Infection Control Today - 01/2002: Healthcare Workers Exposed

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Healthcare Workers Exposed: Chemicals Necessary, Dangerous

By Kelli M. Donley

Chemicals are omnipresent in American society. From crop dusters ensuring the next season's fruits and vegetables, antifreeze protecting engines from the chilly winter, and caffeine coursing through the veins of the tired and overworked, these substances surround us. However, healthcare workers (HCW) are at an increased risk for encountering the potentially dangerous side of chemicals.

One extreme example of this danger became evident after Dartmouth researcher Karen Wetterhahn fell ill in 1997. The college scientist had been working with dimethylmercury when one drop of the toxic compound permeated her glove. The 48-year-old fell into a coma three weeks after being diagnosed and was dead 10 months later from mercury poisoning.

Chemical exposure for HCWs, may it be caused by exposure to a sick patient, an improperly used disinfectant, or a sterilizer that has not been maintained properly, is a possible threat at any healthcare center. To educate workers about the potential dangers surrounding these compounds, the Occupational Safety and Health Administration (OSHA) requires healthcare facilities to have complete Material Safety Data Sheets (MSDS) for each hazardous chemical used and stored.

These sheets must be written in English and must provide the following information: product identity, hazardous ingredients, physical and chemical characteristics, fire and explosion hazard data, reactivity data, health hazards, precautions for safe handling and use, and control measures.1

Additionally, the National Fire Protection Association (NFPA) has ranked in a visual diamond chart the health, flammability, reactivity, and related hazards of specific chemicals. These red, blue, yellow, and white diamonds are common in areas where chemicals are stored. The ranking system varies from 0, signifying the chemical is relatively harmless, to 4 meaning the chemical can potentially cause death.1 More detailed information about the NFPA's chemical ranking system can be found at: www.nfpa.org.

Patient Exposure

According to the Agency for Toxic Substances and Disease Registry (ATSDR), a branch of the Centers for Disease Control and Prevention (CDC), HCWs who are active in the emergency room should understand the basics of treating acute exposure cases. Registry officials developed medical management guidelines to aid emergency room HCWs when a patient in this situation arrives at their facility. The guidelines teach professionals how to effectively decontaminate patients, protect themselves from becoming contaminated, communicate with other HCWs involved, transport patients to other medical facilities if necessary, and provide an efficacious medical evaluation and treatment to those exposed.2

The guidelines are available for more than 40 specific chemicals at: www.atsdr.cdc.gov. One of these examples includes the precautions that should be taken when a patient is exposed to an unidentified chemical. In this situation, ATSDR officials recommend a variety of precautions including isolating any patient who enters the ER with chemicals on his or her skin and clothing. If a patient is covered in a chemical substance, other patients and HCWs can easily become ill as well. It is important to isolate the patient quickly to protect others in the area. Those HCWs responsible for the isolation and treatment procedure also need to have proper personal protective equipment (PPE). Officials at the registry also recommend HCWs keep a worst-case scenario in mind when treating patients who have been exposed to an unknown chemical in order to provide the highest protection to others in the surrounding areas.

The American National Standards Institute (ANSI) has also written guidelines for HCWs personally exposed to chemicals in the workplace. The organization recommends the following flush time after exposure:

  • 5 minutes for mild irritants
  • 20 minutes for moderate to severe irritants
  • 20 minutes for non-penetrating corrosives
  • 60 minutes for penetrating corrosives

If there are any questions about the chemical's irritation level, the MSDS should be reviewed and the manufacturer can be contacted. However, penetrating corrosives are usually alkalies, hydrofluoric acid, and phenol. Most acids, according to ANSI, are penetrating corrosives. Non-penetrating corrosives form a protective layer over human tissue. This usually limits the extent of damage.3

ANSI officials also recommend immediate first aid with oxygen if a HCW is exposed to:

  • Ammonia, phosgene, and chlorine--these chemicals can interfere with the ability of oxygen to cross through the lungs to the bloodstream, causing pulmonary edema.
  • Carbon monoxide can reduce the blood's ability to transport oxygen, causing anemia, or methemoglobinemia.
  • Cyanide and sulfide can compromise the use of oxygen used by body tissue.

If a HCW is exposed to any of these chemicals, oxygen and/or emergency care should be administered.

Chemicals in the Workplace

HCWs are responsible for washing their hands repeatedly through the day, wearing gloves, using disinfectants, and keeping their areas free of infection-causing pathogens. These sterile steps to a clean healthcare center can leave HCWs working with a plethora of potentially harmful chemicals.

For example, disinfectants used to clean surfaces contain many chemicals that can cause bodily harm if used incorrectly. Kirsten Buck, a principle technical affairs specialist at Ecolab in Mendota Heights, Minn., said there are several precautions HCWs should keep in mind when working with Huntington phenolic disinfectants.

