By Kelly M. Pyrek
U.S. hospitals recorded nearly 58,000 work-related injuries and illnesses in 2013, amounting to 6.4 work-related injuries and illnesses for every 100 full-time employees -- almost twice as high as the overall rate for private industry. In June, the Occupational Safety and Health Administration (OSHA) announced it was targeting some of the most common causes of workplace injury and illness in the healthcare industry, and is expanding its use of enforcement resources in hospitals and nursing homes to focus on patient or resident handling; bloodborne pathogens; workplace violence; tuberculosis, and slips, trips and falls.
“Workers who take care of us when we are sick or hurt should not be at such high risk for injuries – that simply is not right," says David Michaels, PhD, MPH, assistant secretary of labor for occupational safety and health. "Workers in hospitals, nursing homes and long-term care facilities have work injury and illness rates that are among the highest in the country, and virtually all of these injuries and illnesses are preventable. OSHA has provided employers with education, training and resource materials, and it’s time for hospitals and the healthcare industry to make the changes necessary to protect their workers.”
OSHA has advised its staff through a memorandum that all inspections of hospitals and nursing home facilities, including those prompted by complaints, referrals or severe injury reports, should include the review of potential hazards.
“The most recent statistics tell us that almost half of all reported injuries in the healthcare industry were attributed to overexertion and related tasks. Nurses and nursing assistants each accounted for a substantial share of this total,” says Michaels. “There are feasible solutions for preventing these hazards and now is the time for employers to implement them.”
Let's take a look at three key components of occupational health in the healthcare industry.
This foundation of occupational health is more critical than ever, given that OSHA recently updated instructions for conducting inspections and issuing citations related to worker exposures to tuberculosis in healthcare settings. This instruction incorporates guidance from the Centers for Disease Control and Prevention (CDC) report, “Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005.” The revised directive does not create any additional enforcement burdens for employers; it simply updates the agency’s inspection procedures with the most currently available public health guidance. This directive also covers additional workplaces regarded as healthcare settings such as sites where emergency medical services are provided and laboratories handling clinical specimens that may contain M. tuberculosis. Other changes include: the introduction of a newer screening method for analyzing blood for M. tuberculosis; classifying healthcare settings as low risk, medium risk, or potential ongoing transmission; and reducing the frequency of TB screenings for workers.
According to the CDC, nearly one-third of the world's population is infected with TB, which kills almost 1.5 million people per year. In 2013, 9,582 TB cases were reported in the United States, and approximately 383 of those cases were among healthcare workers. Multidrug-resistant and extremely drug-resistant TB continue to pose serious threats to workers in healthcare settings. TB infection occurs when a susceptible person inhales droplets from an infected person who, for example, coughs, speaks or sneezes. It is the second most common cause of death from infectious disease in the world after HIV/AIDS.
Respiratory protection is a mainstay of any occupational health program, and the Association of Occupational Health Professionals in Healthcare (AOHP) identifies respiratory protection as a critical area of competence for the occupational health professional (OHP) in healthcare. The AOHP emphasizes that "Respiratory protection programs led by competent staff, including OHPs, are for healthcare workers who treat patients in isolation with airborne precautions. In addition, emerging infectious diseases such as Ebola have demonstrated the importance of healthcare workers being skilled in the use of PPE including respiratory protection."
"Building the respiratory protection competence of OHPs and frontline healthcare workers will better equip healthcare to be prepared for any airborne illness," says AOHP executive president Dee Tyler, RN, COHN-S, FAAOHN. "AOHP supports training strategies that promote the proper use of PPE, and AOHP will continue to advocate for and participate in national efforts that build a culture of safety in healthcare."
The organization recently adopted a new position statement on respiratory protection for healthcare workers. This position statement highlights AOHP's ongoing efforts to encourage the implementation of effective respiratory protection programs in hospitals and better training on the proper use of PPE. AOHP was a member of an inter-professional advisory group formed in response to a 2011 report by the Institute of Medicine regarding OHPs and respiratory protection, whose work led to the development of Respiratory Protection Competencies for OHPs. AOHP also collaborates with and supports the work of a number of other national organizations regarding respiratory protection initiatives, including the National Institute for Occupational Safety and Health (NIOSH), the Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC) and the Joint Commission.
