OCCUPATIONAL HEALTH

Because occupational health addresses a broad continuum of topics, infection control practitioners (ICPs) and staff educators must ensure that the healthcare workers (HCWs) at their facility are fully aware of the risks associated with the day-to-day aspects of their jobs. These can include communicable diseases for both patients and HCWs sharps injuries, allergies to latex and other potentially risky items in the healthcare environment, and other hazards such as wet floors and infectious-fluid splashes.

From A to Z, occupational health-related issues can include:

  • Adaptive clothing/personal protective equipment (PPE) 
  • Back injuries 
  • Communicable diseases 
  • Disinfectants/sterilants 
  • Eye protection 
  • Fluid splashes 
  • Hand hygiene 
  • Infection control adherence 
  • Latex allergies 
  • Maintenance and housekeeping 
  • Needlesticks 
  • Outbreaks 
  • Radiation exposure 
  • Stress in the workplace 
  • Violence in the workplace 
  • Wet, slippery floors 

While the ICP must focus on the prevention and spread of disease, the remaining topics often fall to occupational health staff, and both groups of healthcare professionals must provide education to the facility staff, follow up to ensure that it has sunk in, and then provide ongoing surveillance and reminders so that recommendations and rules are being observed.

The American Association of Occupational Health Nurses (AAOHN) defines occupational and environmental health nursing as a specialty practice that provides for and delivers health and safety programs and services to workers, worker populations and community groups. The practice focuses on promotion and restoration of health, prevention of illness and injury, and protection from work related and environmental hazards. These nurses must provide case management, counseling and crisis intervention;

health promotion; legal and regulatory compliance; and worker and workplace hazard detection.

The AAOHN and the Occupational Safety and Health Administration (OSHA) have formed an alliance to help employers address their most critical workplace health and safety challenges, including workplace violence and musculoskeletal disorders. This alliance allows AAOHN to work with OSHA for purposes of training and education, outreach and communication and promotion of the national dialogue on workplace safety and health.

Contact Precautions, Standard Precautions, and Sharps Safety

Contact precautions, according to the Centers for Disease Control and Prevention (CDC), are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients, bathe patients, or perform other patient- care activities that require physical contact, says the CDC.1

These instructions are clear, but still, employees often do not fully comply, even though it protects them as well as the patients. Linda J. Burton, RN, BSN, CIC, an ICP at the University of Colorado Hospital and a member of the board of directors at the Association for Professionals in Infection Control and Epidemiology (APIC), says employees may hear the information they need to hear, but refuse to process it. Its one of the things we encounter more often than not the staff member says, My mind is made up; dont confuse me with facts. This is how so-and-so said to do this, and thats what Im going to do.

Everyone realizes the sense in sharps safety devices, but they are often reluctant to use them properly. Our occupational health nurses last report about that to our committee shows that with most of our clinical care outside the OR, needlesticks are occurring because people are not activating the safety devices, Burton reports.

It may be a lack of time, or rushing to accomplish a task, or it may just be habit on the part of HCWs to not utilize the safety feature. Its the same with contact precautions. If a patient needs to be housed in an isolation room, theres no hesitation about putting the patient in that room but there is an ongoing issue with staff members wearing the appropriate personal protective equipment (PPE) for the particular pathogen.

One of our major problems with standard precautions is that HCWs dont wear face protection when theyre handling fluids. We get fluid splashes to the face because they dont consider their eyes to be vulnerable, Burton says. Weve been preaching about that until were blue in the face.

As with any healthcare facility, staff adherence to basic hand hygiene, and standard and contact precautions, is much better when they know theyre being observed. Every place has hand hygiene problems, Burton offers. Every place has isolation compliance problems mainly with physicians or even with non-employees. Nursing gets tired of being the policeman for everybody, cleaning up after everybody. Mainly, the problem with adherence lies with the physicians, who are not wearing gloves and gowns as they should. They breeze in and out of isolation rooms no matter what the signs say.

The solution is to actively observe compliance and step in when the rules are not being followed. We had an outbreak situation during which we cohorted all the positive patients and stationed ourselves at the nurses station and watched to see who would adhere to the guidelines. We observed people [who went in and out of the cohort area], and caught them in the act, she recalls. Our medical director was right there to take them aside and tell them why they should be observing the precautions.

