Avoiding Healthcare's Hazards:
An Occupational Health Update
By John Furman, PhD, MSN, CIC
Healthcare organizations are constantly challenged to provide a safe environment for those to whom they deliver care and for healthcare personnel. Since 1983, when the Centers for Disease Control and Prevention (CDC) released its first "Guideline for Infection Control in Healthcare Personnel," there has been increased awareness of the occupational health hazards to healthcare personnel. Due to advances in occupational medicine, such as HIV post-exposure prophylaxis recommendations, in 1998 the CDC updated its guideline.1 This article sets forth the minimum qualifications for an occupational health program in the healthcare setting.
Infection control professionals have a critical role within the healthcare setting in interfacing with occupational health, identifying risks to healthcare personnel, assessing potential adverse outcomes, implementing protective policies and procedures, and evaluating the effectiveness of measures taken. Factors such as increasing regulation, rising patient acuity, and staffing shortages combine to make these responsibilities ever more complex and demanding. The infection control professional must keep abreast of current regulations and literature in the occupational health arena to ensure that appropriate measures are being taken to reduce the risks of nosocomial infections in healthcare personnel.
The following is an overview of recent occupational health issues in healthcare:
Occupational Health and Safety
In September 2001, the American Nurses Association (ANA) released the results of its Nursing World Health and Safety Survey.2 More than 4,800 nurses from across the US responded to this online survey. Eighty-eight percent of the nurses said safety and health concerns influence their decisions to continue working in the field of nursing and the kind of nursing work they choose to perform. Fear of contracting an infectious disease at work was a common thread in the survey responses.
In addition to the No. 1 concern of stress and overwork, nurses cited contracting HIV or hepatitis from a needlestick injury (45%) among their top three health and safety concerns. Other concerns included being infected with tuberculosis or another disease (37%), developing a latex allergy (20.9%), toxic effects from exposure to hazardous chemicals such as glutarahdehyde or ethylene oxide (7%), exposure to hazardous drugs such a pentamidine or ribavirin (5%), and exposure to smoke from laser or electrocautery devices (3%).
The ANA also completed another survey looking at staffing patterns and related working conditions.3 The results from this survey indicated a relationship between the current nursing shortage and the risk of occupational illness. Factors such as increased stress, mandatory overtime, and lost sleep adversely affect the immune system making healthcare personnel more susceptible to infectious disease. Staffing deficits have a direct relationship to the practice of infection control and occupational health. Practicing appropriate hand washing, antisepsis, and isolation practices suffer under adverse working conditions. Forty eight percent of the respondents reported they had contracted job-related illnesses or their illnesses have been made worse at work.
The National Institute of Occupational Safety and Health (NIOSH) is concerned about occupational health issues in the healthcare industry. NIOSH's National Occupational Research Agenda (NORA) has recognized that bloodborne (HBV, HCV, and HIV) and airborne pathogens (TB and influenza) represent a significant class of exposures for the 6 million US healthcare workers. The goals of ongoing research are to determine the extent of occupational transmission of these infectious diseases, to understand the barriers to the use of safe work practices and vaccines, and to develop and evaluate new control methods.
In addition, NIOSH has established a research focus on the occupational safety and health needs of working women. Ninety two percent of the 4.3 million nurses and nursing assistants in the US are women. Musculoskeletal disorders, workplace violence, exposure to hazardous substances, needlestick prevention, and latex allergy have been identified as major research priorities. NIOSH will be sponsoring two stakeholder meetings, one each on the West and East coasts, during the first quarter of 2002 to discuss the healthcare industry. Be on the lookout for announcements of the meetings, as this will be a great opportunity for infection control and occupational health professionals to provide direct input.
The Occupational safety and Health Administration (OSHA) has revised its Bloodborne Pathogens Standard to conform to the requirements of the federal Needlestick Safety and Prevention Act.4 The revisions include (a) new examples in the definition of engineering controls along with definitions of "needleless systems" and "sharps with engineered sharps injury protections (SESIP);" (b) to require that Exposure Control Plans (ECPs) reflect how employers implement new developments in control technology; (c) to require employers to solicit input from employees responsible direct patient care in the identification, evaluation, and selection of engineering and work practice controls; and (d) to establish and maintain a log of percutaneous injuries from contaminated sharps.