"Our MSDS/s for all of our chemicals were written quite conservatively and refer to the concentrate form. Our phenolics have a health rating of 3--the product is corrosive to eyes and skin (overexposure to concentrate), causing skin irritation and possible chemical burns. Phenolics may also be absorbed through the skin. It may be harmful if swallowed, with damage to mucosal tissue. Large doses may cause circulatory shock, respiratory depression, and convulsions. If inhaled, the vapor or mist may cause irritation," she said.

The Association for Professionals in Infection Control and Epidemiology (APIC) has specific guidelines for the use of disinfectants to protect HCWs from such exposure. The organization has classified disinfectants by their active ingredients: alcohol, chlorine and chlorine compounds, formaldeyde, glutaraldehyde, hydrogen peroxide, iodophors, phenolics, and quaternary ammonium compounds. Each of these ingredients carries its own danger. For example, alcohol is flammable, chlorine is reactive to other chemicals, and formaldeyde is a carcinogen. Yet these chemicals can be used properly and safely with the right direction.

Lauren Crawford, a research and development chemist for Metrex/OBF, based in Orange, Calif., said even the most basic chemical compounds can be fatal if not monitored.

"Potential dangers may occur when any chemical is not used properly. Even a harmless chemical such as water may drown and harm a careless person. Thus, healthcare workers should be aware of label directions and precautions and follow them closely. For example, glutaraldehyde products require the use of adequate ventilation and proper personal protective equipment such as gloves or eye protection," she said.

HCWs should be trained at each center what PPE is required and necessary for working with such chemical products. Buck also says staff members are willing to teach these guidelines if administration requests their help.

"Our sales force is also prepared to conduct in-service training for employees on the safe and effective use of our products. Depending on the type of product, wall charts and other literature are available, many in languages other than English," she said.

While some chemicals can be heat and light sensitive, most disinfectants have been designed to be efficacious after sitting at room temperature.

"For the most part, normal warehouse conditions are appropriate for our products. In the development of a new product, the packaging engineers assume a wide range of conditions and choose appropriate materials to ensure safe transportation and handling. If the product is flammable or if the integrity is compromised by freezing, the MSDS will indicate specific storage instructions," Buck said.

Jack Kinville, a marketing manager at Ruhof in Long Island, NY, says their products do not have a specific temperature at which they should be stored. Although Ruhof products are enzymatic-based cleaners, they also come with precautions.

"Our products are always accompanied by tech sheets and MSDS, educating workers how to use them. At the full-strength concentrate, Endozime and our other enzymatic products contain 10% isopropanol (2-propanol) that can irritate the eyes and the skin. We recommend the use of goggles and plastic or rubber gloves when diluting and using the product," he said.

PPE is also an important element to safely using many cleaning products.

"In general, when using any cleaning solution, goggles and gloves are suggested as an added safety measure," Kinville said.

No matter how the MSDS are written for the product, having the HCW wear appropriate gloves is essential.

"With reference to disinfectants, because our MSDS/s are written quite conservatively, we recommend eye protection and skin protection when handling any of the concentrates. We usually recommend gloves also for handling use solutions-mostly to protect the skin from repeated damage from the mechanical action of cleaning, as well as repeated exposure to moisture and the product. Keeping the skin intact is the objective-wearing gloves will prevent any irritant dermatitis as well as possible infection related to fissures in the skin," Buck said.

However, also just as important as wearing appropriate PPE is reading the directions concerning how the chemical product is diluted and used. If this step is skipped, a HCW can be seriously harmed.

"It is possible that individuals with asthma, allergies, or respiratory sensitivity can develop an allergic reaction to enzymes (proteins) that are inhaled in spray, mist, or dust. With our liquid enzymatic concentrated products, normal handling and use as directed do not involved generation of spray, mist, or dust. Therefore, there is very little inhalation risk. However, we recommend respiratory protection (a NIOSH approved mask) for individuals with asthma, allergies, or respiratory sensitivity. If staff members are allergic or sensitive to fragrances, use of our unscented, colorless versions instead of the regular enzymatic products can be considered," Kinville said.

Crawford agrees that understanding and following the directions are crucial.

"Read the instructions of the labels carefully, follow directions, and use appropriate protective equipment. The labels for many of the regulate products go through rigorous screening and are very carefully worded to tailor a specific usage for the customer. Thus, it is important to follow directions," she said.

HCWs who use chemicals in healthcare centers should double check they are in compliance with both the manufacturer and their administrative policies. Understanding the possible dangers surrounding these necessary compounds is crucial to keeping healthcare centers functioning at their highest and most efficient levels and maintaining the health and well being of staff members.

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