As the AOHP position statement emphasizes, "In healthcare, the primary use of respiratory protection is for patients who are in isolation airborne precautions. The diseases that most often require respiratory protection include Mycobacterium tuberculosis, rubeola, varicella, disseminated herpes zoster and severe acute respiratory syndrome (SARS). In addition, there have been and will be future emerging infectious diseases, such as Ebola, that have demonstrated the importance of healthcare personnel (HCP) being prepared and competent in the use of personal protective equipment including respirator use."
AOHP points to the additional work that is being done to develop tools to build the competence of frontline healthcare personnel who use respiratory protection. Research has shown that healthcare workers do not use personal protective equipment (PPE), including RP properly. The NIOSH NPPTL Respirator Evaluation for Acute Care Hospitals (REACH) Studies I and II revealed the following trends:
1. RP programs exist on paper
2. Healthcare personnel provide different responses to questions about RP than hospital/unit managers
3. Healthcare workers are unclear about when to use RP including what type of protective device should be used and how to properly don/doff the equipment
4. The focus is on fit testing rather than training with training being less than 15 minutes per year.
AOHP says that these results indicate the need for the ongoing development of strategies to educate frontline healthcare personnel and implement successful RP programs in healthcare settings.
There are a number of resources available to assist occupational health professionals and infection preventionists in their RP program development. The Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH) recently released the Hospital Respiratory Protection Toolkit, a resource for healthcare employers to use to protect hospital staff from respiratory hazards. OSHA’s Respiratory Protection Standard requires that healthcare employers establish and maintain a respiratory protection program in workplaces where workers may be exposed to respiratory hazards. The toolkit covers respirator use, existing public health guidance on respirator use during exposure to infectious diseases, hazard assessment, the development of a hospital respiratory protection program, and additional resources and references on hospital respiratory protection programs.
The toolkit explains the “hierarchy of controls" that should be employed for healthcare hazard-mitigation, starting with the most effective controls—the elimination of hazards or substitution of less hazardous processes, chemicals, or products. Next in the hierarchy are engineering controls, which involve isolating the hazard and/or using specialized ventilation (e.g., isolation rooms or laboratory hoods). Where these controls are not feasible or adequate, administrative controls (e.g., providing vaccinations or triaging chemical emergency patients) and work practices (e.g., following respiratory hygiene/cough etiquette strategies or keeping chemical containers capped) are used to reduce risk, most often by minimizing the extent or duration of the exposure, or reducing the number of employees exposed. Respirators and other personal protective equipment (PPE) are used as a last line of defense when exposures cannot be reduced to an acceptable level using these other methods.
The toolkit emphasizes that every healthcare facility should develop policies and procedures which address the control methods used at their institution: "The hazards associated with ATDs (e.g., infectious patients with a transmissible disease or, in rare situations, environmental sources of anthrax or fungi) cannot be eliminated from or substituted out of the hospital setting. ATD pathogen exposures cannot routinely be measured in the air, and have no established occupational exposure limits. In addition, ATD pathogens vary in infectivity and severity of outcome. In order to protect employees from ATDs, healthcare facilities must implement comprehensive infection control plans utilizing a combination of engineering, administrative (including training and vaccination), and work practice controls, and provide for the use of respirators and other PPE. Healthcare personnel who care for patients with ATDs must work in close proximity to the source of the hazard; even with controls in place, they are likely to have a higher risk of inhaling infectious aerosols (droplets and particles) than the general public. These personnel, and others with a higher risk of exposure related to the tasks they perform (e.g., lab or autopsy workers), must often be protected further through the proper use of respirators."
“Hospitals are one of the most hazardous places to work,” says assistant secretary of labor for occupational safety and health Dr. David Michaels. “One of the ways that we can protect workers in a healthcare setting is by providing employers with the resources needed to ensure a safe workplace. This toolkit will help protect those workers who dedicate their lives to caring for others.”
