針灸操作安全指引
Contents
1. water Gloves should be worn for handling blood stains When there is a pool of blood use disposable strong absorbents to perform preliminary cleansing Then disinfect the surface with 1 in 4 diluted household bleach by mixing 1 part of household bleach with 4 parts of water Allow the bleach on the surface for 10 minutes before rinsing with water Environmental cleansing during communicable disease outbreak in the community 4 Use higher concentration of bleach for environmental cleansing For routine cleansing 1 in 99 diluted household bleach is used During the outbreak period l in 49 diluted household bleach is recommended by mixing 1 part of household bleach with 49 parts of water 2 Increase the frequency of environmental cleansing 3 Pay special attention to toilets kitchen and frequently touched surfaces such as switches of lamps door handles and rail Methods to prepare diluted bleach and points to notice when using bleach a b c d e Make all necessary items cleansing tools and personal protective equipments ready such as bleach water large and small measuring cups rubber gloves plastic apron goggles brush mop towel and buckets Open windows to ensure good ventilation while diluting or using bleach so as to decrease the irritability on respiratory tract Caution of bleach splashes during the dilution process Operators should put on personal protection equipment gl2. for Health Protection Department of Health June 2011 1 Environmental hygiene a b c d e The treatment room for acupuncture should be clean dry well ventilated and well lit There are sufficient facilities for hand hygiene in the treatment room All work surfaces should be smooth and impervious so that they could be cleaned and disinfected thoroughly To keep the linen clean soiled linen should be replaced immediately Another option is to cover the treatment bed with single use paper towel Appropriate disinfectants should be chosen for environmental cleansing and disinfection For the details regarding use of bleach please refer to Appendix I 2 Handling of instruments and equipment a b c d e g h i k Use pre packaged disposable sterile acupuncture needles and guide tubes Each sterile needle should be used once only Check the expiry dates of sterile items before use Package should be opened just before use to prevent contamination Acupuncture needles should be examined carefully to ensure their quality before use Acupuncture needles of poor quality should be disposed Sterile items e g alcohol pads sterile needles sterile cotton wool balls and sterile cotton wool sticks etc should be stored in cabinets and their expiry date should be checked regularly Non disposable items with patient contact such as cupping scraping plates dressing cylinder sterile co
3. minutes and then rinsed thoroughly with water Points to notice when using bleach Do not use bleach on metals wool nylon silk dyed fabric and painted surfaces If bleach splashes into eye immediately rinse with copious amount of water and then consult a doctor Bleach should not be used or mixed together with any detergent or acidic solution Otherwise its effectiveness of disinfection will be reduced and toxic gas will be produced which may cause accident Therefore whenever detergent has been used rinse thoroughly with water before using bleach for disinfection When exposed to sunlight high concentrated bleach liberates toxic gas Thus it should be stored in a shaded cool place which cannot be reached by children Note the date of production when purchase as bleach sodium hypochlorite decomposes over time and loses efficacy Bleach recently manufactured is better Furthermore avoid over stocking of bleach Diluted bleach should be used within 24 hours after preparation Appendix II Disinfection sterilization methods Among various sterilization disinfection methods steam sterilization is the only method that can achieve the sterilization standard required in acupuncture needles Please note that both boiling and chemical disinfection do not meet the sterilization standard required in acupuncture needles 1 Steam sterilization Special re usable needles e g plum blossom needles triangular needles si
