Cause of Device-Related Incident
*Not stated

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Clinical Laboratory; Emergency Medicine; Infection Control; Nursing; Pathology; Pharmacy / IV therapy

Device Factors
*Not stated

Document Type
Guidance Articles

External Factors
*Not stated

Mechanism of Injury or Death
Exposure to bloodborne pathogens; Infection

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

Recommendations for Complying with the Bloodborne Pathogens Standard



Guidance [Feb 1993;22(2):71-91

The following recommendations cover specific ways to comply with the standard based on information from the Occupational Safety and Health Administration (OSHA), hospitals, and other sources. ECRI's recommendations derive, in part, from research conducted to answer questions asked by Center for Healthcare Environmental Management (CHEM) members. Where we have no recommendations, CHEM believes compliance is straightforward.

Multiemployer Work Sites

Most hospitals are multiemployer work sites. Physicians maintain offices at the hospital, sometimes staffed with their own employees; surgeons are often not employees of the hospital; and many other services, such as security and laundry, are often performed by contract personnel. Just who is responsible for compliance at multiemployer work sites is a valid question.

In its compliance instruction (CPL 2-2.44C:7), OSHA issues the following guidelines for multiemployer work sites:

  1. "Employers shall be cited for violations of the standard to which their own employees are exposed." OSHA is clear that the employer, not the facility, is responsible for compliance. Therefore, if a physician maintains an office in a hospital and staffs that office with his or her own personnel, the physician is responsible for compliance with any applicable provisions of the standard.
  2. "[Employers] shall also be cited for violations to which employees of other employers on their premises are exposed to the extent that they control the hazard. For example, they shall be cited for not providing [personal protective equipment—PPE] to unprotected employees of other employers on their premises." However, even though the employer is primarily responsible for compliance, the facility is not excused from responsibility when it has the power to prevent exposure. This case is a good example of performance-based application of the requirements.
  3. "Physicians who are members of professional corporations are generally considered to be employees of that corporation. Therefore, the corporation may be cited for violations affecting those physicians, such as failure to provide the hepatitis B vaccine. Also, the hospitals where they work may be cited for violations to which they are exposed." Again, the hospital has the responsibility to protect nonemployees against exposures that are in its control. For instance, the hospital would be required to provide surgical gowns, masks, and gloves to physicians.
  4. "No citation shall be issued where the only persons exposed are physicians who are sole practitioners or partners, and thus not employees under the Occupational Safety and Health Act."

The compliance instruction makes it clear that employers bear the responsibility for what they can control, such as hepatitis B vaccine or training, while the facility bears the responsibility for controlling exposure. So, who is responsible when a nonhospital employee causes exposure to a hospital employee? This is not a trivial question; the circumstance arises frequently in operating rooms where surgeons, who are not employees of the hospital, are directly responsible for injuring nurses, who are employees of the hospital, with suture needles.

According to the compliance instruction, in such cases, the facility would be responsible for protecting its nurses against such exposures, which it could easily do by establishing safe needle-passing procedures and monitoring compliance with them.

The Exposure Control Plan

Because the requirements of the bloodborne pathogens standard are different in thrust and in legal standing from other infection control practices, ECRI believes that the exposure control plan should be separate from the general infection control plan, regardless of the size of the hospital. If the plan is to serve as an effective training tool for employees at all levels, it should not be buried within guidelines for other procedures and practices.

ECRI recommends that copies of the plan be kept in each department and at each nursing station. They should not be locked in an office or a desk, but should be available to employees at any time. Employees should not have to ask permission to review the plan. In fact, they should be encouraged to consult the plan and to make suggestions for improvements.

ECRI's Recommendations for Creating an Exposure Control Plan

Aside from engineering controls and hepatitis B vaccine, much of the bloodborne pathogens standard is aimed at minimizing exposure through commonsense work procedures. In the sections that follow, ECRI offers specific recommended practices and procedures for various types of routine hospital tasks. These can be codified "as is" into an exposure control plan or adapted to meet the specific needs of the hospital.

It is important to bear in mind that the exposure control plan must be tailored to the individual circumstances of the facility. Although a number of generic exposure control plans are on the market, these plans do not, in ECRI's opinion, offer much benefit.

Performing an Exposure Determination

All personnel who are at risk of occupational exposure are entitled to the protection of the standard (64111). ECRI does not believe that performing an exposure determination is as formidable a task as it would first appear. Consider these facts:

  • OSHA does not require quantitative risk assessment. Exposure control measures are not implemented according to quantified risks of exposure, but are implemented if any chance of exposure exists. Furthermore, OSHA requires that the exposure determination be made without considering risk reduction due to PPE. Therefore, hospitals just have to come up with a list of those tasks that entail the potential for exposure to blood or other potentially infectious material (OPIM).
  • Those exposure-prone tasks are well-known. OSHA is not requiring hospitals to dig into their operations to come up with little-known or unsuspected sources of exposure.
  • The exposure scenarios are the same from hospital to hospital. All hospitals perform the same basic tasks: the risk of exposure from venipuncture, surgery, or other procedures is the same for all.

The following discussion represents ECRI's suggestions for performing exposure determinations.

Gathering Sources of Information

Using the OSHA Employment Classification Scheme. OSHA provides some help in determining who is at risk. To get an idea of the number of people at risk of exposure to bloodborne pathogens and the number and type of facilities affected by the bloodborne pathogens standard, OSHA compiled a job/exposure classification scheme. OSHA collected its information from the Bureau of Labor Statistics, the Census Bureau, and the Bureau of Justice Statistics; the results of its surveys are published in Fed Regist 1991 Dec 6;56(235):64043-5.

Following are the four classifications of workers in OSHA's scheme:

A: Workers directly involved in providing healthcare;

B: Laboratory workers, emergency responders, and fire fighters;

C: Housekeepers and janitorial workers; and

D: Additional workers (e.g., health aides, service personnel, couriers/drivers).

