaminated

Sandwich wrapper XCap left from used needle and syringe XNeedle and syringe used to vaccinate a baby

X Contaminated sharp

Found lancet X Contaminated sharpAutomatically retractable safety syringe, needle inside X Contaminated sharpFingernail XPaper no longer needed with patient information

X Destroy to protect patient’s privacy

Bloody bandages X ContaminatedLeftover beef stew XOut-of-date manuals XBic pen, out of ink XBloody bed linens X Handle with PPE to the laundry

not waste bagsOrange peel XA used tissue X Contaminated

47


Facilitator Notes

48


Module 4: Final Disposal of Medical Waste


Duration 20 minutes (allow additional time if you wish to use the activities)

Learningobjectives

Participants will be able to: Describe different methods of final waste disposal Identify the method of final waste disposal used at this facility Describe how to handle waste going to final disposal Describe personal protective equipment needed for handling waste Describe how to transport medical waste

Materials Facilitator: As usual, leave out parts of this module that do not apply to the work situation. For example, if a pit is used instead of incineration, do not cover incineration except to mention that it is the best, safest way.

Posters, tape, Job Aids




“In this module, we will discuss final disposal of medical waste. Final disposal may happen at your facility. Or you may have to store waste until

it is taken for disposal. We will discuss incineration and burying: how to dispose of medical waste in a

way that protects the community from disease.”

Tell participants:

“Taking care of waste properly is an important way to protect the community as well as yourself.”

Then ask participants these questions:

Q1 “What kind of final waste disposal do you do at this facility?”

<Depends on facility>

Q2 “Is all waste destroyed the same way? That is, if you incinerate, does all waste need to be incinerated?”

No. Each kind of waste is destroyed in its own way.

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Q3 “What kind or kinds of waste is dangerous to the community?”

Infectious waste, sharps waste.

Handling and Storage

Introduction Explain the following:

“You will need to move almost filled sharps containers and bags of infectious waste somewhere. The filled ones cannot be left in areas with patients and visitors.

Keep records of sharps containers that are incinerated at your site. Or keep records of sharps containers sent from your facility to another site for incineration if that is what you do.

Keep records of infectious waste bags that are incinerated or autoclaved at your site. Or keep records of infectious waste bags containers sent from your facility to another site for incineration if that is what you do.

Why is this recordkeeping done?”

To keep track of the waste and ensure correct disposal.

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Storing sharps containersand other medicalwaste

Tell participants:

“Tape shut an almost filled (3/4 way) sharps container. Store in a secure, dry location. For example, store in a locked room that is used for nothing else but sharps containers until final disposal at this facility or transport for disposal.

Tie off infectious and non-infectious medical waste bags when almost full.

Store for no more than two days in a secure, dry location with controlled access until transport or final disposal.”


Q1 “Why must sharps containers and medical waste bags be stored in one locked, dry location before final disposal or transport to the final disposal site?”

Secure: You don’t want anyone to have access to them. People or animals may scavenge unsecured bags and sharps containers and be stuck or infected.

Dry: Wet boxes can collapse, causing needles to spill out. One location: You do not want medical waste collecting in a number of areas.

Keep it contained. When it is time for disposal or transport, it is all together.

Q2 “Do you collect and store filled sharps containers and medical waste bags (liners) at your health care facility?”

<Answers based on personal experience>

Q3 “Where are they stored?”


Q4 “Who stores them?”


Q5 “Do you think the sharps and medical waste are stored properly at your facility? Why or why not? May I see your storage?”


Q6 “If you are picking up sharps containers and taking them to storage, what sort of PPE (protective gear) should you wear?”

Apron, gloves, long boots

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Transporting Medical Waste

Transporting medical waste


If you are loading or operating a vehicle to transport waste or transporting specimens:

Be sure you are aware of the transport schedule. Keep records of sharps containers or specimen lots loaded for transport. Use PPE when loading your vehicle with medical waste or specimens. Have a spill kit in the vehicle to clean up spills. Keep boxes or specimen lots upright during transport. Avoid direct contact of sharps containers with other waste or medical supplies

in the same vehicle. Keep sharps containers dry. If transporting specimens, move them to the lab first. After transport, clean vehicle surfaces with freshly made 1% bleach or other

disinfectant.

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Final Disposal Methods

Facilitator Notes:

Limit training to the type of disposal method the participants will be using. Tell the participants that not every facility has an incinerator. If they do not, they will need to have

secure storage until the sharps and infectious waste bags are transported to the final disposal site. Update the step-by-step instructions to reflect exactly what the participants need to do.


Q1 “What PPE should you wear when you are incinerating or burying waste?”

Hard hat (for incinerator) Safety goggles Mask Heavy duty, heat resistant gloves and heavy duty, heat resistant boots for

incinerating. Heavy work gloves and boots for burying waste. Apron Clothes that cover the arms and legs.

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Q2 “How do you dispose of medical waste at your facility?”