The intervention worked those seven patients were the only ones who had the illness. It did not spread any further. In that case, Burton says, the transmission was stopped, but, she adds, Most physician compliance, in our experience, has a limited shelf life. Its a constant thing with almost everybody. You get results from a survey of hand hygiene compliance, and you present those results of your latest observations to the staff. If you observe them again within the next two weeks, youll find a marked improvement, but if you give them six weeks and then go back to observe, youre almost back to the baseline. Its a constant battle of reminding them, and just making it almost instinctive for them to perform hand hygiene, put on a gown or mask, or protect themselves {in the appropriate way).

Time is certainly a factor in the lack of compliance with any of these factors. Nobody has enough time anymore, she confirms. There is understaffing throughout healthcare there are shortages of every kind. Theyre always wanting us to do more with less, but were reaching the crunch point at which we cant do any more. I was talking to a coworker the other day, and we realized that were doing three times as much clinical stuff with only about a third more staff than we had six years ago.

So the problem is not a deliberate effort to thwart authority. Everybody in healthcare wants to do whats right, she comments. If they had a minute to think about it, I think they would [follow the recommendations]. Its a matter of a six-foot-tall to-do list, and the time youre given to accomplish all this is only sufficient to get through four feet. If the HCWs had a chance to think about what they were doing, wed see a lot better practice across the board. They need reminders, reminders, reminders.

Coming up with innovative ways to reach the staff is a constant struggle. Currently, Burton says, the medical director is giving talks all around the hospital, and the grapevine is now at work. The rumor spreads Did you hear that were only at 36 percent in hand hygiene? and that gets their attention, she adds. Its one thing to educate the employee. But the educator cannot force them to comply with facility policies. Tackling those who just dont bother to follow the rules hand hygiene, PPE, immunization is a leadership responsibility, says Claire Everson, RN, CNOR, CCAP, LMT, a perioperative clinical educator at Banner Desert Samaritan Hospital in Mesa, Ariz., and a member of the board of directors of AORN.

With influenza immunizations, for example, the facility educator sends out a flyer, and every person in a leadership role is supposed to post the flyer and encourage staff to participate. Theres a saying here at Desert the educators job is to provide the water, but it is managements job to make the employee thirsty, Everson clarifies.

Education is provided for these topics, but it is the employees own responsibility to observe the hospital rules. We do have education on PPE, and it is an online mandatory class that all employees have to complete prior to annual evaluation, so completion of that class ties into the annual raise, she adds. But completion of a course does not always link to a change in performance.

Educating the employee and ensuring compliance with proper protocol is a partnership, she adds, and management needs to be the one reinforcing the expectations.

Immunizations

With the upcoming flu season, its more important than ever that staff be immunized against influenza. But the rate of HCWs being vaccinated is distressingly low approximately 38 percent each year. So, he says, it is incumbent upon the facility to convince their staff members that flu immunization in particular is the professionally and ethically correct thing to do.

But it isnt as simple as that. William Schaffner, MD, professor and chair of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville, notes that there are many reasons why staff members avoid being immunized.

One reason, he observes, is that infection control practitioners havent been clear enough about the main reason to be immunized to avoid making patients sick. The other reasons are to avoid reducing staff numbers, to maintain personal health, and to avoid passing it on to family. And finally, he says, some HCWs just dont like shots, or they think theyre too busy to fit it into their schedules.

Vanderbilt Medical Center is currently in the midst of two educational campaigns, says Schaffner. One is an intensive handwashing initiative, and the other is our annual education about influenza and immunization, he explains. Both present challenges to us, because we think that we have measured improvements in the past, in both of those, but theres always an opportunity to improve even further. We are educating almost constantly.

In order to educate well, you must first listen well, he stresses. Create an environment where people can respond to your main educational message, so you can understand what has been misperceived, and what it is you have not covered. Although you keep providing reassurance, some myths have an absolute tenacious persistence for example, that you can get flu from the flu vaccine. That has no more validity than the man in the moon. But it continues to be heard by our staff as they educate, Schaffner says.

Each time an infection control practitioner or an educator explains away the myth, they pick up a few more converts to their way of thinking. But, he says, there will always be those who resist learning the new way. Some of our old healthcare workers remember the older, less pure vaccinations that were more apt to cause a sore arm, swelling, and a degree of fever, because of local inflammation, he observes. That wasnt flu then, but they remember the inflammatory responses. There are other people who get inoculated and a week and a half later get a cold, and attribute one to the other. We have to keep educating them that were not injecting them with the flu virus, only parts of it. They might get a sore arm, but if you get the sniffles in a few days, you got that on your own!