In CPL 2-2.44C, OSHA offers an expanded list of jobs that might entail exposure:

  • Physicians, physicians' assistants, nurses, nurse practitioners, and other healthcare employees in clinics and physicians' offices;
  • Employees of clinical and diagnostic laboratories;
  • Housekeepers in healthcare facilities;
  • Personnel in hospital laundries or commercial laundries that service healthcare or public safety institutions;
  • Tissue bank personnel;
  • Employees in blood banks and plasma centers who collect, transport, and test blood;
  • Employees in freestanding clinics (e.g., hemodialysis clinics, health maintenance organization clinics, family planning clinics);
  • Employees in clinics in industrial, educational, and correctional facilities (e.g., those who collect blood and clean and dress wounds);
  • Employees assigned to provide emergency first aid;
  • Dentists, dental assistants, and dental laboratory technicians;
  • Staff of institutions for the developmentally disabled;
  • Hospice employees;
  • Home healthcare workers;
  • Staff of nursing homes and long-term care facilities;
  • Employees of funeral homes and mortuaries;
  • HIV and HBV research laboratory and production facility workers;
  • Employees handling regulated waste;
  • Medical equipment technicians, paramedics, and other emergency medical service providers; and
  • Fire fighters, law enforcement personnel, and correctional officers.

For each classification within each healthcare facility, OSHA gives the estimated number of employees and the estimated number exposed to blood splash and splatter. OSHA estimates that Category A under hospitals, for instance, has 1.9 million workers, with 1.6 million exposed to splash and splatter. That's an exposure rate of 84% of all employees in those job categories. In hospitals, the rate of exposure for other classifications is 85% for Category B and 54% for Category C; no worker population was considered for Category D.

Hospitals should offer HBV vaccination and other protective measures, as appropriate, to every employee in classifications A and B. When the exposure rate is that high, no good reason exists to discriminate by task. Classification C, on the other hand, will require more careful consideration according to what particular materials and substances the employees handle. With an exposure rate slightly above 50%, vaccinating every worker would not be cost-effective. If, for instance, some workers handle only clean or sterile supplies, facilities could determine that their exposure risk is minimal.

For classification D, the news is good. Hospitals employ a large number of workers in tasks that involve neither patient contact nor contact with contaminated materials (such as administrative duties or food preparation). These workers are, according to OSHA's own reckoning, not at risk of exposure.

Gathering Information from Employees. Hospitals can gather complete exposure information by simply asking each employee to list assigned tasks that involve potential exposure. However, ECRI suggests that it would be more efficient to form committees by department to develop lists of exposure-prone tasks.

Quantitative Risk Assessment. A simple, quantitative risk assessment can determine which tasks are the most exposure prone. Such information could help a hospital decide which tasks would be best suited for new engineering controls, changed procedures, and intensive training of employees responsible for the tasks. The reporting program, if compiled accurately, should include all injuries, whether or not they require medical follow-up.

One tool for reporting and tracking sharp object injuries (SOIs) and other exposure incidents is Dr. Janine Jagger's EPINet program, which she developed in association with Becton Dickinson and which is available through the American Hospital Association (AHA). Two incident report formats are available, one for SOIs (including needlesticks) and one for blood and body fluid exposures not involving SOIs.

By contrast, the OSHA 200 injury and illness reporting form reports only those injuries that result in lost workdays or that require medical follow-up. Even so, Form 200 is supposed to provide an information base from which to assess risk. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also includes risk assessment as one of the duties of the safety officer. Therefore, ECRI believes that it would not be too difficult to look through several years' worth of Form 200 reports to determine which tasks present the greatest risks, either numerically or as a percentage of procedures performed.

Hospitals can choose a range of exposure determination methods, from the simple job classification scheme to a comprehensive risk analysis of different tasks. A more comprehensive determination will probably cost more in time and expenses. Yet, it could pay off in two ways: 1) by reducing the number of employees at risk and thereby reducing the costs of HBV vaccine and training and 2) by pinpointing those tasks that are the most significant sources of exposure.

Making a Grid

A simple grid with exposure-prone procedures along one axis and job classifications on the other will provide a broad picture of a hospital's potential exposures. A list would include such exposure-prone procedures and tasks as the following:

  • Phlebotomy,
  • Intramuscular injection,
  • IV access,
  • Emergency intubation,
  • Use of surgical power drills and saws,
  • Suturing,
  • Handling contaminated laundry,
  • Assisting in surgery,
  • Collecting filled sharps containers,
  • Changing wound dressings, and
  • Servicing contaminated equipment.

Two points on this very short list are noteworthy:

  1. The procedures do not always pose the same type of exposure and would demand different types of controls. Therefore, each procedure is further qualified as to the type of risk it poses, such as an SOI (e.g., a needlestick) or splashing and splattering (contact exposure). Some SOI risks can be reduced by engineering controls, such as self-sheathing needles, and others by procedural changes, such as better methods of passing needles during suturing. Some procedural changes might reduce splashing and splattering risks, but protective clothing would more likely provide better protection.
  2. The nature of the tasks, like the job classifications, can be general or narrowly defined. Narrower definitions might provide more specific guidance on types of exposures and protective measures that are appropriate.

An exposure-prone jobs list would include the following:

  • Floor nurse,
  • Operating room nurse,
  • Phlebotomist,
  • Operating room technician,
  • Anesthesiologist,
  • Nurse-anesthetist,
  • Clinical engineer,
  • Medical (clinical laboratory) technologist,
  • Laundry worker, and
  • Housekeeper.

The type of exposure potential of these jobs is not the same. Persons who handle contaminated laundry, for instance, can be exposed both to SOIs and splashing and splattering. Biomedical technologists can be exposed to SOIs not only from needles, but also from broken slide cover plates or collection tubes. In addition, they can be exposed to splashing and splattering if equipment malfunctions.

ECRI recommends the grid format as a convenient way to record this kind of exposure information and to present an exposure determination. The advantage of the grid is that it clearly and simply relates exposure-prone procedures to job classifications. The grid should be added to the exposure determination part of the exposure control plan.

Evaluating an Exposure Incident

Paragraph (f)(3)(i) of the standard requires that the circumstances surrounding exposure incidents be evaluated. OSHA states in the preamble that such an evaluation "could include the following elements: an evaluation of the policies and 'failures of control' at the time of the exposure incident; the engineering controls in place at the time of the exposure incident; and, the work practices and protective equipment or clothing used at the time of the exposure incident. The goal of this evaluation is to identify and correct problems in order to prevent recurrence of similar incidents" (64109).