Remove medical waste from active work areas with patients and visitors. Store it (for later transport), bury it or burn it (depends on the facility)

To temporarily store, use a dry, secure, designated space. Do not store medical waste in the incinerator.

To bury infectious waste:o Cover the pit with a metal or wooden cover.o When the pit is nearly full, cover it with earth; dig a new pit.o Disinfect with 10% bleach or other disinfectant then wash after waste disposal

To burn it, use the incinerator. When it is cool after burning, remove ash from the burn box with a spade and place in a pit for ash.

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Job Aid 4.1. Wear Your PPE When You Operate the Incinerator

Remind your colleagues to wear their PPE also!

Incinerating

Wear: Clothes that cover the body Hard hat Safety goggles Mask Heavy duty, heat resistant gloves Apron Heavy duty, heat resistant boots

Source: PATH, Training Health Workers in the Management of Sharps Waste. Version 1. Seattle: PATH; 2005.

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General Directions on How to Use an Incinerator

Using an incinerator

Explain the following steps.

Step Do this…

1 Don PPE!

2 Remove ash from the incinerator while it is cool.

3 Load the sharps containers in the chamber. Do not fill too full.

4 Open the inspection door and load with fuel (coconut shells, wood, old papers, kerosene; whatever is generally used at your facility).

5 Pour ½ to 1 liter on the sharps containers of the fuel used in your incinerator.

6 Light a fire through the inspection door. Leave the door open so that the fire burns well.

7 Close the door when the fire burns hot. The temperature of the stovepipe thermometer should be approximately 600ºC (it may take 20-30 minutes to reach this temperature) before medical waste is added.

Color tells the temperature of a flame. Light blue is hottest part of the flame. Yellow, orange are cooler. Red is the coolest flame. To burn sharps containers, there should be no smoke coming out of the

chimney, just heat waves. Burn for 10-12 minutes with the hot fire.

8 Wait for the fire is finished and the loading door is cool to touch to remove ash.

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Facilitator: During your familiarization, determine final disposal method in this facility. If the facility has an incinerator, get their local instructions. The directions below are general and apply to older incinerators.


Do not incinerate!


“Some things must not be incinerated. They can explode or give off poison gases: X-ray/photographic materials Aerosol cans/gas containers Glass vials (reminder: broken glass goes in the sharps container)”

Source: Training Health Workers in the Management of Sharps WasteGuide for Training Waste Handlers, Version 1, PATH, October 2005

Maintainincinerator

Explain to participants the following:

“Incinerators work at very high temperatures. To protect yourself, do the following general checks (De Montfort and other

double-chamber incinerators require additional checks).”

Step Do this…

1 Before each operation:

Check that ashes have been completely cleared from the grate and floor of incinerator.

Check that loading door closes properly.

2 Every six months:

Check for loose bricks or cracks in mortar, interior and exterior. Repair or replace damaged bricks.

Inspect and repair metal. Check doors, hinges, grate, chimney cap. Replace metal if bent or damaged.

Check chimney vertical supports. Clean soot from inside the chimney. Clear brush from the area around the incinerator. If the ash pit is full, dig a new pit.

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Facilitator Notes

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Module 5: Summary


The questions are a review of questions from the course. If there is time, divide the room into two teams to make the review a game. Tell the teams to

choose a team name. Give points for each correct answer. Another way to review: Ask the teams to ask each other questions. They can use their Job Aids

as reminders of the key information.


Q1 “Describe how to segregate medical waste”

Colored bags or bins. Tell them to describe the colors they use. [WHO scheme is: black for non-infectious, yellow for infectious and sharps container for sharps but their facility may have different colors]. Be consistent with the medical waste bag colors in your facility.

Q2 “Describe the clothing you should wear to protect yourself when you are:

a. Collecting and disposing of waste and cleaning:” Gloves Apron Boots Mask

b. Incinerating waste:” Hard hat Safety goggles Mask but respirator better Heavy duty, heat resistant gloves Apron Clothes that cover your arms and legs Heavy duty, heat resistant boots.

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Q3 “Name three ways you can avoid getting diseases from medical waste or giving diseases to your coworkers or the patients.”

Be careful of sharps. Don’t get stuck by needles or other sharps: be careful even if medical waste appears to be general. Other healthcare workers may not dispose of sharps properly.

Wear PPE when handling waste. Get vaccinations for HVB and Tetanus.

Q4 “How do you safely dispose of infectious waste?”

For infectious waste, incinerate completely or prepare for transport. If there appears to be infectious waste mixed with general waste, handle it as if it is

infectious waste and tell your supervisor about the mixing. Make your supervisor aware of problems. Wear PPE and remind others handling waste to do so also. Use a sharps container or leakproof, puncture proof container (such as a plastic

bleach bottle) for sharps.

Q5 “What should you do if you get stuck by a needle or sharps when you are handling medical waste?”

If your skin is broken from sharps injury:

Step Do this…

1 Do not squeeze or rub the injured site! Wash immediately using soap and water or mild disinfectant.

2 If no running water is available, clean the site with gel or other hand-cleaning solution that you normally use at your site.