4. Guidelines on Infection Control related to Acupuncture There is a three month consultation period for the guidelines from today till 30 October 2011 You are welcome to email your comments to us at no_icb3 dh gov hk Thank you Centre for Health Protection Department of Health June 2011 Guidelines on Infection Control related to Acupuncture Contents MIMO GUC LION ese 8 oh hace Nese ce E Oecd ae E ceeded hia aaa eck ones Mi paca ie andl sea aa ek a bel ct 3 l En yir nmental hyg ee 242055 e i E R a AE EAE EA A E A ERa S 5 2 Handling of instruments and equipment ssnssessseseeeeeesseesseesseesseeessstessetsseessersseeessseesseessessee 6 3 Preparation of ACUpuUnCtunrists 2 5 ja tinen Gein ite i MMOs en nde ieee eee tead 7 A Preparation of clients 605 coak cade cacesanegianSevecuceslee Seed een M ooer reer eoor rres tenes 9 5 Aseptic acupuncture techniques s esses eooo gms oe ce nececoetescetseecensersenteccetteccetseesontens 10 6 Clinical waste disposal ccccccccssscecncece epee T MEM sccessscsesssssesssccsssssessnsseseneeeenees 11 7 Management of post acupuncture complications ee eeeceeeeteececeeeceeceseeeeseecaeenseenseeesaees 12 8 Management of sharps 1njUry MER L eener eee MMMM sscsssssescnsscssnnsesenaseeenees 12 Appendix I Use of bleach sessssonnsseese Ne eee ss ge essers orsessessoreeeso 13 Appendix II Disinfection sterilization methods stiesesee
5. SY Chong KTK Cheung EYL Yuen KY Relatively 19 alcohol resistant mycobacteria are emerging pathogens in patients receiving acupuncture treatment Journal of Clinical Microbiology 2002 40 4 1219 24 18 Woo PCY Li JHC Tang W Yuen K Acupuncture mycobacteriosis New England Journal of Medicine 2001 345 11 842 3 19 Wu JC Lin HC Jeng FS Ma GY Prevalence infectivity and risk factor analysis of hepatitis C virus infection in prostitutes J Med Virol 1993 39 312 7 20 Zhang JH Shang HC Gao XM et al Acupuncture related adverse events a systematic review of the Chinese literature Bulletin of the World Health Organization Online 27 August 2010 http www who int entity bulletin online_first 10 076737 pdf 21 40 Ai EP SRA SR GRBERALATR gt ADT A R A A a H RE A KR Bw HH KR BS BR A 207 F 9 AF http www chp gov hk files pdf g198 20080128 tc pdf 22 4 ft w HB Ps Bak KH KH A 2007 11 A http www chp gov hk files pdf grp useofbleach_rev_ tc NovO7 pdf 23 RERA REE REG 2010 43H 20
6. alth HP LEALE LOEN Organization Appendix IV Hand hygiene techniques 7 parts for 20 seconds OD aya How perform and hygiene i638 Thumbs 42 Finger tips FR Wrists Germano References 1 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities 2008 Available at http www cdc gov hicpac pdf guidelines Disinfection_Nov_2008 pdf 2 Chen MH Chen MH Huang JS Cervical subdural empyema following acupuncture Journal of Clinical Neuroscience 2004 11 8 909 11 3 Hong Kong Hospital Authority Physiotherapy COC Operation Guidelines for Acupuncture by Physiotherapists July 2009 4 Kent GP Brondum J Keenlyside RA LaFazia LM Scott HD A large outbreak of acupuncture associated hepatitis B Am J Epidemiol 1988 127 591 8 5 Kim JK Kim TY Kim DH Yoon MS Three Cases of Primary Inoculation Tuberculosis as a Result of Illegal Acupuncture Annals of Dermatology 2010 22 3 341 5 6 Koh S Song T Kang YA Choi JW Chang KJ Chu CS et al An outbreak of skin and soft tissue infection caused by Mycobacterium abscesses following acupuncture Clinical Microbiology and Infection 2010 16 7 895 901 7 Matsumura Y Inui M Tagawa T Peritemporomandibular abscess as a complication of acupuncture a case report Journal of Oral and Maxillofacial Surgery 1998 56 4 495 6 8 Ogasawara M Oda K Yamaji K Takasaki Y Polyarticular septic arthritis with bilateral psoas abscesses following acupunc
7. ency virus HIV infection Vittecoq et al 1989 Wiwanitkit 2003 acupuncture associated bacterial infections e g methicillin sensitive Staphylococcus aureus abscesses Matsumura et al 1998 Woo et al 2003 Chen et al 2004 Seeley amp Chambers 2006 Ogasawara et al 2009 methicillin resistant Staphylococcus aureus arthritis Woo et al 2009 mycobacterial infections Woo et al 2001 Woo et al 2002 Koh et al 2010 Listeria monocytogenes arthritis Tien et al 2008 and other infections Studd amp Stewart 2004 Kim et al 2010 Most blood borne diseases have long incubation periods and the carriers often are asymptomatic e g hepatitis B virus HBV hepatitis C virus HCV and human immunodeficiency virus HIV Therefore it is recommended using single use disposable or strictly re processed sterile acupuncture needles and strictly performing skin disinfection and standard precautions to prevent acupuncturists or clients from infection We would like to express our gratitude to the following professional organizations for their generous and valuable advice during preparation of the guidelines Hong Kong Registered Chinese Medicine Practitioners Association Association of Hong Kong and Kowloon Practitioners of Chinese Medicine The Hong Kong Federation of China of Traditional Chinese Medicine Hong Kong Acupuncturists Association Hong Kong Physiotherapy Association Hong Kong Physiotherapists Union Centre