ECRI offers the following hypothetical scenarios as samples of what should be considered during the exposure incident review process:

  • A nurse is stuck while disposing of a needle. Was the exposure caused by a sharps disposal container that was too full? If so, the waste collection schedule should come under review, as should the type of container used. Would a transparent container that makes the fill-level visible have prevented the injury?
  • An operating room nurse is stuck by a suture needle during closure. Was the error due to an incorrect procedure by the surgeon or the nurse? Were forceps used? If so, were they defective or inadequate? Would a better procedure for passing the suture needle have prevented the injury?
  • A security officer is splashed with blood while trying to restrain a patient in the emergency room. Is the exposure incident atypical for the hospital? Or should security guards be provided with PPE for such circumstances? Or should security guards not be called on to restrain patients in such circumstances?
  • A filled biomedical waste bag (red bag) bursts during removal, exposing a member of the housekeeping staff to medical waste. Was the bag handled correctly? Was something in the bag that shouldn't have been there? Was the bag defective? Should the hospital purchase sturdier bags?

In each of these scenarios, three points are considered:

  1. The procedures used to carry out the task.
  2. The equipment involved or that should be involved in the incident.
  3. The hospital's policy.

ECRI stresses the importance of obtaining an understanding of the practical problems and concerns of the uses of the protective controls, procedures, and equipment involved. If failure to follow policy, for example, is a problem, perhaps the policy has not been adequately explained, or it may not cover all anticipated circumstances. It is not enough to dismiss the incident simply as "failure to follow policy." Employees who use protective measures should be included in the discussion and review of corrective measures (e.g., by focus groups, user equipment evaluations).

The section of the plan covering exposure incident review should, in ECRI's opinion, stipulate the process for review and the people involved in the review.

Implementing Engineering Controls

When available, engineering controls offer the potential for the most effective exposure controls to implement and are much easier to install compared with the effort it takes to implement procedural changes.

Reducing Sharp Object Injuries

SOIs—which include all parenteral injuries, such as needlesticks—are the most effective route for the occupational transmission of bloodborne pathogens. Although some evidence supports the possibility of transmission by mucous membrane contact, bloodborne pathogens infect most efficiently through direct blood-to-blood contact, such as that provided by an injury with a contaminated sharp object. Healthcare professionals have been aware of the SOI problem for a long time, but until the first cases of occupationally acquired HIV infection were recorded, they paid little attention to it.

ECRI believes that two mechanisms can reduce SOIs:

Use of Safety Needles. ECRI believes that the most effective way to reduce parenteral exposure is to use safety needle devices, such as self-sheathing needles. The efficacy of these devices has been demonstrated. For instance, needleless IV systems have significantly reduced injuries among nurses who perform IV insertions and removals (Jagger 1992 [Letter]; Gartner 1992).

While it does not endorse a specific technology, OSHA also believes that safety needle devices provide the best protection: "Most preferable is the use of devices which offer an alternative to needles being used to perform the procedure. Examples of such devices include stopcocks (on-off switch), needle-protected systems or needleless systems which can be used in place of open needles to connect intravenous lines. Other devices which are integral to the syringe, such as self-sheathing needles, allow both hands to remain behind the needle and require very little manipulation to isolate the needle safely" (CPL 2-2.44C:15).

ECRI urges hospitals to begin substituting safety for nonsafety devices for all devices for which a safety product is available. However, safety products may not be available for all applications, and some products promoted as safety devices may not be effective in preventing needlesticks. (For a further discussion, see our articles on needlestick-prevention devices in Health Devices 20[5], May 1991, and 20[2], December 1991; this should help hospitals begin their own evaluations to determine which products work best for their employees and their particular exposure circumstances.)

Reporting. Reliable information about the number and rates of SOIs is hard to come by; thus, a tracking mechanism is needed. For many years, SOIs were simply regarded as part of healthcare work and were not reported or recorded. Today, underreporting continues for two reasons: 1) workers are afraid of reprisals for inflicting on management the cost of postexposure follow-up and prophylaxis, and 2) many workers prefer to remain unaware rather than face the terrifying prospect that they might be infected by HIV. OSHA responds to the reluctance of employees to report exposure incidents by stating that "reporting an exposure incident right away permits immediate medical follow-up. Early action is crucial. Immediate intervention can forestall the development of hepatitis B or enable the affected worker to track potential HIV infection. Prompt reporting can also help the worker avoid spreading bloodborne infection to others" (OSHA 1992 [Bloodborne facts: Reporting exposure incidents]).

Disposing of Safety Needles

Self-sheathing needles or any other type of safety sharp must still be disposed of in sharps containers that meet OSHA criteria. OSHA regards needle sheaths as temporary containers: "The needle sheath is not to be considered a 'waste container' because it is viewed as a temporary measure. Self-sheathing needle products must be disposed of in a sharps container" (CPL 2-2.44C:42).

OSHA goes on to state that, although other products are available that may provide some measure of safety, these devices must still be disposed of in sharps containers because it is not possible to guarantee their correct usage or proper functioning. (For example, some self-sheathing devices contain a fast-curing colored liquid adhesive that is released inside the sheath after administering a substance through the needle. This product is intended to permanently adhere all components of the syringe needle and needle sheath, rendering the syringe and needle assembly inoperable and incapable of causing injury. Nevertheless, such devices must be disposed of in sharps containers because correct usage and proper functioning cannot be guaranteed.)

Using Recapping Devices

Although OSHA considers them engineering controls, ECRI does not recommend these for general, hospitalwide needlestick prevention. They may be effective in limited, specialized applications. It is better to instill a "no-recapping consciousness" (except in limited circumstances when it is necessary for repeated use of a needle, not for disposal) among personnel than to provide devices to make recapping safer. In our Special Report and Product Review, "Needlestick-prevention Devices" (Health Devices 20[5], May 1991), we noted that, in hospitals where recapping devices are provided, they are seldom used by employees, who find them awkward to carry and inconvenient.

Handling Used Sharps

ECRI does not see a reason to distinguish between used contaminated sharps and used decontaminated sharps. All sharps that are not in sterile wrappers or currently being used to administer medications should be handled as contaminated. For instance, if a laundry employee finds a sharp in a washing machine after a wash cycle, he or she is probably correct in assuming that the sharp has been decontaminated by the wash process. However, ECRI advises hospitals to tell the employee to handle the sharp as any other contaminated item and to put it into a sharps disposal container. Employees should never have to make a decision about a sharp item found anywhere in the hospital.