“Appropriate respiratory protection is a vital line of defense against airborne hazards hospital workers might face on the job,” says NIOSH director John Howard, MD. “This toolkit is an important resource to help healthcare employers ensure their workers are out of harm’s way when it comes to respiratory hazards.”
OSHA's toolkit emphasizes the need for a multi-modal approach to infection prevention and control, encompassing employee vaccination; hand hygiene and proper and PPE usage, among other strategies. As the toolkit notes, "Multiple approaches are often required since many controls reduce hazards without eliminating them and many controls are subject to failure." Chief among these approaches is the Centers for Disease Control and Prevention (CDC) Healthcare Infection Control Practices Advisory Committee’s (HICPAC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, which describes Standard and Transmission-Based Precautions.
CDC and HICPAC state that transmission of an infectious disease requires three elements: a source of infectious agent, a susceptible host with a route of entry, and a mode of transmission. Standard Precautions are the foundation of infection control and represent the minimum infection prevention measures that apply to all patient care. They include practices such as hand hygiene, use of personal protective equipment (e.g., gloves, gowns, facemasks) depending on the anticipated exposure, cough etiquette, safe injection practices, and safe handling of potentially contaminated equipment or surfaces in the patient environment. Standard Precautions apply to all patients, clients, and staff, regardless of the presence of infectious agents, and are intended to reduce the risk of transmitting infections from known and unknown sources.
When a patient is known or suspected to be infected and Standard Precautions are insufficient, CDC and HICPAC have prescribed one or more of three categories of Transmission-Based Precautions to eliminate or reduce the mode of transmission: Contact Precautions, Droplet Precautions, and Airborne Precautions. Contact Precautions include the use of gloves and gowns to prevent the direct or indirect transmission of disease between patients and healthcare personnel. Droplet Precautions include the use of facemasks to prevent large droplets from travelling from the respiratory tract of a patient to the mucosal surfaces (i.e., nasal mucosa, conjunctivae, and, less frequently, the mouth) of the healthcare personnel and also include use of gloves, gowns, and eye protection if substantial spraying of body fluids is anticipated. Airborne Precautions reduce the risk of healthcare personnel inhaling small infectious airborne particles. Airborne Precautions require the use of respiratory protection.
The OSHA toolkit explains that the CDC and HICPAC describe the distinction between droplet transmission and airborne transmission based on particle size and the distance and time over which the pathogens remain infectious. CDC and HICPAC indicate that droplets responsible for droplet transmission have traditionally been defined as being greater than 5 micrometers in diameter, while the particles or “droplet nuclei” responsible for airborne transmission are less than 5 micrometers in diameter and remain airborne and infectious long enough to travel substantial distances (e.g., through a ventilation system). Although a distance of 3 feet had historically been used to define the area of risk when working with patients suspected or known to have diseases requiring Droplet Precautions, CDC and HICPAC report that infection has occurred at distances greater than 3 feet. Thus, CDC and HICPAC state that observing Droplet Precautions at a distance up to 6 or 10 feet or upon entry into the patient’s room may be prudent. When Droplet Precautions are recommended, surgical masks function to reduce the transmission of large infectious droplets between the source (patient) and the mucosal surfaces of a susceptible host (healthcare personnel). When Airborne Precautions are recommended, respirators and other control measures, such as patient isolation in an airborne infection isolation room (AIIR) with specialized ventilation, are used to protect healthcare personnel from inhaling infectious particles that are of small diameter, likely to remain infectious over long time or distance, or both.
