Occupational Hazards & The Healthcare Worker
By Kelly M. Pyrek
While hospitals are designed to be places of treatment and healing for patients, they present a significant number of occupational hazards to healthcare workers (HCWs).
A survey1 of registered nurses by the American Nurses Association revealed that stress/overwork, disabling back injuries, and contracting a bloodborne disease were the top three health and safety concerns.
A National Institute for Occupational Safety and Health (NIOSH) report indicated that an estimated 600,000 to 800,000 percutaneous injuries occur annually to HCWs,2 and that nurses sustain the majority of these injuries.3 The Association of periOperative Registered Nurses (AORN) says in its position statement on workplace safety, Nurses practicing in the perioperative environment are at distinct risk for percutaneous injury due to prolonged exposure to open surgical sites, frequent handling of sharp instruments, and the presence of large quantities of blood and other potentially infectious body fluids.4
Of particular concern to an aging nursing population are ergonomic-related injuries. Back injuries pose a significant risk to perioperative nurses and are the most prevalent occupational injury in the healthcare industry.5 Direct costs associated with occupational back injuries of HCWs average $37,000, while indirect costs associated with back injuries can range from $147,000 to $300,000.6
We must consider the needs of an older nursing population, says Denise Strode, RN, BSN, COHN-S/CM, president of the Association of Occupational Health Professionals in Healthcare (AOHP). Its a real concern to occupational health professionals (OHPs) who see the potential for a serious problem in the future. OHPs must conduct analyses of injuries, looking closely at workers patient-handling and transfer practices, stopping as much manual lifting as possible, and taking appropriate safety measures in the healthcare environment. Facility administrators must look at the return on investment they can achieve from equipment such as patient lifts and positioning devices.
Strode says emphasis on proper ergonomics must be made to non-nursing hospital employees, too, who are at risk of injury. Dont forget to educate individuals such as housekeepers, radiologists, or members of the dietary department, because almost no one is immune to occupational accidents and injuries, Strode adds. Its critical to ensure that all staff members understand proper workplace safety protocols and practices, and that there is buy-in from all employees of all hospital departments.
According to AORNs workplace-safety position statement, Key indicators to an organizations culture and commitment to ensure a safe workplace include maintaining safe equipment, providing adequate nurse staffing levels, and fostering safe work practices. An unsafe workplace contributes to work-related injuries and diseases that often result in physical, emotional, and financial difficulties for perioperative nurses. Occupational injuries resulting from an unsafe workplace impact the healthcare organization by increased costs and a reduced ability to provide services. Occupational hazards in the workplace have been identified as a major contributor to nurses leaving the profession, contributing to the growing nursing shortage.7-8
The aforementioned nursing shortage has tangible implications for occupational health. AORN states that the ongoing shortage of skilled RNs and other allied health personnel has not only impacted the delivery of safe, quality patient care, but has affected these workers decision to continue their pursuit of nursing as a vocation. AORN states, A safe workplace will have a positive impact on the retention and recruitment of qualified nurses to provide safe patient care.
Healthcare organizations play a critical role in influencing employee compliance with safe work practices. A commitment to cultivating a culture of safety in the workplace is increasingly import as workloads and emphasis on productivity increase, and patient-acuity levels increase.9 One study demonstrated that strong support from senior management resulted in a reduced rate of occupational exposure to blood and body fluids.10
One of the key factors of creating a safe workplace is employee buy-in and compliance with safety measures. You would like to assume that all HCWs know the basics of proper hand hygiene or PPE usage, Strode comments, but you cant. You must continually communicate and educate, taking into consideration factors such as staffs cultural diversity and differences in learning styles. Its also important to provide good role models and strong leadership from the top. You want to walk the walk if you talk the talk.