Should hospitals decontaminate all used sharps? If filled sharps containers are burned on-site, there is no reason to disinfect them before incineration. If they are processed through a grinder, they will be decontaminated during the destruction process. If they are boxed and hauled to a disposal site by a licensed waste contractor, ECRI still sees no reason to disinfect them because, as studies by the Agency for Toxic Substances and Disease Registry (ATSDR), EPA, the Government Accounting Office (GAO), and OTA have shown, medical waste poses little or no infectious hazard to the public outside the hospital (ATSDR 1990; EPA 1990; GAO 1990; OTA 1989).

However, medical waste regulation is not based on rational science, but on public pressure. And the public fears medical waste. Consequently, Congress rushed to pass the Medical Waste Tracking Act of 1988, and since then, most states have adopted their own medical waste regulations. Now, many states require the decontamination of medical waste, including sharps, before disposal in a landfill. If disinfection is required by state regulation, used sharps will have to be chemically or heat treated. If state regulations do not require medical waste decontamination, ECRI sees no benefit to employees or the public from decontaminating sharps.

Use of Personal Protective Equipment (PPE)

Gloves

The most important item of PPE for all medical care is gloves. By far, the hands come into contact more often with blood and OPIM than other parts of the body. Yet, despite training, healthcare workers too often neglect to glove for one reason or another. The best remedy for neglect is to use "consciousness raising" tactics, such as putting up gloving signs and posters in all patient care areas and having frequent, brief safety meetings at which safety-related topics are discussed.

Glove quality. Glove quality is a long-standing problem. Examination and surgical gloves must be strong enough to withstand hard use, yet flexible and thin enough to allow for good tactile sensation. Therein lies the problem: a significant number of holes are introduced during the manufacturing process, and because of their thinness, gloves frequently develop holes and/or tears during use. To compound the problem, the number of foreign-made gloves that entered the market during the 1980s called into question manufacturing processes, quality control, and raw materials.

Although FDA classifies gloves as Class I devices—devices that pose little or no risk to the patient or user—it imposed premarket approval and good manufacturing practice requirements on glove makers after Centers for Disease Control and Prevention (CDC) issued its recommendations for UP. FDA's acceptable quality limit for surgical gloves is 2.5% defective and for examination gloves, 4.0% (21 C.F.R. § 800.20). In addition, FDA has incorporated glove-testing methods promulgated by the American Society for Testing and Materials (ASTM).

Nevertheless, estimates of the percentages of gloves with holes remain high, ranging anywhere from 1% to 6% for surgical gloves and over 50% for examination gloves (DeGroot-Kosolcharoen and Jones 1989). Furthermore, the ASTM test methods leave much to be desired. The two test standards (D3578-77 for latex exam gloves and D3577-78a for surgical gloves) require filling the gloves with water or inflating them with air and checking for leaks. At least one study found that the tests failed to reveal small holes that were still large enough to admit material in the HIV size range (Carey et al. 1989).

Furthermore, the water-fill and inflation tests are inadequate. Gloves are complex shapes, and the test methods fail to create a uniform stress over their entire surface. Thus, when gloves are filled or inflated, they are more likely to stretch and develop leaks in the palms than in the fingers. As a result, defects in the fingers are often not revealed by the tests.

Practitioners have put forth ideas to compensate for glove inadequacies. Two writers suggested taping gloves up to but not including the fingertips. The tape acts as reinforcement while leaving the fingertips sensitive (Paglia and Sommer 1989). But the most common suggestion is double gloving. The National Committee for Clinical Laboratory Standards (NCCLS) recommends double gloving in some circumstances (see Clinical Laboratory Procedures, below), pointing out that, if the risk of glove failure is 1 in 100, the risk of two gloves failing at the same time is 1 in 10,000. However, many surgeons, as well as other healthcare professionals, assert that double gloving reduces tactile sensitivity too much.

Compliance with the Standard. To meet the requirements of the standard—that is, to provide PPE that fits the user comfortably and does not hinder the performance of duties (and, furthermore, that is accessible)—each patient care unit will have to stock a rather large supply of gloves. While it might impose a burden on hospitals, ECRI believes that keeping a large stock of gloves on each floor is the only way to ensure employee safety and to comply with the standard. ECRI suggests the following:

  • Hospitals should stock three types of surgical and examination gloves: nonlatex or hypoallergenic gloves for employees who are sensitive to the proteins in latex; powderless gloves for employees whose skin reacts to talc; and regular powdered gloves for those who have no problems with allergies or powders.
  • Each type of glove should be stocked in the range of available sizes.
  • All types and sizes of gloves should be made available in each patient care unit.
  • Thought should be given to encouraging surgical personnel to double glove. Studies have shown that double gloving tends to reduce exposure to the hands (Gani et al. 1990; Sheeler 1990; Eckersley and Williamson 1990).
  • Anesthesia personnel should be included among those who must glove during surgery. Studies have shown that anesthesia personnel are at higher risk of exposure from blood than from saliva (Harrison et al. 1990).
  • Hospitals should consider providing industrial or safety gloves to employees who handle contaminated laundry, which might conceal used sharps, or who handle contaminated sharp surgical instruments postoperatively for reprocessing. These gloves might provide additional protection against needlesticks.

In some hospitals, employees open surgical suction canisters for disposing of the contents or adding blood solidifiers. Users have been cut by sharp edges on these systems. The need for industrial or safety gloves for this use may depend on the type of system used; users should determine whether an alternative collection system is available that does not pose this risk. ECRI recommends against the practice of opening suction canisters.

Other Protective Clothing

Unfortunately, penetration times for blood and OPIM have not been calculated for most protective clothing, making it difficult to choose protective clothing for specific exposure scenarios. Hospitals should keep in mind that OSHA does not consider uniforms that employees wear to work as PPE. ECRI recommends the following:

  • Provide lab coats or aprons to all personnel, uniformed or not, whose assigned duties might involve exposure to mild splashing or splattering, such as during phlebotomy, or to samples, such as in clinical labs.
  • Require all uniformed personnel whose duties entail possible exposure to keep a clean uniform at work in case one uniform becomes soaked in blood or OPIM.
  • Launder at the hospital any employee's personal uniform that becomes badly contaminated with blood. ECRI defines "badly contaminated" as contaminated to the point at which the employee or a supervisor thinks the uniform should be removed and replaced by a clean one. A few drops of blood on a uniform do not constitute "badly contaminated."
  • Handle contaminated personal uniforms with the same procedures and precautions as other contaminated laundry.
  • Provide coveralls or other complete body covering, shoe and head coverings, and heavy utility gloves to laundry workers who handle contaminated linens (note that, because patient linens might contain sharps, ECRI recommends considering the use of industrial or safety gloves, which might provide additional protection). PPE for laundry workers who work with contaminated linens should have long sleeves. Surgical scrubs should not be considered PPE because they do not provide soak-through protection.
  • Place contaminated protective clothing that is to be decontaminated in the same bags used for contaminated laundry and subject it to the same procedures as any other laundry.
  • Place contaminated protective clothing that is to be discarded in medical waste "red bags."
  • Discourage employees from providing their own personal protective clothing.

