Keeping Employees Healthy:
The Far-Reaching Effects of Occupational Health
By Patricia Tydell, MSN, BSN, MPH
1. To identify the components of an injury-illness prevention program.
2. To describe the selected hazards found in the workplace.
3. To state methods designed to prevent workplace injury and illness.
|Test Questions: Answer True or False|
|1. The purpose of educating staff is to help them be more compliant with a prevention program.||T||F|
|2. Policies that implement the program should have input from frontline staff.|
|3. Patients and /or families should not be bothered with safety issues when they are in the hospital.|
|4. The goal of occupational health is the prevention of injury and illness in the workplace.|
|5. A comprehensive program to assure prevention would include assessment of the environment, engineering controls, work practices and monitoring|
|6. An external consultant who is an expert in safety must do a hazard risk assessment of the work area.|
|7. The development of an assessment tool will help to ensure that the team conducts a thorough review of the environment.|
|8. If a dangerous situation is uncovered during the assessment, it should be documented for future reference.|
|9. An example of an engineering control is needleless sharps systems.|
|10. Smoke plumes from laser/electro-surgery are minor issues in healthcare today.|
|11. Toxic gases, dead and alive cellular material and viruses can be transmitted into the air during laser/electrosurgery procedures.|
|12. To alleviate the dangers from laser/electrosurgery procedures, a combination of engineering controls and work practices need to be in place|
|13. All tubing, filters and absorbers from laser/electro-surgery procedures are considered infectious waste|
|14. An example of a work practice designed to protect employees from injury or illness is the practice of using safe sharps during medical procedures|
|15. The most common protective equipment used in healthcare today is gloves.|
|16. Bioterrorism is the use of biologicals to inflict harm on persons to intimidate or coerce them for some political or social cause|
|17. Biological toxins can enter the body by only one route|
|18. An indicator that signals a toxin may have been used includes an unusual number of sick or dying people or animals|
|19. The three methods to protect self and others from terrorist attacks are time, distance and shielding|
|20. Exposure to infectious agents only concerns those employees in direct caregiver positions|
|21. A common practice to ensure a healthy work force includes handwashing|
|22. Immunization programs are suitable for only those employees who provide care to infected patients|
|23. Monitoring of the prevention program should include the practice of mock drills|
|24. Feedback to employees about their performance during drills and rounds helps them improve their performance|
|25. Preventing injury and illness in employees is the sole responsibility of the occupational health and infection control professionals|
It is estimated that more than 8 million people in the United States are healthcare workers (HCWs). They work in traditional settings such as hospitals and nursing homes, but frequently work outside of these areas in places such as homes and clinics. They are direct caregivers such as doctors, nurses, respiratory therapists, and non-direct caregivers like laboratory staff, central supply staff and pharmacists. They can also be students, volunteers, researchers and contracted personnel.
While registered nurses are the least likely of occupations to lose time from work due to injury or illness (25.7 percent), nursing aides and orderlies are the third highest group of all occupational groups to loose time from work due to injury or illness (75.7 percent).1 Regardless of job category, these persons have the potential to be exposed to hazardous conditions in the workplace; hazards such as needlestick injury, TB exposure, laser/electrosurgery plume, bioterrorism and exposure to other infectious diseases through the environment of care and equipment. These hazards are manageable through the use of policies and practices as well as engineering controls. A well-defined prevention program that includes prevention of work-related illnesses and injury, education of staff, monitoring of the environment, engineering controls and work practices support the goal of prevention of occupational injury and illness.
Education of Staff
Personnel are more compliant with a program if they understand its rationale. Knowledge of the cost of illness and injury to the employee in terms of time, money and disability helps the employee to accept accountability for practices required. Policies that are clearly written, coordinated between departments and have employee input have the best chance of being used by employees. While the consequences for not following established policy must be addressed, the motivation to practice safely in the workplace should be based on knowledge of facts. Many educational programs overlook the importance of indirect caregivers, administrative personnel and patient/families when designing and presenting programs. In the era of patient safety, all employees need to be responsible for workplace safety. The patient and/or family often are in a unique position to see unsafe situations that caregivers do not see. Providing them with an opportunity to speak up about what they see can greatly assist the staff in this time of staff shortages. Through unit orientation and printed materials, the organization can communicate their concern about prevention to the patient and family.
Prevention is Key
Prevention of injury and illness has always been the goal of occupational health. A comprehensive program of prevention includes risk assessments of the environment where necessary, implementation of engineering controls, work practices designed to reduce the risk and monitoring the environment to determine if the actions are effective.