AORN suggests the following strategies for developing and maintaining a safe workplace:
- The facility has the responsibility to establish and promote a safe work environment and strive to use best practice models (e.g., magnet hospital status criteria, workplace of choice)
- Each facility should develop a comprehensive workplace safety program that includes a written plan for each topic covered in the program, a written plan to provide education on safety initiatives, and monitoring of compliance for employees and other healthcare providers
- Every perioperative nurse is responsible for following safety policies and participating in the safety programs
- The perioperative nurse has a responsibility to identify safety hazards, take appropriate action, and report them through the appropriate channels
AORN acknowledges that there are multiple occupational hazards that create a risk of personal injury; they are:
- Biological: Exposure to bloodborne pathogens from percutaneous injuries, splashes, and other contact; exposure to infectious microorganisms; exposure to biological components of surgical smoke from use of lasers and electrosurgical units; and exposure to the chemical and protein allergens in latex gloves
- Ergonomic: Static or awkward posture; standing for long periods of time in one position; back injuries; repetitive motion; and moving patients or carrying heavy instruments and equipment
- Chemicals: Anesthesia gases, disinfecting/ sterilizing agents, and cleaning agents
- Physical hazards: Fire, electrical, radiation, lasers, smoke plume, and compressed gases
- Psychosocial: Long hours, mandatory overtime, demographic diversity, nursing shortage, trauma, burnout, verbal and physical abuse
- Cultural: Tolerance of abuse from physicians; lack of commitment by management to adhere to an optimal workplace safety program; absence of respect from peers and other healthcare professionals; absence of a code of conduct for all team members; and workplace safety strategies.
OSHA estimates that 8 million HCWs are at risk of occupational exposure to bloodborne pathogens including Human Immunodeficiency Virus (HIV), hepatitis B Virus (HBV), hepatitis C Virus (HCV) as well as other potentially infectious materials (OPIM). HCWs are at risk when handling sharp devices or equipment such as scalpels, sutures, hypodermic needles, and blood-collection devices. EPINET data shows that needlestick injuries occur most frequently in patient rooms, and various hospital studies indicate that as many as one-third of all reported sharps injuries are related to the disposal process.
To help prevent exposure to blood and OPIM from contaminated sharps, HCWs should follow the requirements of OSHAs Bloodborne Pathogens Standard and implement engineering and work-practice controls. According to OSHA, engineering and workpractice controls must be the primary means used to eliminate or minimize exposure to bloodborne pathogens. Engineering controls are measures, such as sharps disposal containers, self-sheathing needles, or needleless systems, that isolate or remove the bloodborne pathogens hazard from the workplace. OSHA describes work-practice controls as measures that reduce the likelihood of exposure by altering the manner in which a task is performed, such as prohibiting recapping of needles by a two-handed technique.
The revised Bloodborne Pathogens and NeedleStick Prevention Standard requirements that went into effect in April 2001 include the following points:
- Employers must implement the safer medical devices that are appropriate, commercially available, and effective, and document consideration and implementation of safer medical devices annually.
- Employers must get input for these devices from those responsible for direct patient care; this input must be documented.
- Employers must train employees to use new devices and/or procedures and document training in the facilitys OSHA-mandated exposure control plan.
- Employers must maintain a log of injuries from contaminated sharps.
- Compliance with standard precautions, an infection control principle that treats all human blood and OPIM as infectious.
Exposure to bloodborne pathogens and OPIM can be limited through the proper use of personal protective equipment (PPE) as well as proper handling and containerization of sharps.
According to 1996 data from EPINET, in an average hospital, workers incurred approximately 30 needlestick injuries for 100 beds per year. HCWs are at risk of exposure to blood and OPIM due to unsafe needle devices and improper handling and disposal of needles. It is recommended that HCWs:
- Do not bend, recap, or remove contaminated needles and other sharps unless such an act is required by a specific procedure or has no feasible alternative.
- Do not shear or break contaminated sharps (OSHA defines contaminated as the presence or the reasonably anticipated presence of blood or OPIM on an item or surface).
- Have needle containers available near areas where needles may be found.
- Discard contaminated sharps immediately or as soon as feasible into appropriate containers.
According to OSHA, appropriate containers must be:
- Closable, puncture-resistant, and leak-proof on sides and bottom
- Accessible, maintained upright, and not allowed to overfill
- Labeled or color coded
- Colored red or labeled with the biohazard symbol
- Labeled in fluorescent orange or orange-red, with lettering and symbols in a contrasting color; red bags or containers may be substituted for labels
Other Sharps Injury
Other contaminated sharps, including scalpels, broken glass, or broken capillary tubes, are a hazard to HCWs. For example, glass capillary tubes may break when handled incorrectly, resulting in a penetrating wound to the HCW, or used disposable razors could be contaminated with blood. In a 1999 joint document, Glass Capillary Tubes: Joint Safety Advisory About Potential Risks, OSHA and NIOSH recommend using:
- Capillary tubes that are not made of glass
- Glass capillary tubes wrapped in punctureresistant film
- Products that use a method of sealing that does not require manually pushing one end of the tube into putty to form a plug
Another sharps-related hazard is IV connector systems. OSHA and NIOSH recommend the use of needleless connector systems with IV set-ups to minimize occupational exposure.