Housekeeping Procedures

Housekeeping employees are exposed to blood and OPIM when they clean up spills, clean up operating rooms and emergency rooms, and collect contaminated waste. Therefore, hospitals should provide housekeeping employees with fluid-resistant coveralls, aprons, or lab coats; heavy rubber gloves; and shoe covers.

ECRI recommends the following procedures for employees who handle regulated waste (OSHA's term for infectious waste):

  • All wastes that are wet with blood or OPIM should be placed in leakproof bags that are marked with the biohazard sign.
  • Infectious waste bags should not be filled to the point that they are stretched tight. Overfilling can cause bags to break.
  • If the outside of a bag becomes contaminated, the bag should be placed inside another bag.
  • To avoid contact with sharp items in red bags, employees should pick up bags by the top—that is, the part of the bag that is gathered above the closure point. Employees should not carry bags in their arms.
  • Filled bags should be placed on collection carts as soon as possible. Employees should not walk any farther than necessary with infectious waste bags. Collection carts should be brought into the room or parked at the door of the room.
  • If the outside of a bag is visibly contaminated, it should be placed inside another bag.

ECRI recommends these procedures for cleaning up spills of blood and OPIM:

  • Make every effort to avoid contact between the blood or OPIM and skin and clothing.
  • Always wear protective equipment, including rubber utility gloves, apron, lab coat or coveralls, and shoe covers.
  • Use a mop for cleaning up spills on floors. Use a rag only for spills on other surfaces.
  • Flush mop water into a sanitary sewer as soon as possible.
  • Use disposable mop heads in operating rooms.
  • Dispose of used mop heads and contaminated cleanup rags as infectious waste in containers marked with the biohazard sign.
  • Decontaminate exposed surfaces with bleach or another disinfectant approved by the hospital.
  • If protective equipment becomes soaked or covered with infectious materials, change it for clean equipment. Dispose of contaminated equipment as contaminated waste, or decontaminate it in an approved manner.

ECRI recommends the following procedures for employees who handle potentially infectious waste for final disposal:

  • They should wear utility gloves and coveralls.
  • Contact with bags marked with the biohazard sign should be minimized. Bags should be picked up by the top only, not held in the arms.
  • Boxes and bags destined for final disposal should not be opened.
  • If the contents of a bag spill, the bag should be picked up with a shovel or broom and long-handled dustpan and put immediately into the incinerator, autoclave, or shipping box.
  • If boxes of waste destined for disposal off-site are contaminated on the outside, they must be put into clean boxes.

Laundry Procedures

OSHA's requirements for laundry workers are designed to protect against both needlesticks from concealed sharps and exposures from blood-soaked linens. ECRI believes that simple, commonsense procedures can help workers minimize contact with blood and OPIM. ECRI recommends the following procedures to minimize exposure risks to laundry employees:

  • PPE must be worn. Protective clothing for workers who handle contaminated laundry includes shoe covers, surgical caps, and fluid-resistant coveralls.
  • If employees are splattered or splashed by contaminated laundry, they should be provided with surgical masks and goggles.
  • If PPE becomes soaked or covered with blood, it must be changed for clean equipment as soon as possible. Contaminated equipment should be disposed of as contaminated waste or decontaminated in an approved manner.
  • Eye protection should be decontaminated with warm water and household bleach, followed by warm water and soap.
  • Employees should handle contaminated laundry in such a way that dripping, splashing, and splattering of blood and OPIM are minimized.
  • When bed linens are wet or visibly contaminated, they should be balled and bagged without picking them up. They should not be held or carried in the arms.
  • Contaminated laundry should not be separated from noncontaminated laundry. All dirty patient laundry should be treated as contaminated and placed in a bag marked with the biohazard sign at the site where it is generated; it should not be sorted outside the laundry room.
  • Employees should not reach into bags of contaminated laundry. If dissolving bags are not used, contaminated laundry should be emptied directly from the bag into the washing machine.
  • Any sharps found in contaminated laundry or in washers should be placed in a conveniently located sharps disposal container, which should be replaced at regular intervals. If it becomes filled to capacity, it should be replaced with a new container.

Dealing with the Heat Problem

Many hospital laundries are not air-conditioned, which becomes a problem if workers are required to wear protective clothing in the summer. Protective clothing and other protective devices are hot and can become unbearable very quickly. Work procedures should be developed, and perhaps engineering controls implemented, that make full-body protective clothing unnecessary. Until such methods are available, PPE should be worn.

Use of Dissolvable Laundry Bags

Dissolvable laundry bags are a good engineering control to prevent exposure. But ECRI has received reports from hospitals that the bags begin to dissolve before they are placed in the washers if they are filled with wet laundry. Therefore, before purchase, hospitals should test these bags by filling them with wet laundry at collection points distant from the laundry area to determine whether, under normal work conditions, they will hold up until placed in the washers.

Use of Outside Laundry Services

Hospitals that send their laundry to an outside service are obligated to use correctly marked bags for contaminated laundry. Although the standard does not stipulate any obligation further than that, ECRI believes that it is in the hospital's best interest to ensure that its laundry contractor provides its own employees with the proper protective equipment, clothing, and training mandated under the standard. Those employees of outside contractors who handle contaminated laundry should be provided with hepatitis B vaccine at the contractor's cost.

Servicing Contaminated Medical Equipment

The standard requires that contaminated medical equipment be decontaminated before it is sent out for servicing or is serviced in the hospital. If the equipment cannot be decontaminated, the hospital must tag it, and information about its contamination must be conveyed to hospital employees, as well as to outside service representatives. Under the standard, a hospital could be held liable for infection contracted by an equipment repair contractor or even a manufacturer's employee who services the company's devices.