Careful listening and addressing issues immediately are key, he says. Its also important to have strong administrative support for the major lessons youre trying to teach. Having the administration involved provides some supportive structure and clout. There are carrots and there are sticks, and both are important. Whatever the issue, if you listen, and take a survey to find out what peoples attitudes are, they will speak to you honestly, he adds. You have to structure your questionnaire, so they know that their honest responses are sought, and will remain anonymous.

When we have issues regarding conformance with isolation guidelines, the most frequent thing we hear is I dont have enough time; Im too busy, Schaffner says. Unfortunately, theres a little bit of truth in every tease, as my mother used to say. There is a nursing shortage, and hospitals run on very tight budgets. If your unit is full, with every bed occupied, you may be understaffed, and the administration may not be able to get you an extra nurse. You also have the attitude, the nonchalance of physicians who say It doesnt apply to me. The problems with isolation precautions and hand-washing are, doctors go into a room but if they dont touch the patient, they dont think they have to conform to respiratory precautions or precautions against multi-drug organisms stating that everyone entering the room has to suit up. You must address each of those in a clear fashion, saying, Its important that you do this for the following reasons. The reason were asking you to do this is not frivolous.

He jokes, You get whining from people who almost think that putting on this PPE or getting a flu shot is somehow punishment, he says. But we tell them, This is for your patients benefit, your familys benefit, and your benefit. 

As we become more successful in persuading people to wash their hands and accept influenza immunization, the remaining population of holdouts is more resistant. We have to work harder to get those people aboard. Always, the holdouts always are the most disinclined to participate. Sometimes it is personality issues. And every once in a while it doesnt happen frequently we have had to let healthcare workers go, because they regularly did not adhere to aseptic precautions, even after progressive discipline. We had to tell them, We dont want you taking care of our patients.

Latex Allergies

Allergy to latex especially in gloves has been an ongoing issue for years. According to the CDC, natural rubber latex, which is manufactured from a milky fluid derived from the rubber tree, Hevea brasiliensis, is a useful component in gloves to prevent transmission of infectious diseases. But continued exposure to latex (and even, occasionally, infrequent exposure) can lead to an allergic reaction.2

The amount of latex exposure needed to produce sensitization or an allergic reaction is unknown. Increasing the exposure to latex proteins increases the risk of developing allergic symptoms. Skin contact is not the only exposure latex proteins can attach to the lubricant powder used in some gloves. When gloves are changed, the protein/powder particles can become airborne and be inhaled.

However, there are other reactions besides a true latex allergy. The most common reaction to latex products is irritant contact dermatitis dry, itchy, irritated areas on the skin, usually the hands which is caused by irritation from wearing gloves and by exposure to the powders added to them. Irritant contact dermatitis is not a true allergy. Allergic contact dermatitis (also known as chemical sensitivity dermatitis) is not a true allergy, either. It results from the chemicals added to latex during harvesting, processing, or manufacturing. These chemicals can cause a skin rash similar to that of poison ivy.

To reduce the risk of developing a sensitivity or allergy to latex, the National Institute for Occupational Safety and Health (NIOSH) recommends wherever feasible the selection of products and implementation of work practices that reduce the risk of allergic reactions. These recommendations include using non-latex gloves if possible; using powder-free gloves with reduced protein content if possible; avoiding the use of oil-based creams or lotions with latex gloves; clean areas contaminated with latex dust and change ventilation filters and vacuum bags used in these areas; and see a physician if you develop symptoms of latex allergy.3

Reports of work-related allergic reactions to latex have increased in the past few years; studies suggest that 8 percent to 12 percent of health-care workers regularly exposed to latex are sensitized, compared with 1 percent to 6 percent of the general population. However, total numbers of exposed workers are not known. In healthcare, workers at risk include physicians, nurses, aides, dentists, dental hygienists, operating room staff, laboratory technicians, and housekeeping personnel.

Latex has even recently been implicated in food. According to a press release from the journal Chemistry & Industry, a recent study in the United Kingdom (UK) showed that one-third of food packaging tested was contaminated with latex. The latex was even transferred to food in some cases. In one chocolate cookie, the amount of latex found was 20 times the level that might cause a reaction in a sensitive or allergic individual.