Studies have demonstrated that most needlestick injuries result from unsafe needle devices rather than carelessness by HCWs. Safer needle devices have built-in safety control devices, such as those that use a self-sheathing needle, to help prevent injuries before, during, and after use through safer design features. In 2000, the CDC estimated that 62 percent to 88 percent of sharps injuries in the hospital setting could be preventing by using safer medical devices. According to the revised Bloodborne Pathogens Standard, employers with the help of employees, must select safer needle devices to use in work environments.
Safety features being incorporated into medical devices include:
- Passive safety features that remain in effect before, during and after use
- Active safety devices that require the HCW to activate the safety mechanism
- Integrated safety design which incorporates a safety feature as an integral part of the device and cannot be removed
- Accessory safety devices have safety features that are external to the device and must be carried to, or be temporarily or permanently fixed to, the point of use
According to OSHA, desirable characteristics of safety devices include:
- The device is needleless
- The safety feature is an integral part of the device
- The device is easy to use and practical
- The device performs reliably
- The safety feature cannot be deactivated and remains protective through disposal
- The devices work effectively and reliably, and are acceptable to the healthcare worker, and do not adversely affect patient care
The Food and Drug Administration (FDA), which is responsible for clearing medical devices for marketing in the U.S., recommends safer needle devices with a fixed safety feature that:
- Provides a barrier between the hands and the needle after use; the safety feature should allow or require the workers hands to remain behind the needle at all times
- Is an integral part of the device and not an accessory
- Is in effect before disassembly and remains in effect after disposal to protect users and trash handlers, and for environmental safety
- Is as simple as possible, and requires little or no training to use effectively
There are many types of safety devices, including needleless connector systems such as blunt cannula for use with pre-pierced ports and valved connectors that accept tapered or luer ends of IV tubing; sliding needle shields attached to disposable syringes and vacuum tube holders; disposable scalpels with safety features such as a sliding blade shield; needles or sharps that retract into a syringe, vacuum tube holder, or back into the device; syringes with a retractable needles; retractable finger/heel-stick lancets; self-blunting phlebotomy and winged-steel butterfly needles; and hinged or sliding shields attached to phlebotomy needles, winged steel needles, and blood-gas needles.
According to NIOSH, when selecting and evaluating needle devices with safety features, the healthcare facility should form a multidisciplinary team that includes HCWs to develop, implement, and evaluate a plan to reduce needlestick injuries in the institution, and evaluate needle devices with safety features. NIOSH further recommends that facilities identify priorities based on assessments of how needlestick injuries are occurring, patterns of device use in the institution, and local and national data on injury- and disease- transmission trends. The highest priority should be given to needle devices with safety features that will have the greatest impact on preventing occupational infection, such as hollow-bore needles used in veins and arteries. Facilities should identify a safety devices intended scope of use and any special technique or design factors that will influence its safety, efficiency, and user acceptability. Conduct a product evaluation, ensuring that the participants represent the scope of eventual product users.
Airborne Transmission of Pathogens
One of the more hazardous risks in hospitals is the airborne transmission of infectious organisms, such as tuberculosis, influenza, and severe acute respiratory syndrome. The debate still rages in hospitals over revised mask fit-testing requirements mandated by OSHA. A number of hospitals and healthcare professionals think there is no true science behind fit-testing, or that because they have had no conversions, why must they change the way they have been doing things for a long time, says Strode. But sometimes you must re-examine what you have been doing because its all about championing HCW safety and patient wellbeing.
The most effective way to control respiratory hazards is to follow correct work practices and prescribed engineering controls. When additional protection is needed, respiratory protection (masks/respirators) is used to further ensure that individuals are not exposed to hazardous airborne contaminants. Masks/respirator must be approved by NIOSH, and personnel are to be fit tested for different facial sizes/characteristics. HCWs are instructed to perform a fit check, in accordance with OSHA standards and good industrial hygiene practice, each time the mask/respirator is worn.