The revisions to the Bloodborne Pathogens Standard became fully effective in all federal and state health and safety plan states Oct. 18, 2001 (if you are in a state with its own occupational heath and safety plan, additional requirements may apply). The standard requires employers to establish written ECPs to minimize employee exposures to bloodborne pathogens through the use of engineering and work practice controls. Employers are required to update ECPs to document consideration and implementation of appropriate and effective engineering controls, which includes the use of safer medical devices. For purposes of the standard, an "appropriate" safer medical device includes only devices whose use, based on reasonable judgment in individual cases, will not jeopardize patient or employee safety or be medically contraindicated. An "effective" safer medical device is a device that, based on reasonable judgment, will make an exposure incident involving a contaminated sharp less likely to occur in the application in which it is used.4
The requirements of the Bloodborne Pathogens Standard are enforced through general OSHA and state plan inspection procedures. Citations and monetary fines may be issued for:
- Failure to have an ECP.
- Failure to review and implement commercially available "safer medical devices."
- Failure to include procedures for documenting exposure incidents.
- Failure to review and update the ECP at least annually.
- Failure to follow Universal Precautions or other barrier system such as Body Substance Isolation or Standard Precautions.
- Failure to comply with most current public health guidelines for immunization, post-exposure evaluation, and follow-up.
The standard now clearly requires that any time an employee may be exposed to blood or other potentially infectious material, the employer must evaluate and implement safer medical devices that eliminate exposures to the lowest extent feasible. No exemptions to this requirement are provided in the standard. All employers must evaluate the hazards present in their workplace. All employers who have employees with exposure to bloodborne pathogens must review and implement commercially available safer medical devices to the extent that they reduce occupational exposure to the lowest possible extent feasible.
The Bloodborne Pathogens Standard requires that employers provide postexposure evaluations, follow-up, and prophylaxis according to the current US Public Health Service recommendations. In June 2001, the CDC issued its "Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Post-exposure Prophylaxis."5 The report updates an consolidates all previous US Public Health Services recommendations for the management of healthcare personnel who have occupational exposure to blood or other potentially infectious material.
Recommendations include initiation of the hepatitis B vaccine series to susceptible HCP, along with post-vaccination antibody screening. Provision of the hepatitis B immune globulin (HBIG) and/or the hepatitis B vaccine series should be considered for all exposures after evaluation of hepatitis B surface antigen status of the source and the vaccination and vaccine response status of the exposed person.
When HBIG is indicated, it should be administered as soon as possible after exposure (preferably within 24 hours). The effectiveness of HBIG if administered >7 days after exposure is unknown. When hepatitis B vaccine is indicated, it should be administered as soon as possible (preferably within 24 hours) and can be administered simultaneously with HBIG at a separate site.
Immune globulin and antiviral agents (e.g., interferon with or without ribaviron) are not recommended for post-exposure prophylaxis of hepatitis C. For HCV exposure management, the HCV status of the source and the exposed person should be determined. For the person exposed to an HCV positive source baseline testing for anti-HCV and ALT is recommended. Follow-up testing should be done at 4 to 6 months.
Recommendations for HIV post-exposure prophylaxis (PEP) include a basic four-week regimen of two drugs (zidovudine and lamivudine [3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and an expanded regimen that includes the addition of a third drug for HIV exposures that pose an increased risk for transmission. The likelihood of drug resistance should also be considered when selecting a drug regimen. PEP should be administered as soon as possible. The CDC does not give any specific time recommendations. But animal studies have shown increased benefits if PEP is started within hours after exposure rather than days.
Because of the increasingly complex circumstances involved (e.g., nevirapine is not recommended for PEP because it has been associated with severe hepatotoxicity) the CDC is recommending consultation with local experts and/or the National Clinician's Post-Exposure Prophylaxis Hotline at (888) 448-4911 before prescribing PEP.
Injury and Illness Record-keeping
OSHA's revised Occupational Injury and Illness recording and Reporting Requirements rule6 became effective Jan. 1, 2002. OSHA will delay the effective dates of sections involving the recording of cases involving occupational hearing loss, and the recording of cases involving work-related musculoskeletal disorders, until Jan. 1, 2003. All other sections of the rule published Jan. 19, 2001, remain unaffected. The record-keeping rule seeks to improve how the government tracks occupational injuries and illness through increased employee involvement, simplified forms, and allows employers to use computers to meet OSHA record-keeping requirements. In addition to replacing the OSHA 200 logs with the new 300 and 301 forms, there are several revisions that are of interest to infection control and occupational HCPs.
As discussed earlier the Bloodborne Pathogens Standard now requires the establishment of a Sharps Injury Log. The record-keeping rule will require sharps exposures to be recorded on the OSHA 300 and 301 forms.
Sharps injuries (along with HIV, hepatitis, and TB infection) will be considered "privacy cases," which means that no employee identification information will be included in the OSHA documentation. Sharps exposures must also be documented separately from other injuries and illnesses. Requiring maintenance of a separate sharps injury log or use of a computer program that can sort sharps exposures from other injuries and illnesses.