8. giene before aseptic procedure No matter before washing hands with liquid soap and water or before rubbing hands with alcohol based hand rub sleeves have to be rolled up and all kinds of things below the elbows that allow pathogens to be hidden e g rings watches bracelets etc should be removed Clean hands with liquid soap and water when visibly soiled or likely contaminated with blood or body fluid Steps are as follows 4 Wet hands under running water 2 Apply liquid soap and rub hands together to make a soapy lather 3 Away from the running water rub the palms back of hands between fingers backs of fingers thumbs finger tips and wrists Appendix IV Do this for at least 20 seconds 4 Rinse hands thoroughly under running water 5 Dry hands thoroughly with a clean cotton towel a paper towel or a hand dryer 6 The cleaned hands should not touch the water tap directly again The tap may be turned off by using the towel wrapping the faucet or after splashing water to clean the faucet i When hands are not visibly soiled hand hygiene could be performed by using 70 80 alcohol based hand rub Steps are as follows 1 Apply a palmful of alcohol based hand rub and cover all surfaces of the hands 2 Rub the palms back of hands between fingers back of fingers thumbs finger tops and wrists Appendix IV 3 Rub for at least 20 seconds until the hands are dry j Surgical gloves should be worn wheneve
9. ieesseeseserssesrersersetetiesressrseresresseserss 16 Appendix III WHO recommended five moments for hand hygiene 17 Appendix IV Hand hygiene techniques 7 parts for 20 seconds eeseeeseeeseecseeeseeeeeeeenees 18 References eese Ro O Ooae s cael SSezeld ds Ua dean a eaedci vas 19 Introduction Acupuncture refers to needling and moxibustion It produces therapeutic effects by applying pressure inserting needles into or burning moxa herb above various human body acupuncture points Acupuncture has a long history which is originated from China Under good management by a qualified practitioner acupuncture associated infections are extremely rare Acupuncture is an invasive procedure Though needles used for acupuncture are very small and fine they break the integrity of skin Theoretically as for any subcutaneous injection acupuncture could pose risks of infection Moreover usually many acupuncture needles are inserted in each course of treatment and kept in situ for a period of time they may have contact with blood In fact acupuncture requires aseptic techniques any lapse in preparation or the acupuncture process can provide opportunities for viruses bacteria or fungi to invade human body and cause infections There are case reports in literatures of acupuncture associated infections including blood borne viral infections e g hepatitis B Kent et al 1988 hepatitis C Wu et al 1993 and human immunodefici
10. l waste and are collected by a licensed collector for incineration Disposal records of clinical waste have to be kept for twelve months 11 7 Management of post acupuncture complications a b c Post moxibustion blisters should be covered with sterile dressing to prevent infection and they should be allowed to absorb naturally If the penetrated sites develop redness abscess or signs of infection medical advice should be sought immediately Ear press needles are usually retained for no more than five days If there are signs of infection or severe itching at the needling sites the needles should be removed immediately 8 Management of sharps injury a b Before commencing health care related jobs prospective workers should check their hepatitis B immune status For non immune workers they should first receive hepatitis B vaccinations for their protection When being injured by used sharps the health care worker should follow the below to manage the situation 4 Clean the wound under running water immediately Gently squeeze out the blood from the wound then disinfect the wound and cover it with dressing 2 Perform risk assessment by checking the HBV HCV and HIV status of the blood source In case of doubt immediately consult the nearest emergency department for blood testing and follow up Appendix I Use of bleach Among household disinfectants bleach is strong and effective is sodium hypochl
