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OSHA Explores Infectious Exposure Issues


By Kelly M. Pyrek

Editor's note: This article originally appeared as part of the 2012 Regulatory Update in the January 2012 print issue of ICT. To access a slide show presenting the highlights of the 2012 Regulatory Update, CLICK HERE.

The Occupational Safety and Health Administration (OSHA) is continuing to examine occupational exposure to infectious agents in healthcare settings, and members of the infection prevention and healthcare epidemiology communities are weighing in with their perspectives as the federal agency gathers data.

OSHA says it is interested in strategies currently being deployed in healthcare settings to mitigate the risk of work-acquired infectious diseases. As such, OSHA is collecting information and data on the facilities and the tasks potentially exposing workers to this risk; successful employee infection control programs; control methodologies being utilized (including engineering, work practice, and administrative controls and personal protective equipment); medical surveillance programs; and training. It solicited public comment and also held stakeholder meetings to gather additional insights. Last summer, OSHA solicited public comment and the agency will use the information received to determine what action, if any, the agency may take to further limit the spread of occupationally-acquired infectious diseases in healthcare settings. More than 200 comments were submitted, many from healthcare professionals at hospitals and healthcare systems, departments of health, associations serving the infection prevention community, and members of industry.

"OSHA is exploring the possible development of a proposed rule to protect workers from occupational exposure to infectious agents in healthcare settings where direct patient care is provided and other settings where workers perform tasks with occupational exposure," explains Kimberly Tucker in the Office of Communications at OSHA. "The July 29, 2011 meetings were designed as an open discussion so that participants could share with OSHA not only regulatory options and concerns but also alternative approaches. The stakeholder meetings were just one of many sources of information that the agency is using to inform its decision on how to proceed on the issue of infectious diseases. OSHA received substantial input from stakeholders during the request for information, all of which is publicly available in the docket. OSHA is also continuing to review and evaluate the scientific literature which contains a great deal of information on adherence in infection control guidelines."

One action that OSHA is considering is the development of a program standard to control workers’ exposure to infectious agents in settings, either where workers provide direct patient care or where workers perform tasks other than direct patient care which also have occupational exposure. These other tasks might include such tasks as providing patient support services (e.g., housekeeping, food delivery, facility maintenance); handling, transporting or wastes (e.g., laundering healthcare linens, transporting medical  specimens, disposing of medical waste, reprocessing medical equipment);  maintaining, servicing or repairing medical equipment that is  contaminated with infectious agents; conducting autopsies (e.g., in  medical examiners' offices); performing mortuary services; and  performing tasks in laboratories (e.g., clinical, biomedical research,  production laboratories) that result in occupational exposure.

"All workplaces must be safe workplaces," says David Michaels, PhD, MPH, assistant secretary of labor. "We know that workers in healthcare and related facilities may be exposed to infectious agents, and they deserve to be protected. Preventing infectious disease among workers also will reduce exposure to their family members and to patients." Michaels is tasked with making the final recommendation on a potential standard and as of press time in late November, no decision has been made.

The July 29 stakeholder meetings were conducted as group discussions on views, concerns and issues surrounding the hazards of occupational exposure to infectious agents and how best to control them. At the meeting, Andrew Levinson, director of the OSHA Office of Biological Hazards, described OSHA's traditional approach to a program standard, which follows the principle of "plan, train, do." The planning element of this approach details the hazards and provides a framework that employers use to execute the training and implementation elements of a program standard. This approach allows for a large amount of flexibility -- if something changes, employers can just adjust the plan and retrain their workers. OSHA is also considering a vertical approach for a potential standard. Vertical standards apply to a particular group of workers where a hazard exists, while horizontal standards apply to any worker in any industry where the hazard exists. Vertical standards emphasize scope, and take into account the hazard and the specific workers and settings.

The potential standard that OSHA is considering would encompass all exposure pathways (e.g., contact, droplet, airborne), but would only cover contact transmissions that are not covered by the bloodborne pathogens (BBP) standard. For example, it would cover methicillin-resistant Staphylococcus aureus (MRSA) but not hepatitis B. In developing such a standard, OSHA would review the Healthcare Infection Control Practices Advisory Committee (HICPAC)'s guidelines and extract programmatic and administrative elements for incorporation. Levinson emphasized that the meeting should focus on four elements: validation of metior elements, blind spots or errors in major elements, areas with unintended consequences, and issues associated with non-hospital settings (e.g., mortuary, ambulatory, long-term care, home health, laboratories).

Essentially, OSHA representatives sought specific information on the potential development of a program standard that would include the following sections: the scope, application, costs, and availability; Worker Infection Control Plans (WICPs) and methods of compliance;  medical screening, surveillance, and vaccination; and communication of hazards and recordkeeping.

The meeting discussions focused on such major issues as:
     - Whether and to what extent an OSHA standard on occupational exposure to infectious diseases should apply in settings where workers provide direct patient care, as well as, settings where workers have occupational exposure even though they don't provide direct patient care. Whether and to what extent there are any other settings where an OSHA standard should apply.

     - The advantages and disadvantages of using a program standard to limit occupational exposure to infectious diseases, and the advantages and disadvantages of taking other approaches to organizing a prospective standard.

     - Whether and to what extent an OSHA standard should require each employer to develop a written worker infection control plan (WICP) that documents how the employer will implement the infection control measures it will use to protect the workers in its facility. Some of  the elements that might be appropriate to include in such a WICP are: Designation of the plan administrator responsible for WICP implementation and oversight; designation of the individual(s) responsible for conducting infectious agent hazard  analyses in the work setting; and written standard operating procedures (SOPs) to minimize or prevent exposure to infectious agents (e.g., SOPs for early identification of potentially infectious individuals and for implementation of standard and transmission-based precautions). According to OSHA, in settings where direct patient care is provided, SOPs would likely also include: patient scheduling and intake; standard precautions; transmission-based precautions (contact, droplet, airborne); patient placement and transport; and medical surge procedures.

    - Whether and to what extent SOP development should be based upon consideration of applicable regulations/guidance issued by the Centers for Disease Control and Prevention, the National Institutes of Health, and other authoritative agencies/organizations.

     - Whether and to what extent an OSHA standard should require each employer to implement its WICP through a section addressing methods of compliance. OSHA envisions that this section would require, among other control measures, that an employer conduct an infectious  agent hazard analysis, follow appropriate SOPs, institute appropriate engineering, work practice, and administrative controls, provide and ensure the use of appropriate personal protective equipment, clean and decontaminate the worksite, and conduct prompt exposure investigations.

     - Whether and to what extent an OSHA standard should require each employer to make available routine medical screening and surveillance, vaccinations to prevent infection, and post-exposure evaluation and follow-up to all workers who have been exposed to a suspected or confirmed source of an infectious agent(s) without the benefit of appropriate infection control measures.

     - Whether and to what extent an OSHA standard should contain signage, labeling, and worker training requirements to ensure the effectiveness of infection control measures.

     - Whether and to what extent an OSHA standard should require the employer to establish and maintain medical records, exposure incident records, and records of reviews of its worker infection control program, and whether and to what extent an OSHA standard should contain other recordkeeping requirements.

     - The economic impacts of a prospective standard.

     - Whether and to what extent OSHA should take alternative approaches to rulemaking to improve adherence to current infection  control guidelines issued by the Centers for Disease Control and Prevention, the National Institutes of Health, and other authoritative agencies/organizations.

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