Ideally, manufacturers should always include decontamination instructions with their equipment. Unfortunately, they do not always do this. Thus, the biomedical engineering or maintenance staff, in conjunction with housekeeping, should develop written decontamination procedures that cover the following:

  • All equipment that is serviced by hospital personnel,
  • All equipment that must be sent out, and
  • All equipment that is serviced by contractors in-house.

Written procedures developed by the hospital should include any procedures provided by manufacturers. Such procedures are not, however, a mandatory part of the exposure control plan, but they may be included.

ECRI recommends that hospitals do the following:

  • Urge manufacturers to include decontamination procedures in their instruction manuals. Procedures should also indicate which parts of the equipment are likely to be contaminated and define the level of decontamination required.
  • Make sure that decontamination responsibility is spelled out in service contracts.
  • Try to arrange for the manufacturer's representatives or service contract personnel to assume responsibility for decontaminating equipment such as centrifuges, clinical analyzers, oxygenators, or hematology analyzers that may be difficult to decontaminate, may not have a prescribed decontamination method, or may be damaged by an incompatible disinfectant.
  • If manufacturers or service contractors request a waiver of liability for contaminated equipment, submit the waiver to risk management and to the hospital legal department for consideration.

(Also see ECRI's Health Devices Inspection and Preventive Maintenance System "Infection Control, Decontamination, and the Clinical Engineer" in Health Devices 18[10], October 1989.)

Clinical Laboratory Procedures

Causes of Exposure

One study of laboratories at the National Institutes of Health (NIH) found high levels of exposure in general (Evans et al. 1990). The authors attributed their findings to four causes:

  1. Inappropriate Behaviors. Workers routinely wore gloves when handling blood at only 33% of the workstations monitored. Four workers were observed mouth pipetting serum and live virus suspensions despite prohibitions against this practice in the proposed standard and in every manual of good laboratory practice.
  2. High Workloads. Simple, repetitive tasks performed under the pressure of time lead to a breakdown in attention to precautions and safety procedures.
  3. Faulty Instruments. Some instruments splattered blood about. Devices with sample containers that have to be washed present the greatest risk.
  4. Faulty Technique. The authors observed blood spills that occurred even when written procedures were followed to the letter. Image and flow cytometric systems had the greatest frequency of spills.

Most exposures were attributed to behaviors, including failure to follow procedures and use of faulty technique. In light of the potential for exposure in clinical laboratories, ECRI recommends the following:

  • Every clinical laboratory should have a written biosafety manual;
  • Every clinical laboratory should have a manual of standard operating procedures (SOPs);
  • New employees should demonstrate proficiency in the SOPs before beginning work;
  • Employees who perform repetitive tasks should be rotated between tasks to help prevent the negligence that comes from monotony;
  • Operators of automated clinical analyzers and other instruments should wear gloves, lab coats, and eye or face protection, as appropriate;
  • Wastes from analyzers should be disposed of directly into a sanitary sewer (if permitted by local sewer authorities) without the need for employee handling in any way;
  • Blood and OPIM in collection tubes should be discarded into appropriate rigid containers;
  • Biomedical engineering or laboratory staff should use safety precautions when checking instruments for proper function;
  • Safety measures in using centrifuges should be incorporated (see our Hazard Summary on centrifuges in Health Devices 21[12], December 1992); and
  • Potential exposure should be an important factor in selecting equipment for purchase.

Reducing Exposure

According to Dr. Janine Jagger and her colleagues, "The potential for exposure to lab specimens contaminated with hepatitis B virus remains high, and the prevalence of HIV-contaminated specimens continues to increase. . . . Because of the volume of blood and body fluid specimens processed in most clinical laboratories, it is probable that a high proportion of laboratory workers are likely to handle many HBV and HIV positive specimens daily" (Jagger et al. 1992). The nature of that risk was analyzed by Evans, Henderson, and Bennett, who found that "workers who process blood from numerous donors (high workloads typically associated with diagnostic testing) increase their risk of occupational exposures to blood-borne pathogens" (Evans et al. 1990:426). It is not surprising, then, that studies have found hepatitis B, as measured by antibody counts, to be unusually prevalent among laboratory workers (Levy et al. 1977) and that laboratory epidemics of the disease have been recorded (Pattison et al. 1974).

Clinical laboratory personnel should practice all the engineering and work practice controls and should use the PPE employed against exposure in other scenarios. In addition, NCCLS draft recommendations include the following practices for laboratories.

Use of Gloves

  • Laboratory workers should not cut off the tips of gloves to increase finger sensitivity.
  • Because HBV can be transferred from hand to surface and from surface to hand, gloves should be removed before handling telephones and any other uncontaminated equipment.
  • Workers should double glove for autopsies and other procedures that might involve gross contamination.

Use of Facial Protection

  • To prevent splattering, a plastic-backed gauze pad or a flexible plastic cap should be used to cover specimen tubes when removing rubber stoppers. Screw-top tubes eliminate the hazard.
  • Laboratory safety boxes or other types of shields might be used for unstoppering sample tubes.
  • Full face shields should be used when splattering is anticipated, such as during autopsies.

Treatment of Skin Defects

  • Water-impermeable occlusive dressings should be used for all cuts, abrasions, dermatitis, or lesions.
  • Defects on fingers can be covered by a rolled-end finger cot. For other defects, gauze should be placed over the wound, and latex from a glove or rubber dental dam should be placed over the gauze. The edges should be sealed with waterproof tape, such as that used to cover vascular catheter sites.

Encouraging Use of the Hepatitis B Vaccine

Postexposure Follow-Up

The first hepatitis B vaccines were derived from human serum. Some feared, therefore, that the vaccine could be contaminated by HIV or HBV and that the viruses could be transmitted to those receiving the vaccine. In light of these fears, ECRI's publication Healthcare Risk Control and other experts in hospital risk management advocated the use of an informed consent for hepatitis B vaccine. No case of transmission of either virus from hepatitis B vaccine has ever been reported. Today, the situation is different because recombinant vaccines not derived from serum are available.