11. lver needles and gold needles should be sterilized in an autoclave Temperature should be maintained at 121 C for 15 minutes or at 134 C for 3 minutes WHO 1999 Autoclave should be well maintained and used in accordance with the recommendations of the user manual 2 Boiling disinfection This method is suitable for non invasive items which are made of glass or metal First put the equipment into water The water level should be at least one inch above the items Maintain boiling for 20 minutes after water reaches the boiling point to meet the standard of high level disinfection WHO 1999 3 Chemical disinfection This method is suitable for heat sensitive items Items must be dismantled or opened and fully immersed in the solution Check the expiry dates of disinfectants before use Examples of metallic or glass items cleanse the items first before immersing them into 70 alcohol ethanol for 10 minutes After taking out place in a dryer to blow dry or wipe dry with a clean towel Examples of plastic or glass items cleanse the items first before immersing them into the 1 in 99 diluted household bleach After 30 minutes rinse thoroughly with water then place in a dryer to blow dry or wipe dry with a clean towel The chemical agent should be changed daily Appendix III WHO recommended five moments for hand hygiene Your 5 moments for hand hygiene T E Ys OR RF AY BF Zl World He
12. n site by scrubbing in a rotary motion starting at the centre of the site When using 70 alcohol for disinfection allow the alcohol to evaporate before insertion of acupuncture needles Acupuncturist should not touch the disinfected skin with bare hands Otherwise the skin disinfection has to be done again The acupuncturist should only hold the handle of the needle so as to avoid touching the shaft of the needle that will penetrate into the skin When grasping of the needle shaft deems necessary adequate disinfection should be done first Counted against the insertion record to make sure that the number of needles removed is the same as inserted If there is any missing needle search hard to find it Needles after removal should be discarded immediately into a sharp box and be disposed as clinical waste 6 Clinical waste disposal a b c Used disposable needles or sharps should be disposed directly into a sharp box labelled with clinical waste 4 The sharps box should be sealed when it is 3 4 full 2 Sealed sharps boxes should be put into a red plastic bag securely tied by the swan neck method labelled as clinical waste and are collected by a licensed collector for incineration Wastes with small volume of body fluids or blood stains can be disposed as domestic garbage Dressings or wastes soaked with or containing large volume of body fluids or blood should be disposed in a red plastic bag labelled as clinica
13. ntainer and forceps should be cleaned and disinfected after each use Reusable items should be processed according to the principles of Cleansing before disinfection Items should be cleansed in designated sinks not in handwashing basin Re used acupuncture needles must be strictly disinfected to meet sterility standard Appendix II Both sterilized and disinfected items should be kept in a covered sterile container or sealed in a package to prevent contamination Storage areas must be maintained clean and dry to prevent growth of bacteria or fungi 3 Preparation of acupuncturists a b c d e g h Acupuncturists should wear uniform or put on working coat while working in the treatment room and change clothes or take off the working coat before leaving the treatment room Alcohol based hand rub should be available at bedsides or in pocket of working coat While suffering from hand infection the acupuncturist should not perform acupuncture Fingernails of acupuncturists should be trimmed short and artificial fingernails are not permitted All cuts or breaks on hands or fingers should be covered with water proof dressing Hand hygiene has to be performed in the following situations Appendix MI 1 Before patient contact 2 Before aseptic procedure 3 After patient contact 4 After contact with patient surroundings 5 After contact with blood or body fluids Strictly observe hand hy
14. orite It is able to destroy bacteria fungus and virus Thus diluted bleach is recommended for environmental disinfection However bleach irritates mucous membranes skin and airway It decomposes under Its major ingredient heat or light and reacts easily with other chemicals Therefore caution should be exercised during its use Improper use of bleach not only reduces its effectiveness in disinfection but may also lead to accidents Overuse of bleach will pollute the environment and disturb ecological balance a b c d e All non metallic surfaces such as tables desks chairs and beds should be wiped with 1 in 99 diluted household bleach by mixing 1 part of household bleach containing 5 25 sodium hypochlorite with 99 parts of water 70 alcohol should be used for disinfecting metallic surfaces as bleach will corrode metal Gloves should be worn for handling items contaminated with vomitus excreta or body fluid 1 Use disposable strong absorbents to perform preliminary cleansing 2 Then disinfect the surface with 1 in 49 diluted household bleach by mixing 1 part of household bleach with 49 parts of water allow the bleach on the surface for 15 to 30 minutes before rinsing with water 3 Items with rough and uneven surfaces are difficult to wipe if possible immersion cleaning will be more effective These items should be soaked in bleach for a bit longer at least 30 minutes Then rinse with