HCWs face a significant risk of developing latex sensitivity or latex allergy from exposure to latex in products such as examination and surgical gloves. It has been estimated that 8 percent to 12 percent of HCWs are latex-sensitive, with reactions ranging from irritant contact dermatitis and allergic contact sensitivity, to possibly life-threatening, sensitivity. Many other hospital employees who are not patient-care providers, such as housekeepers or laundry workers, also are exposed to latex products and latex-allergy risks. Employees exposed to latex gloves and other products containing natural rubber latex may develop allergic reactions such as skin rashes, hives, nasal, eye, or sinus symptoms, and asthma. Atopic individuals and those with spina bifida are at increased risk for developing latex allergy.
Latex allergy should be suspected in anyone who develops certain symptoms after latex exposure, including nasal, eye, or sinus irritation; hives; shortness of breath; coughing; wheezing; or unexplained shock. Any exposed worker who experiences these symptoms should be evaluated by a physician, because further exposure could cause a serious allergic reaction. A diagnosis is made by using the results of a medical history, physical examination, and tests. Once a worker becomes allergic to latex, special precautions are needed to prevent exposures during work, as well as during medical or dental care. Certain medications may reduce the allergy symptoms, but complete latex avoidance is the most effective approach. Many facilities maintain latex-safe areas for affected patients and workers.
Healthcare facilities should stock appropriate gloves for latex-sensitive employees, as well as ensure that appropriate PPE is readily accessible. According to OSHA, hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives must be readily accessible to those employees who are allergic to the gloves normally provided. Among the alternatives are synthetic, low protein, and powder-free gloves.
NIOSH recommends the following practices:
- Use good housekeeping practices to remove latex-containing dust from the workplace
- Frequently clean areas contaminated with latex dust (upholstery, carpets, ventilation ducts, and plenums)
- Frequently change ventilation filters and vacuum bags used in latex-contaminated areas
- Use appropriate work practices to reduce the chance of reactions to latex:
- When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration) unless they have been shown to reduce latex-related problems and maintain glove barrier protection.
- After removing latex gloves, wash hands with a mild soap and dry thoroughly.
- Do not use latex gloves when there is no risk of exposure to blood or OPIM.
According to the organization Healthcare Without Harm, hospitals generate more than 2 million tons of waste each year. In the past, many hospitals simply dumped all waste streams together, from reception-area trash to operating-room waste, and burned them in incinerators. Now there is a greater realization that incineration is a leading source of highly toxic dioxin, mercury, lead, and other dangerous air pollutants. Much of the content of a typical hospitals waste stream includes materials that prove to be deadly. For example, a broken mercury thermometer might be tossed into a red bag. When incinerated, mercury is released into the environment as dioxins, potentially causing impaired vision, hearing, taste, and smell. In low doses, dioxins, which are known carcinogens, cause reproductive, endocrine, and immune systems problems.
Hospitals also produce what some experts are calling a simmering chemical soup which contains fumes from high-level disinfectants such as glutaraldehyde, surgical smoke from tissue being cut, vaporized, or coagulated, and waste gases from anesthetic agents that compromise the quality of indoor air and the health of patients and HCWs.
Exposure to glutaraldehyde fumes can cause serious respiratory and dermatologic problems, while surgical smoke or laser plume, can also cause and aggravate respiratory problems, along with causing burning, watery eyes, nausea, and viral contamination.
1. Working conditions are major factor in retaining current nurse workforce. Legislative Network for Nurses 18. Sept 10, 2001) 137; Online health and safety survey, September 2001, Key finding. http://nursingworld.org/surveys/keyfind.pdf.
2. Department of Health and Human Services, National Institute for Occupational Safety and Health. NIOSH Alert: Preventing needlestick injuries in healthcare settings. 1999. http://www.cdc.gov/niosh/2000-108.html (accessed 7 Oct 2002).
4. Jagger, J., Bentley, M., and Tereskerz, P. Study of patterns and prevention of blood exposures in OR personnel. AORN Journal 67. May 1998. 979-996.
5. Blackmon, D. Back injury prevention. Surgical Services Management 5. July 1999. 43-46.
7. Clarke, S., et al. Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses. Am J Infection Control 30. June 2002. 207-216.
8. Legislative Network for Nurses. Working conditions are major factor in retaining current nurse workforce.
9. Gershon, R., et al. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am Journal Infection Control 28. July 2001. 211-221.
11. Department of Health and Human Services, National Institute for Occupational Safety and Health. Healthcare workers. http://www.cdc.gov/niosh/healthpg.html#tb.