In light of the requirements of the standard and the CDC's recommendations for preventing hepatitis B, ECRI advocates the following:

  • Every hospital should begin an active campaign to encourage employees to receive hepatitis B vaccine. Such a program should involve the human resources department, employee health, the unions, and management personnel.
  • Encourage employees undergoing the vaccination series to receive their shots on time. Because full immunity is not conferred until the final dose is administered, employees who delay receiving their shots are at increased risk.
  • Administer postvaccination testing for antibodies only to those persons with the greatest exposure potential, such as operating and emergency room staff. ECRI believes this is important because administration of hepatitis B immune globulin (HBIG) after exposure is not reliable after seven days. Therefore, exposure of persons of unknown immune status may not have time to be tested before the optimal prophylaxis period has expired.
  • Immunize students in healthcare profession programs as early as possible so that they will be immune before their first contact with blood. Ideally, this should be done during the first year of medical, nursing, dental, or other professional school.
  • Immunize all laundry employees and housekeeping personnel as soon as possible. Because of the recommended duration of the vaccination series, it will not be possible to provide full immunity to new workers before they start the job.
  • If a large percentage of housekeeping and laundry employees come primarily from foreign countries or territories with high endemic rates of hepatitis B infection, prescreening them for immune status might prove to be cost-effective.
  • If an employee cannot remember whether he or she has been vaccinated and if no medical records are available, offer the vaccine to that employee without testing for immune status. Revaccination of an immune person has no adverse effects.

Vaccination of Outside Contractors

ECRI believes that outside contractors who work in hospitals are at risk for hepatitis B infection. While it is not the hospital's responsibility to vaccinate contractors, a hospital could possibly be held liable for an infection incurred by a contractor. It is a good practice to encourage (or require as a vendor qualification) contractors to provide hepatitis B vaccine to their employees. As a matter of policy, ECRI offers hepatitis B vaccine to its employees who spend time consulting in hospitals.

Communicating Hazards to Employees

Regarding labels and signs, ECRI does not agree with those commenters who argued that they vitiate UP. We see a parallel between stop signs and biohazard labels: just as the presence of stop signs doesn't mean that people will give up driving defensively, the presence of biohazard labels doesn't mean that workers will ignore the risks of blood and OPIM. Therefore, just as local agencies continue to put up signs at dangerous intersections, so should hospitals continue to label hazardous materials. ECRI advocates that all regulated waste containers be color coded and labeled. Most already come that way from suppliers.

Training

While OSHA does not require supervised training, ECRI believes that the most effective training is conducted with a trainer present because of the following:

  • Supervised sessions guarantee that all employees receive equal training.
  • Studies have shown, unfortunately, that a significant percentage of the U.S. labor force has problems with reading, writing, and using computers.
  • Trainers should have the know-how to deal with individual employee problems; neither computers nor media presentations can offer similar flexibility and adaptability, no matter how cleverly they are designed. Remember, OSHA requires that the training suit the employee's language and educational background.
  • Supervised training protects the hospital from the liability incurred from employees who skip training or who have someone else complete an unsupervised training curriculum for them.

ECRI recommends that hospitals design two basic training curricula, one for nonprofessional staff and one for professional staff. The two programs should differ only in the amount of information presented, assuming that professional employees have an educational background that will enable them to understand more about the biologic, epidemiologic, and clinical features of bloodborne diseases. However, nonprofessional staff should be encouraged to learn all that they wish about these diseases, and materials and instruction should be made available to anyone who wishes to gain more information.

Of the nonprofessional staff, training should be provided at least to all housekeeping, laundry, and central processing personnel; nurses aides; and employees who handle wastes for incineration, autoclaving, or shipping. Of professional staff, training should be provided to all doctors and nurses, phlebotomists, laboratory employees, biomedical engineers, and facility engineers.

A Minimal Training Syllabus

Based on OSHA's bloodborne pathogens standard, the requirements for both training and the hospital's exposure control plan are similar. In fact, training essentially consists of an explanation of the general protective principles in the OSHA standard; the exposure control plan is the facility-specific implementation of those principles. The following syllabus, developed by ECRI, can serve as the foundation both for training employees and for developing an exposure control plan.

The Essential Elements of Training

Once a hospital has determined that assigned duties involve occupational exposure to blood or other potentially infectious materials (OPIM), such as semen and amniotic fluid, a training program must be instituted to protect employees. These substances can harbor infectious organisms, viruses, and bacteria that can be transmitted through contact with blood or mucous membranes, for example in the eyes, nose, or mouth. The training session should advise employees of this risk and tell them what measures the hospital has implemented to protect them from exposure to blood and OPIM.

The epidemiology, transmission, and clinical presentation of bloodborne diseases must be thoroughly reviewed. The OSHA standard definition of "exposure incident" involves a break in the skin by a potentially contaminated item (e.g., a needle, a piece of broken glass) or contact of mucous membranes, eyes, or nonintact skin with blood or OPIM. If employees get blood on their skin, but the skin is not cut or scratched, they are unlikely to become infected by a bloodborne pathogen.

Emphasis should be placed on three points:

Who gets bloodborne diseases? Anybody can get a bloodborne disease; bloodborne diseases are not limited to any sex, sexual behavior, or ethnic or economic group. Case reports show that healthcare workers are by far at greater risk of acquiring occupational hepatitis B virus (HBV) than human immunodeficiency virus (HIV), although HIV is most often fatal.

How does someone get a bloodborne disease? Bloodborne diseases are transmitted by contact between the blood or body fluids of an infected person and the blood and body fluids of a noninfected person. These diseases can be transmitted sexually through semen or vaginal secretions, through breast milk, and through blood contact. They are frequently transmitted among IV drug abusers by infected needles, and they can be transmitted by a bite from an infected person.

Occupationally, the most frequent and efficient route of transmission is through accidental needlesticks and cuts by other sharp, contaminated objects. But pathogens are also transmitted by contact with blood and other body fluids, such as through the nose, eyes, mouth, or cuts or abrasions of the skin (nonintact skin). Bloodborne pathogens are not transmitted through the air from coughing or sneezing or by casual contact with infected individuals; however, they can be carried through the air in blood that is splashed.

How do these diseases affect people? HBV attacks the liver, causing jaundice (a yellowing of the skin), nausea, weakness, and abdominal pain. If left untreated, hepatitis B can become chronic and cause liver destruction, called cirrhosis; it has been linked with liver cancer.

HIV attacks the immune system and causes the disease complex known as acquired immunodeficiency syndrome (AIDS). As the immune system weakens, AIDS patients become susceptible to a wide range of infections, which eventually kill them. Survival time from the onset of infection to death can be as short as 2 years or as long as 10 years. To date, no one has been known to survive AIDS.