OSHA mandates that hospitals and all other employers who require employees to use respiratory protection for control of exposures to airborne contaminants, including ATD pathogens, must comply with the agency's Respiratory Protection standard, 29 CFR 1910.134, or the equivalent state standard. The OSHA Respiratory Protection standard establishes legally enforceable requirements about how respirators are to be used. When respirator use is required, the Respiratory Protection standard requires that all employee use of respirators be done within the context of a comprehensive and effective respiratory protection program. The program must be in writing, have a designated respirator program administrator, and specify the employer’s policies and procedures for the use of respiratory protection in the facility. OSHA requires each respiratory protection program to include several specific elements, but leaves the specifics of the policies and procedures used to meet these requirements up to individual employers. The Respiratory Protection standard does not specify the circumstances under which healthcare personnel must use respirators for protection against ATD pathogens. However, OSHA requires employers to evaluate the respiratory hazards in the workplace, and expects that hospitals develop their respiratory protection policies based on CDC/HICPAC and other public health guidance from CDC, state, and local health departments.
The OSHA toolkit outlines how to develop a respiratory protection program (RPP). Here are the key elements:
• Perform a Hazard Evaluation: The hazard evaluation identifies and evaluates potential exposures in the workplace that might require the use of
respiratory protection. Once identified, these exposures must be assessed to determine how often they are expected to occur and the level of exposure, so that they can be controlled to the extent feasible and, if required, appropriate respiratory protection can be selected. A hazard evaluation must be completed for all respiratory hazards; in the case of infectious agents, OSHA says it is not generally feasible to quantify the level of exposure, nor is it known what level of exposure will cause infection in a specific individual. Therefore, respirators for infectious agents must be selected according to anticipated exposure by task and according to recognized and generally accepted good infection control practices and public health guidance such as that provided by CDC’s HICPAC, federal and state OSHA, and state health departments.
• Develop Policies and Procedures: Once you have determined who will administer the program and which employees will be included, you are ready to develop the policies and procedures that will make up your written RPP. The RPP must have a section that addresses each of the following elements: respirator selection; respirator use; storage, maintenance, repair and disposal; fit testing; training; record-keeping; and program evaluation
To supplement OSHA's toolkit, the Joint Commission developed an educational monograph, Implementing Hospital Respiratory Protection Programs: Strategies from the Field, to assist hospitals in implementing respiratory protection programs. The monograph, produced in collaboration with NIOSH’s National Personal Protective Technology Laboratory, identifies common implementation challenges, provides specific examples of innovative strategies from healthcare organizations and examines the role of leadership, quality improvement, fit testing and training challenges and program evaluation.
The Joint Commission toolkit emphasizes the importance of respiratory protection: "In recent years there has been a renewed focus in healthcare on the appropriate use of respiratory protection. This attention is driven in part by increased awareness of the risk of known hazards, such as the emergence of multidrug-resistant tuberculosis (MDR-TB); exposure to certain disinfectants (e.g. glutaraldehyde); antineoplastic drugs; surgical smoke; and chemical, biological and radiological hazards addressed through emergency preparedness training. This awareness also extends to anticipated new risks which have captured the attention of policymakers as well as workers. Healthcare organizations must be prepared for the next Severe Acute Respiratory Syndrome (SARS)–like outbreak of unknown or novel etiology, as well as the ever-present possibility of pandemic influenza."
The Joint Commission toolkit explains that a respiratory protection program is a cohesive set of worksite-specific procedures and policies that, when implemented, is a key component to occupational health. The following are required elements of a respiratory protection program:
• Annual training of employees in why a respirator is necessary (e.g., the respiratory hazards to which they are potentially exposed during routine and emergency situations); and proper use of respirators, limitations on their use, and their maintenance
• Procedures for selecting appropriate respirators for use in the workplace
• Fit testing for tight fitting respirators (at initial hire and annually thereafter)
• Cleaning, disinfecting, storing, inspecting, repairing, and removing from service or discarding respirators (including established schedules for each of these elements)
• Ensuring adequate supply, quantity, and flow of breathing air for atmosphere-supplying respirators
• Provisions for medical evaluation of employees who must wear respirators
• Maintaining records of medical evaluation, fit testing, etc.
• Regular evaluation of the effectiveness of the program
“Respiratory protection programs enhance safety for both workers and patients, but there are many common challenges associated with their implementation,” says Ana McKee, MD, executive vice president and chief medical officer for the Joint Commission. “We hope that by showcasing the innovative and effective strategies used by healthcare organizations across the country to overcome some of these challenges, hospitals can learn from one another as they implement and improve their own respiratory protection programs.”