3 Do not use strong solutions such as bleach or iodine on the injury. It could make the injury worse.

4 Do not waste time trying to find washing or cleaning supplies.Right away, tell your supervisor, manager or a nurse, whoever is available.

Q6 “Some medical waste is infectious, some is not. What makes waste infectious?”

Presence of germs/bacteria/viruses/micro-organisms in the waste

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Q7 “Who can be hurt by infectious waste?”

Porters, Maids, Laundresses Nurses, Doctors, other HCWs Patients, Clients The Community; families of all the above

Q8 “You notice bloody bandages mixed with office paper in a black bag. What should you do?”

Never re-sort waste! Put it in an infectious waste bag without sorting (both bandages and papers) Inform your supervisor so they can correct the situation

Q9 “You see a sharps container taped shut on a shelf in the clinic admitting area. What should you do?”

Move the taped closed box to the area used to store safety containers/safety boxes and medical waste until final disposal.

Q10 “Describe the containers needed for proper segregation (will depend on your country).”

Two waste bins and a sharps container should be in every ward and at every injection site.

The bins must be black (or one consistent color) for non-infectious waste and yellow (or one consistent color) for infectious waste. If you don’t have these colors, use what you have but to avoid confusion, be consistent with your color for all waste products.

Q11 “What is the proper way to store of waste?”

Medical waste bags should not be stored for more than two days. Store in a dry, secure, designated area such as a locked room.

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Facilitator Notes

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Appendix A: References

Initiatives, Inc., Waste Handler Training: Low Literacy Module Guyana Safer Injection Project, Working Draft, September 2008. Boston, Massachusetts, USA and the Guyana Safer Injection Project funded by PEPFAR, the United States Agency for International Development.

Mishra, Vinod, Shane Khan, Li Liu, and Benny Kottiri. 2008. Medical Injection Use and HIV in Sub-Saharan Africa. DHS Comparative Reports No. 21. Calverton, Maryland, USA: Macro International Inc.

NIOSH/USAID/CDC. 1999. Alert. Preventing Needlestick Injuries in Health care Settings, pp. 10–11.

PATH, Training Health Workers in the Management of Sharps Waste. Version 1. Seattle: PATH; 2005.

Picken, D.J. De Montfort medical waste incinerators, De Montfort University, Leicester, UK © 2005 – 2007 http://www.mw-incinerator.info/en/101_welcome.html

Reid, Una V. Do No Harm: Injection Safety in the Context of Infection Prevention and Control, Facilitators’ Guide. Harare, Zimbabwe and Arlington, VA, USA: WHO-AFRO and MMIS/John Snow, Inc. for the Office of the Global AIDS Coordinator, US Agency for International Development and the HHS Centers for Disease Control and Prevention.

Reid, Una V. Do No Harm: Injection Safety in the Context of Infection Prevention and Control, Training Tools and Job Aids. Harare, Zimbabwe and Arlington, VA, USA: WHO-AFRO and MMIS/John Snow, Inc. for the Office of the Global AIDS Coordinator, US Agency for International Development and the HHS Centers for Disease Control and Prevention.

Joint WHO/ILO Guidelines on Post-Exposure Prophylaxis (PEP) to Prevent HIV Infection. c. World Health Organization, 2008. Published by WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland.

A-1

Appendix B. Glossary

Doff Remove personal protective equipment. “Doff your respirator” means “remove your respirator”.

Don Put on PPE. “Don your respirator” mean “put on your respirator”.

Fit test Special respirator testing conducted by a trained tester. Healthcare worker is tested with and without a respirator using a hood and a harmless bitter or sweet solution. Testing is done the first time a new respirator is worn. The test is to see if this brand, manufacturer and size of respirator blocks aerosols from the healthcare worker’s nose and mouth.

Fit check/User seal check/Placement check

All three terms mean the same thing: A test a healthcare worker does when he or she dons a respirator. The test is to make sure the respirator is seated correctly on the face so that no aerosols can enter.

Immunization (or Immunisation)

Your body’s reaction to a vaccination. The vaccine stimulates your immune system to recognize the disease and protect you from future infection.

MOH (or MoH) Ministry of Health

PEP Post-exposure prophylaxis

PPE Personal protective equipment

Sharps Anything that can cut the skin: broken glass, a needle with or without syringe, lancet, scalpel, infusion set

Sharps container/Sharps box/Safety box

All three of these terms mean the same thing: A box used to safely contain used sharps to prevent injury. The box or container may be: plastic (such as an empty bleach bottle or a purchased plastic

container made for sharps or a World Health Organization-approved treated cardboard box.

The container or box must have: a lid with a large enough hole for sharps thick, puncture-proof walls leak-proof sides and bottom and a biohazard label

It should also be large enough to hold sharps over a number of days.

B-1

SOP Standard operating procedures

Vaccination When a vaccine is administered to you (usually by injection).

B-2

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