An environmental-hazard risk assessment is usually conducted by a multidisciplinary team comprised of housekeeping staff, engineering personnel, infection control practitioners (ICPs), security personnel, fire and safety staff, and patient safety/risk management personnel. Each professional shares his or her expertise in developing the assessment tool. Then using the tool when going to an area of the hospital, the team documents problems it finds. For example, a team going to an acute inpatient psychiatric unit may be looking for environmental hazards that could pose a risk to a suicidal patient: items like break-away shower curtain rods, slanted or solid grab bars, non-breakable mirrors and glass, drop ceilings that hide sturdy pipes, how high up the patient unit is off the ground floor, doorframes and knobs, dining room areas and bedrooms. They may also look at the use of plastic bags and the need to have an ICP determine the best way to assure infection control when disposing of infectious waste while still eliminating the risk of a patient using a plastic bag to attempt suicide. Security personnel may need to look at panic buttons and cameras for the safety of the staff, while housekeeping will need to look at the storage of chemicals in areas that are safe. The team then reviews its assessment and makes recommendations for action. Dangerous situations can be dealt with at the time of the assessment. Staff can be asked questions about safe practices and policies to determine their level of knowledge.
Engineering controls are valuable in providing a safe work environment for employees. Laminate flow hoods for mixing toxic chemicals or working with materials that produce fine particles is an example of an engineering design built into the environment. Negative airflow rooms are an engineering control for airborne infectious organisms such as tuberculosis. The purchase of sharps with engineered sharps injury protections and needleless systems is an example of a common engineer control designed to protect employees from injury and illness.
In September 1996, the National Institute for Occupational Safety and Health (NIOSH) released a health hazard alert about the dangers of smoke plume, a byproduct of the thermal destruction of tissue during surgical procedures using laser or electrosurgical units.2 Smoke plumes contain toxic gases and vapors such as benzene and formaldehyde, dead or alive cellular materials (including blood fragments) and viruses. Exposure during these procedures has been known to cause burning watery eyes, nausea, respiratory problems and viral contamination. As there were some 24 million surgical procedures done in 1995 and 90,000 registered nurses working in operating rooms, the potential affect of this occupational hazard is significant.2 The engineering control recommended is a combination of general room ventilation and local exhaust ventilation. A high efficiency particulate air (HEPA) filter or equivalent is recommended for trapping particulates.3 The use of a room evacuator or room suction must be combined with the work practice of holding the nozzle inlet within two inches of the surgical site to effectively capture airborne contaminates generated.3 All tubing, filters and absorbers are considered infectious waste at the end of the procedure and must be disposed of accordingly. These tubes and filters must be replaced with each new procedure.
Work practices are the most common method of preventing injury and illness. The use of safer devices to protect workers who handle medical sharps is one example of a workplace practice. The Occupational Safety and Health Administration (OSHA)'s Needlestick Safety and Prevention Act provided direction to healthcare facilities to reduce the incident of needlesticks or sharps injury to employees. The act calls for employers to solicit input from frontline employees in choosing safer devices before purchasing them.4 It requires employers to establish a log to track needlesticks and help identify problem areas or operations. This log must maintain the privacy of the employee who was injured.4 The act seeks to clarify and emphasize the importance of annually reexamining the organization's exposure control plan and adopt safer needle devices that protect against accidental needlesticks. Requiring employees to use the equipment purchased helps to reduce the incidence of these types of injuries from occurring.
The use of protective devices is another way that both engineering controls and work practices combine to provide a safer workplace. The most common protective device used in healthcare is the glove. Much has been written about the types of gloves to be worn, when to where them, in what types of situations and for how long. Problems related to latex gloves and double gloving has also been studied. The use of gloves is now an accepted practice not only in healthcare but also in workplaces such as food service and housekeeping services. Used with other devices such as goggles and gowns, they provide protection from infectious materials for a wide range of employees in a variety of work situations.