The CDC, the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that all U.S. healthcare workers get vaccinated annually against influenza; however, vaccine coverage often falls short. For example, overall, Black, et al. (2014) reported that the final 2013-14 flu vaccination coverage among healthcare workers was 75.2 percent, similar to coverage of 72 percent in the 2012-13 season. Coverage was highest among healthcare personnel working in settings with flu vaccination requirements (97.8 percent). By occupation, flu vaccination was highest among physicians (92.2 percent) and nurses (90.5 percent), followed by nurse practitioners/physician assistants (89.6 percent), other clinical personnel (87.4 percent), and pharmacists (85.7 percent). Flu vaccination coverage was higher among healthcare workers whose employers required (88.8 percent) or recommended (70.1 percent) that they be vaccinated compared to those workers who did not have an employer policy regarding flu vaccination (44.3 percent). Coverage by occupation was lowest for assistants/aides (57.7 percent) and non-clinical personnel (68.6 percent). (Non-clinical personnel include administrative support staff or managers, and non-clinical support staff such as food service workers, housekeeping staff, maintenance staff, janitors, laundry workers, etc.) Coverage by occupational setting was highest for personnel working in hospitals (89.6 percent), a 6.5 percentage point increase from the 2012-13 season (81.9 percent). Coverage by setting was lowest for those working in long-term care settings (63.0 percent).
The CDC emphasizes that comprehensive, work-site intervention strategies that include education, promotion, and easy access to vaccination at no cost for multiple days can increase healthcare worker vaccination coverage. Educating healthcare workers on the benefits and risks of influenza vaccination, providing vaccinations in the workplace at convenient locations and times, and providing influenza vaccination at no cost are effective strategies to increase coverage among healthcare workers in all settings.
Black, et al. (2014) report that among vaccinated HCP, the most common reasons given for vaccination were "To protect myself from flu" (43.5 percent), "My employer requires me to be vaccinated for flu" (25.5 percent), and "To protect patients from getting flu" (8.5 percent). Among unvaccinated HCP, the most common reasons given for not being vaccinated were "I might get sick from the vaccine" (20.1 percent), "I don't think that flu vaccines work" (16.3%), and "I don't need it" (16 percent).
In recent years, numerous societies and organizations have issued position statements favoring mandatory immunization of healthcare personnel and that vaccination should be a condition of employment in healthcare facilities. In a joint policy statement released in 2013, the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society (PIDS) call for mandatory, universal immunization of healthcare personnel as recommended by the CDC and the ACIP.
ACIP recommendations for healthcare personnel currently include vaccination against influenza, measles, pertussis (whooping cough), hepatitis B, and varicella (chicken pox). Some voluntary healthcare personnel vaccination programs have been effective when combined with strong institutional leadership and robust educational campaigns, say the societies; however, they add that for the vast majority of facilities, mandatory immunization programs are necessary to achieve target immunization rates. The policy calls for documentation of immunity or receipt of recommended vaccinations as a condition of employment, unpaid service, or receipt of professional privileges.
“Immunization rates for ACIP-recommended vaccines remain low among healthcare personnel,” says IDSA member Barbara Murray, MD. “When voluntary programs fall short, we think vaccination should be a condition of employment for the protection of both patients and healthcare workers from illness and death associated with these diseases.”
Those who cannot be vaccinated due to medical contraindications or because of vaccine supply shortages may need to be reassigned away from direct patient care or take other infection control measures. “ACIP-recommended vaccines are proven to be safe, effective and cost-saving,” says expert Daniel Diekema, MD. “Although there may be exceptions made for individuals for whom vaccination is not appropriate or in circumstances when the vaccine is not available, these exceptions should be extremely rare.” Notably, the policy does not provide for exemptions based on personal belief or religion.