15. oves plastic apron and goggles to protect their mucous membranes and skin Bleach should be diluted with cold water since hot water will decompose the bleach and make it lose efficacy When bleach is containing 5 25 sodium hypochlorite the diluting methods are as follow 4 Prepare 1 in 99 diluted household bleach for usual cleansing by mixing 10ml bleach with 990 ml water total 1000ml 2 Prepare 1 in 49 diluted household bleach for disinfecting items contaminated with vomitus excreta and secretions by mixing 20ml bleach with 980 ml water total 1000m1 3 Prepare 1 in 4 diluted household bleach for disinfecting items contaminated with blood by mixing 20ml bleach with 80 ml water total 100ml 4 Adjust the required amount of bleach if the available bleach is not exactly containing 5 25 sodium hypochlorite For example when the currently available bleach contains only 5 sodium hypochlorite first calculate the multiplier of the required amount of bleach Dividing 5 25 by 5 the concentration of the currently available bleach gets the multiplier of 1 05 If 1 in 99 diluted household bleach is needed multiplying 1 05 by 10 ml gets 10 5 ml g h i which is the required amount for 5 bleach The required amount of bleach should be accurately measured by a measuring cup After disinfected by bleach articles should be rinsed thoroughly with water The used cleaning tools should be soaked in diluted bleach for 30
16. r the acupuncturist may be exposed to blood mucous membranes broken skin or other potentially infectious materials k A pair of gloves should not be used for more than one client 1 Hand hygiene can never be replaced by wearing gloves m Hand hygiene should be performed before putting on and after taking off gloves 4 Preparation of clients a Thoroughly review the client s information and pay attention to the potential risk factors 4 Medical history skin infection infectious disease e g viral hepatitis HIV infection chronic illness e g diabetes mellitus renal disease epilepsy cancer and bleeding tendency 2 Drug history steroid or anticoagulant e g warfarin 3 Allergy history drugs or alcohol allergy 4 Laboratory investigation results microbiology and virology reports international normalized ratio INR and platelet count b Advise clients to observe good personal hygiene If deemed necessary advise them to have shower or wash hair applicable for clients who require acupuncture on the scalp before consultation c Advise clients to wear mask if they have respiratory symptoms such as cough or sore throat 5 Aseptic acupuncture techniques a b c d e 2 Acupuncturists should perform hand hygiene before the procedure to prevent infections Prepare the skin prior to acupuncture Use swab with 70 alcohol or povidone iodine or chlorhexidine in alcohol to disinfect the penetratio
17. ture Acupuncture in Medicine 2009 27 2 81 9 Seeley EJ Chambers HF Diabetic ketoacidosis precipitated by Staphylococcus aureus abscess and bacteremia due to acupuncture case report and review of the literature Clinical infectious diseases 2006 43 1 e6 10 Studd RC Stewart PJ Intraabdominal abscess after acupuncture New England Journal of Medicine 2004 350 17 1763 11 Tien CH Huang GS Chang CC Chang DM Lai JH Acupuncture associated Listeria monocytogenes arthritis in a patient with rheumatoid arthritis Joint Bone Spine 2008 75 4 502 3 12 Vittecoq D Mettetal JF Rouzioux C Bach JF Bouchon JP Acute HIV infection after acupuncture treatments New England Journal of Medicine 1989 320 4 250 1 13 WHO Guidelines on Basic Training and Safety in Acupuncture 1999 http whqlibdoc who int hg 1999 WHO EDM TRM_ 99 1 pdf 14 Wiwanitkit V HIV infection after Chinese traditional acupuncture treatment Complementary therapies in medicine 2003 11 4 272 15 Woo PCY Lau SKP Wong SSY Yuen KY Staphylococcus aureus subcutaneous abscess complicating acupuncture need for implementation of proper infection control guidelines New Microbiol 2003 26 169 174 16 Woo PCY Lau SKP Yuen KY First report of methicillin resistant Staphylococcus aureus septic arthritis complicating acupuncture simple procedure resulting in most devastating outcome Diagnostic Microbiology amp Infectious Disease 2009 63 1 92 5 17 Woo PCY Leung KW Wong S
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