There is no agreement on a safe level of latex, but it has been reported that a billionth of a gram (1ng/ml) can be enough to cause a reaction. Currently manufacturers are not required to label food packaging as containing latex.

A group of experts from the UK Latex Allergy Support Group (LASG) advisory panel said that these results were significant. They also recommended that food packaging be labeled if it contains latex. LASG representative Graham Lowe pointed out that latex transfer to food could account for some currently inexplicable reactions.

Scientists at Leatherhead Food International measured the presence of four major latex allergens in 21 types of food packaging for confectionary, fruit and vegetable produce, meat, pastry and dairy products. A third of the materials tested gave positive results for the presence of latex, and in some cases, this was transferred onto the food. Latex is used in many food packaging materials, including rubber bands, meat netting, stickers found on some fruit and vegetables and the adhesive used for cold sealing of confectionery. One company admitted spraying whole wrappers with latex adhesive, so that they could be sealed with minimal wastage.

Personal Protective Equipment

The idea behind personal protective equipment (PPE) is simple to protect the healthcare worker from contamination with a patients body fluids or by chemicals or other hazardous materials and also to protect the patient from any pathogens the HCW might be carrying. However, like compliance with sharps safety, compliance with PPE recommendations is much easier said than done.

Many areas of healthcare require some kind of barrier product; it is important to be aware of what protective benefits the clothing provides, and to know when additional layers or pieces are necessary, such as a fluid-repelling gown, eye protection, or masks.

There are multiple gloves, gowns, and masks, to suit a multitude of patient care situations and facility or instrument care. When choosing the right product, the healthcare worker must first consider the barrier properties, then comfort. And these products are only as good as the care that is taken with them. Proper storage of these items, as well as proper donning, is necessary to preserve protection for both worker and patient.

According to NIOSH, in the past PPE was not standardized and was often inappropriate for the work being performed. Although standards are now in effect, that does not mean that PPE is a substitute for good engineering, work practice, and administrative controls. Instead, it should be used in conjunction with these controls to provide for a safe and healthy workplace.4

OSHA describes PPE as the solution to employee exposure to hazardous processes or infectious materials or chemicals due to inappropriate or lack of PPE. They require the following:5

Medical Services and First Aid Where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.

Hand Protections Employers shall select and require employees to use appropriate hand protection when their hands are exposed to hazards such as those from skin absorption of harmful substances; severe cuts or lacerations; evere abrasions; punctures; chemical burns; thermal burns; and harmful temperature extremes.

PPE is required by the Bloodborne Pathogens Standard if exposure to blood and other potentially infectious materials (OPIM) is anticipated and where occupational exposure remains, after institution of engineering and work practice controls. PPE can provide some protection from infectious materials as a barrier to protect skin and mucus membranes from contact with blood and other potentially infectious materials. PPE includes gloves, gowns, laboratory coats, masks, face shields, eye protection, mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.

OSHA also decrees that employees must wear gloves when hand contact with blood, mucous membranes, OPIM, or non-intact skin is anticipated, and when performing vascular access procedures, or when handling contaminated items or surfaces. Employees must wash hands immediately or as soon as feasible after removing gloves or other PPE.

PPE is only appropriate if it does not permit blood or other potentially infectious materials to pass through to or reach the employees work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

Some of OSHAs general PPE guidelines include the following:

  • Wear gloves, when handling chemicals and/ or body fluids.
  • Wear safety shoes/boots/covers if hazardous substance is likely to splash.
  • Wear an apron/gown/coveralls if hazardous substance is likely to splash.
  • Use a respirator when a hazardous substance is airborne, such as tuberculosis.
  • Wear hearing protection for loud noises such as those from equipment.
  • Remove PPE carefully to avoid contaminating yourself.
  • Dispose of PPE in designated containers before leaving the area.

Despite these very clear recommendations, as Burton says, many staff members just do not find the time or the inclination to observe the guidelines. It is crucial that the facility stress the importance of PPE to all HCWs, that appropriate PPE always be worn when contact precautions are in place, and that the proper hand hygiene and gloving is performed when observing standard precautions.


References

1. www.cdc.gov/ncidod/dhqp/gl_isolation_contact.html  

2. CDC www.cdc.gov/niosh/98-113.html 

3. NIOSH www.cdc.gov/niosh/latexfs.html 

4. http://www.cdc.gov/niosh/pot_ppe.html 

5. www.osha.gov/SLTC/etools/hospital/hazards/ppe/ppe.html  

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