The American Nurses Association (ANA) is calling for all individuals, including registered nurses (RNs), to be immunized against vaccine-preventable diseases, with the only exemptions being for medical or religious reasons. ANA’s new position on immunization aligns with recommendations from the CDC and the ACIP. ANA’s re-examination of its position was prompted partly by outbreaks of measles cases this year that affected unvaccinated adults and children.
“ANA’s new position aligns registered nurses with the best current evidence on immunization safety and preventing diseases such as measles,” says ANA president Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN. “A critical component of a nurse’s job is to educate patients and their family members about the effectiveness of immunization as a safe method of disease prevention to protect not only individuals, but also the public health.”
During the first seven months of 2015, the CDC said 183 people from more than 20 states were reported to have measles, with five outbreaks resulting in the majority of those cases. In 2000, the United States had declared that measles was eliminated from the country as a result of an effective measles vaccine and a strong vaccination program for children.
Healthcare personnel who request exemption for religious beliefs or medical contraindications – a condition or factor that serves as a reason to withhold an immunization due to the harm it would cause – should provide documentation from “the appropriate authority” supporting the request. Individuals who are granted exemption “may be required to adopt measures or practices in the workplace to reduce the chance of disease transmission” to patients and others, the new policy says.
ANA’s position on immunization for healthcare personnel aligns with the newly revised Code of Ethics for Nurses with Interpretive Statements, which says RNs have an ethical responsibility to “model the same health maintenance and health promotion measures that they teach and research,” including immunization.
The Association for Professionals in Infection Control and Epidemiology (APIC)'s influenza immunization position statement advises that “seasonal influenza vaccination of HCP offers an important method for preventing transmission of influenza to high-risk patients. Evidence supports the fact that influenza vaccine is effective, cost efficient and successful in reducing morbidity and mortality. Evidence also demonstrates that the current policy of voluntary vaccination has not been effective in achieving acceptable vaccination rates.” APIC says that healthcare providers have an obligation to ensure that all HCP are vaccinated against influenza: “As healthcare providers, we have an obligation to ensure that all HCP are vaccinated against influenza. As a profession that relies on evidence to guide our decisions and actions, we can no longer afford to ignore the compelling evidence that supports requiring influenza vaccine for HCP. This is not only a patient safety imperative, but is a moral and ethical obligation to those who place their trust in our care.” The statement adds that "As a profession dedicated to the prevention of infection, we have an ethical responsibility to protect those individuals entrusted to our care. We must do a better job of immunizing HCP every year to ensure patient safety and to protect those individuals at high risk of developing complications of influenza.”
The AOHP's position statement on influenza vaccination of healthcare personnel says the organization has examined this issue quite extensively, and finds that there are many nuances to consider regarding mandating influenza vaccine in healthcare personnel. For example, the variability of vaccine effectiveness is controversial when discussing mandating influenza vaccination, the AOHP notes, pointing to the CDC's admission that “The effectiveness of inactivated influenza vaccine depends primarily on the age and immunocompetence of the vaccine recipient, and the degree of similarity between the viruses in the vaccine and those in circulation. In years when the vaccine strains are not well matched to circulating strains, vaccine effectiveness is generally lower. The vaccine may also be lower among persons with chronic medical conditions and among the elderly, as compared to healthy young adults and children. In addition, estimates of vaccine effectiveness vary, based on the specificity of the outcome that is being measured.” According to a 2010 revised Society for Healthcare Epidemiology of America (SHEA) position paper, “a mismatch between the vaccine and the circulating wild-type strains is infrequent, but even in years with a substantial mismatch, the vaccine still may be partially effective. Vaccination of HCP serves several purposes: to prevent transmission to patients, including those with a lower likelihood of vaccination response themselves; to reduce the risk that HCP will become infected with influenza; to create 'herd immunity' that protects both HCP and patients who are unable to receive vaccine or are unlikely to respond with a sufficient antibody response; to maintain a critical societal workforce during disease outbreaks, and to set an example concerning the importance of vaccination for every person.”
In its position statement, AOHP advocates for the following:
A policy with the coordination of local, state and national government that supports mandating influenza vaccination for healthcare personnel if the organization cannot reach a 90 percent compliance rate with a voluntary vaccination program.