How the Bloodborne Pathogens Standard Protects Employees

The seriousness of bloodborne diseases and the potential for occupational exposure prompted OSHA to enact a standard that sets forth regulations to protect workers from exposure to bloodborne pathogens through contact with blood or OPIM.

The standard requires hospitals to implement eight protective measures:

  1. Universal Precautions (UP)—A work practice under which all blood, OPIM, and contaminated devices are handled as if they were infectious. It is not possible to tell whether blood is infectious without laboratory testing, and it is often not possible to tell whether a device, such as a needle, is contaminated. Employees should never be asked to determine whether blood, OPIM, or medical devices are infectious—and should use UP so that they will not have to.
  2. Engineering Controls—Devices that can be used to eliminate sources of exposure. Puncture- and leak-resistant sharps disposal containers are required; self-sheathing sharps are another control that could be used.
  3. Personal Protective Equipment (PPE)—Gloves, lab coats, face shields, and other equipment designed to protect the skin, eyes, and mucous membranes against exposure.
  4. Work Practices and Procedures—Hand washing, removing contaminated clothing, and other practices that minimize contact with blood and OPIM.
  5. Hepatitis B Vaccine—A serum that immunizes employees against HBV infection and eliminates the threat of hepatitis B.
  6. Postexposure Prophylaxis and Follow-up—Procedures that provide the best medical help after exposure has occurred.
  7. Signs and Labels—Warnings used to clearly mark containers of contaminated materials so that others are alerted to the risk.
  8. Training and Information—Methods of teaching employees how to avoid exposure and what to do when exposure occurs.

The Hospital's Exposure Control Plan

OSHA requires all employers to produce a written exposure control plan that incorporates their specific methods of controlling exposure based on the provisions of the standard. The plan contains the hospital's determination of who is at risk for exposure to blood and OPIM and describes practices and procedures applicable to all employees of the hospital, as well as to the performance of specific duties and tasks. The plan must be enforced by the hospital and obeyed by all employees. Copies should be made available to employees at any time; they do not need permission to review it.

The plan should consist of at least the following six measures:

Engineering Controls and Work Practices. The rules for hand washing and other engineering controls or work practices that affect the majority of trainees should be reviewed. Applicable engineering controls and practices should be identified and described, and instruction (hands-on, if possible) provided. The hospital should verify that trainees understand both how and why they are to use the controls and practices. In addition, the schedule for collecting sharps containers should be discussed.

Signs and Labels. All OPIM or their containers must be labeled. The exception to this is blood collection tubes that are used by phlebotomists and seen by patients. The general meaning of the biohazard symbol should be explained, and all items and containers that should bear the symbol or other warning signs should be so labeled. Any container marked with the biohazard symbol should not be used for other than its intended purpose, such as to contain noninfectious materials or noncontaminated items. Decontaminated items may not be put into a container bearing the biohazard symbol. Any particular color codes used in the hospital to indicate potentially infectious materials should be described.

Personal Protective Equipment (PPE). Any task involving exposure to blood or OPIM requires the use of PPE, which should be specified to meet each type of exposure. All PPE will be provided by the hospital at no cost to employees. Methods of using articles of PPE and removing contaminated clothing should be demonstrated, and employees must wash their hands immediately or as soon as possible after removing PPE. PPE must be removed at the work site; it may not be taken out of the facility. Contaminated PPE should either be decontaminated on-site (according to the manufacturer's instructions, by cleaning with bleach, or by laundering with other contaminated laundry) or should be disposed of as infectious waste in a container marked with the biohazard symbol. Personal clothes are not considered PPE, and personal items of clothing should be protected from contamination.

Hepatitis B Vaccine. The fact that the vaccine confers immunity from HBV infection, is 90% effective, and has minimal side effects should be explained, as should the method of determining who should get the vaccine. The vaccine will be provided at no cost to the employee. The series of injections and the schedule should be explained—the sooner employees begin their vaccination series, the sooner they will be protected against hepatitis B infection. The OSHA declination statement should also be presented; employees can change their minds about vaccination at any time without penalty.

Reporting Exposure Incidents. The hospital should stress the importance of reporting exposure incidents and explain the reporting mechanism. Reporting an incident will not adversely affect employment, and confidentiality of medical findings is maintained.

In the event of an exposure incident—a penetration of the skin by a contaminated item or contact of the mucous membrane, eye, or nonintact skin with blood or OPIM—the exposed employee or a coworker should contact a supervisor at once. Reporting is essential so that proper medical care can be administered. The supervisor should immediately contact employee health services. If an exposure incident occurs when the employee health office is closed, the number of an appropriate department should be immediately available to obtain emergency medical help. The OSHA 200 report should be described. Supervisors should receive training on encouraging reporting and on handling reports.

Postexposure Prophylaxis and Follow-up. Any employee who experiences an exposure incident will be provided with medical surveillance and treatment (if required) at no cost to the employee. If possible, the hospital will determine whether the substance to which the employee was exposed is actually infectious and inform the employee of any findings. However, patients are not obligated to report their infection status or release such information. Any subsequent medical treatment will be based on the opinion of the healthcare professional who is in charge of the case.

The employee will be informed of the results of the postexposure evaluation. The employer is entitled to know only whether the employee should receive HBV vaccine, has received the vaccine, and has been informed of any medical conditions resulting from exposure. All other medical information relating to the employee's health is confidential and will not be revealed to the employer or anyone else not designated by the employee to review the medical record.

In Summary

Rules and procedures notwithstanding, compliance with safe practices is ultimately the responsibility of each individual worker. Employers can implement programs in good faith, but for success, workers have to demonstrate good faith, as well. ECRI advocates positive incentives to encourage employees to become more aware of risks and safe practices in their jobs.

At APIC's 1992 meeting (San Francisco, May 31 to June 4), Gina Pugliesi of AHA gave an effective talk on motivating compliance. Her points included the following:

  • Positive incentives versus disciplinary action,
  • Visible commitment by management to employee safety and health,
  • Employee input into the compliance process, and
  • Role models.

ECRI believes that positive incentives are important. Hospitals should welcome innovative suggestions for increasing awareness among staff. They should give serious consideration to poster and safety contests, buttons, and regular safety meetings. ECRI is aware that hospitals have rejected such strategies as childish, or nonscientific, or not staid enough. But they work, as general industry well knows. ECRI recommends that hospitals take a look at the "Safety Compliance Initiative" kit offered by Becton Dickinson, which contains materials and ideas to help get a motivational program started.

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