The criteria for recording TB cases includes three provisions designed to help rule out cases where occupational exposure is not the cause of infection. An employer is not required to record a case involving an employee who has a skin test conversion if (a) the worker is living in a household with a person who has been diagnosed with active TB, (b) the public health department has identified the worker as a contact of a case of active TB unrelated to the workplace, or (c) a medical investigation shows that the employee's infection was caused by exposure to TB away from work or proves the case was not related to TB exposure. The rule envisions a more active role by public health departments in determining the cause of TB infections with a suspected relationship to the workplace. Many health jurisdictions already classify TB skin test conversions as reportable conditions.
OSHA has simplified its approach to determining whether care provided to an employee is classified as medical treatment or first aid. In the past medical treatment was simply defined as "any medical cure or treatment beyond first aid." The new rule contains a comprehensive list of treatments that is classified as first aid; all other treatments not contained on this list will be considered "medical treatment." These include, but are not limited to, (a) visits to a healthcare provider limited to observation, (b) diagnostic procedures, including the use of prescription medications solely for diagnostic purposes (e.g., eye drops to dilate the pupils), (c) simple administration of oxygen, and (d) administration of tetanus or diphtheria shots or boosters. Administration of any other vaccine (e.g., hepatitis B or rabies vaccine) after an injury or exposure even if prophylactic in nature is considered medical treatment and is a recordable event on the OSHA 300 log.
OSHA Record-keeping Rule provides partial exemptions for workplaces in Standard Industry Classification codes 801-807 & 809. These include workplaces such as physicians' offices, and dental and medical laboratories. For those states with their own safety and health plans, they must adopt rules as least as effective as federal OSHA rules. These states do not need to exempt employers from record-keeping requirements and may institute more stringent requirements when justified. Refer to your state plan for specific record-keeping requirements.
The CDC has published its "Draft Guideline for Hand Hygiene in Healthcare Settings"7 and is presently soliciting public comment. You can review the draft guideline and provide comments via e-mail directly to the CDC's Hospital Infection Control Practices Advisory Committee (HICPAC) at www.cdc.gov/ncidod/hip/hhguide.htm. The draft guideline is designed to provide a thorough review of evidence dealing with hand washing and hand antisepsis. Recommendations to promote improved hand-hygiene practices along with such issues as gloving, the use of hand lotions, and wearing of jewelry and artificial fingernails are provided.
New studies support the efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use. Alcohol-based hand rubs have been shown to be more effective than traditional soap and water hand washing in reducing the transient microbiological load on hands. Using a waterless antiseptic product may overcome many of the factors (e.g., accessibility, time, skin irritation) associated with poor compliance with hand washing practices.
The draft guideline recommends the use of an alcohol-based waterless antiseptic agent for decontaminating hands when hands are not visibly soiled. This recommendation contradicts OSHA's requirement in the Bloodborne Pathogens Standard that the use of a waterless product may only be used when hand-washing facilities are not readily available. Hands must then be washed with soap and water as soon as feasible thereafter. As more scientific, research-based information becomes available, OSHA and other agencies will need to review their regulations on hand hygiene in order to support the most current infection control practice.
Laser or electrocautery procedures result in the destruction of tissue and creates a smoke byproduct. This surgical smoke can contain toxic gases and vapors such as benzene, hydrogen cyanide, and formaldehyde. Research has shown that bioaerosols containing dead and live cellular material, blood components, and microorganisms such as viruses can also be present. Although there has been no documented transmission of infectious disease through surgical smoke, the potential exists.
OSHA has considered developing a standard on controlling the hazards associated with exposure to surgical smoke but has yet to release draft regulation. When a hazard is not covered by a specific standard, OSHA may choose to cite the general duty clause when reasonable control measures are not utilized by employers to abate recognized hazards in the workplace. In this case, reasonable control measures could include the use of recommendations on ventilation and respiratory protection by product manufacturers and groups such as the American National Standards Institute (ANSI).
NIOSH has published a Health Hazard Alert on the dangers of exposure to surgical smoke.8 NIOSH recommends that exposure to airborne contaminates contained in surgical smoke be controlled through the use of ventilation and work practice controls. Recommended ventilation techniques include the use of both general room ventilation and local exhaust ventilation. A high efficiency particulate air filter (HEPA) should be used to trap any airborne particles. Recommended work practice controls include proper positioning of suctioning hoses and continuous use of local exhaust ventilation during any procedure that may generate surgical smoke. Infection control measures such as universal or standard precautions should also be used as appropriate.
John E. Furman, PhD, MN, CIC is an occupational health consultant for the Department of Labor and Industries, WISHA Policy and Technical Services in Olympia, WA.