Prior to September 11, employees and employers did not spend too much time or money in planning for a terrorist attack even though they knew about the World Trade Center bombing in 1993 and the Oklahoma City bombing in 1995.5 That changed significantly on September 11, 2001. The Federal Bureau of Investigations (FBI) defines terrorism as the unlawful use of force against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in the furtherance of political or social objectives.6 The definition includes three elements:
- Terrorist activities are illegal and involve the use of force
- The actions intend to intimidate or coerce
- The actions are committed in support of political or social objectives6
Because terrorist acts are designed to inflict harm to persons and damage to property, these emergencies are different from the ones planned for in the past in terms of their size and type. These emergencies involve mass destruction of property, widespread injury and death, unsafe conditions for caregivers and the emotional stress brought upon by the intentional devastation. There are five categories of terrorist incidents: biological, nuclear, incendiary, chemical and explosive.6 Although nuclear, incendiary, chemical and explosive incidents are all critically important, biological incidents are the ones most likely to impact the occupational health professional and ICP. These biological toxins can enter the body through inhalation, absorption, ingestion and injection. These routes of entry are key to protecting self and others. The use of toxins is a preferred because they are more easily extracted for use, are highly effective and are more easily transported. Four common toxins thought to be potential biological agents are botulism, staphylococcal enterotoxin B (SEB), ricin (derived from the castor bean plant) and mycotoxins.6
Biological indicators that could signal the use of a toxin may include an unusual number of sick or dying people or animals, dissemination of unscheduled and unusual sprays, especially outdoors or at night, and abandoned spray devices with no distinct odors6
A comprehensive public response to a biological terrorist act involves epidemiological investigation, health care treatment, and prophylaxis for affected individuals, and the initiation of disease prevention or environmental decontamination measures.6 The Centers for Disease Control and Prevention (CDC) will assist state and local health agencies in developing resources and expertise for investigating unusual events and unexplained illness. When a terrorist attack is confirmed, the CDC will coordinate with other federal agencies. The FBI will be the lead agency for crisis planning and the Federal Emergency Management Agency (FEMA) will ensure an adequate federal response to the disaster.
There are actions that employees can take to protect themselves and others from the effects of terrorist attacks prior to the arrival of help. These protective measures are time, distance and shielding from the biological, nuclear, incendiary, chemical and explosive incident. These protective measures are linked.6
Time spent in the area of the event is critical if the hazard is expected to gradually diminish over time. The use of rapid entries to execute rescue or treatment minimizes the effects of the hazard to the worker. The greater the distance from the source of harm, the less chance of exposure to it. If at all possible, being uphill or upwind from the site is preferable. Adding to the time and distance advantages, shielding with physical barriers such as vehicles, buildings, walls and personnel protective equipment helps reduce the harm caused by the incident.6
Given the likelihood that the terrorist acts will continue, being familiar with local, state and federal plans for disaster will help the organization respond more effectively.
Exposure to infectious disease through the environment of care and equipment is a hazard that affects all areas of the organization. All employees are potentially susceptible to infectious agents or can cause the spread of infection. Controlling this hazard is important because of its widespread affects on the organization. It can also be more difficult. One of the most important behaviors to decrease exposure to infectious agents is basic information on how to prevent the spread of infection. Practices as simple and commonplace as using tissues to cover the nose and mouth when sneezing, not eating or drinking in the work area, keep the environment clean and of course, handwashing.
Immunization programs play a role in preventing infections from occurring in employees. Optimal use of vaccines can prevent transmission of vaccine-preventable disease and eliminate unnecessary illness and work disruptions. An immunization program is far more cost effective than case management and outbreak control. In addition to the childhood vaccinations that all employees should have (unless they were born before 1957), immunizations such as hepatitis B, and influenza are recommended.7
Completing the prevention program is monitoring of the environment to assure that practices to reduce the incidence of injury and illness are actually being used. Monitoring activities include rounds, mock drills, reports and feedback to the staff.
During multidisciplinary rounds, the staff is asked to participate in identifying workplace problems that could cause injuries or illness. Having the supervisor of the area along on the rounds is helpful to increase the awareness about the work area. Engineering controls and workplace practices that should be in place can be assessed. For example, are gloves being used correctly? These rounds can be used to inspect for cleanliness and safety in the area. For situations that the staff is expected to handle but may encounter infrequently, mock drills are useful for checking their performance. Aside from the required fire drills, mock drills for other emergency situations like lose of electricity from a terrorist attack provides a great deal of information to the staff and supervisors about the glitches in the back-up systems and the staff's knowledge of who is to do what, when and how. Having a real-time drill gives the staff the opportunity to experience the problems of having to move patients and call in staff that they may not have by just reading the disaster plan. They know better what to expect.
Using written and verbal reports on aspects of the environment like air and water quality provides employees with information about their environment. These reports are quickly disseminated to a wide group. As with any monitoring activity, the purpose is to assure that what is suppose to be occurring is actually happening in the work area.
The hazards facing our workplace and the people in it have become more complex. Along with the well-known hazards are the new challenges brought about by modern threats and actions that go beyond any unexpected workplace emergency of the past. Keeping our employees healthy has taken on new directions and new risks.
Patricia Tydell, MSN, BSN, MPH is risk manager for the North Chicago Veterans Administration Medical Center in North Chicago, Ill.