All healthcare personnel should be offered the influenza vaccine, at no charge, as long as it is not medically contraindicated.
AOHP strongly supports that all HCP receive the influenza vaccine based upon an informed decision through education regarding influenza illness, vaccine efficacy and safety, and infection control practices, including CDC recommendations.
AOHP supports local, state and national policies/recommendations that increase influenza vaccination rates.
AOHP supports that research and evidence-based practice is necessary related to influenza transmission in the healthcare environment and vaccination of HCP. Prompt communication of current study findings to the association and partnering organizations is critical in improving influenza prevention programs.
AOHP says that influenza management through vaccination is vital to the protection of patients, and this approach is a cornerstone to minimize absenteeism related to influenza in healthcare workers and states, "Occupational health professionals should strongly encourage a comprehensive influenza prevention program within the facilities they serve."
While strides have been made to address occupational injuries and exposures in the healthcare environment, the obstacles remain, and experts say that a greater commitment to safety among all stakeholders -- healthcare personnel, healthcare institutions and industry -- is necessary to achieve a reduction in the numbers of individuals experiencing these adverse events.
The International Safety Center's Exposure Prevention Information Network® (EPINet) database is a treasure chest for stakeholders who wish to see how sharps injuries and blood and body fluid exposures are trending. The EPINet Report for Needlestick and Sharp Object Injuries for the reporting period of Jan. 1, 2012 to Dec. 31, 2012 -- the very latest data available as of press time -- shows that nurses were the category of healthcare worker most injured by sharps and sustaining exposures, at 216 or 32 percent of all individuals suffering an incident. This was followed by staff doctors at 92 (15 percent) and interns or attending physicians, at 79 (13 percent). As for where the vast majority of injuries are occurring, 233 (39 percent) took place in the operating room/recovery, followed by 146 incidents (24.6 percent) in the patient room/general ward. The emergency department saw 38 incidents (6 percent). In 397 incidents (68 percent), the injured worker was the original user of the sharp item, and the sharp item was considered to be contaminated in 521 reported incidents (89 percent).
The majority of the reported incidents involved an intramuscular or subcutaneous injection (162/27 percent) followed by suturing (150/25 percent). Furthermore, the injury was sustained during use of item in 265 incidents (45 percent). A disposable syringe was the top device causing injury (183/35 percent), followed by suture needles (114/22 percent).
Safety-engineered devices were implicated in 201 injuries (36 percent); and nonsafety-engineered devices in 330 incidents (60 percent). In terms of the safety mechanism being activated at the time of the injury, the device was fully activated in 19 incidents (10 percent; partially activated in 42 incidents (23 percent); and not activated in 117 incidents (65 percent). When a safety-engineered device was used, the incident occurred before activation (81/50 percent); during activation (57/35 percent); and after activation (23/14 percent).
The EPINet Report for Blood and Body Fluid Exposures for the reporting period of Reporting period of Jan. 1, 2012 to Dec. 31, 2012 shows that nurses were again the most affected by blood and body fluid exposures, at 83/47 percent; followed by staff doctors at 13/7 percent; and interns/attending physicians at 11/5 percent. The majority of these kinds of exposures occurred in the patient room/general ward (59/33 percent), followed by the operating room (35/20 percent) and the emergency department (32/18 percent). Urine as the most common body fluid exposure (154/88 percent), followed by blood (125/71 percent). The exposure most often involved the body fluid touching the healthcare worker's unprotected skin (154/88 percent) during direct patient contact (96/55 percent).
For further information, EPINet reports may be accessed at: https://internationalsafetycenter.org/exposure-reports/
To further characterize the current occupational health landscape, the Association of Occupational Health Professionals in Healthcare (AOHP) recently released the results of EXPO-S.T.O.P.-2012, a survey of its members to ascertain the incidence of sharps injuries and mucocutaneous blood exposures among healthcare workers in U.S. hospitals. AOHP's EXPO-S.T.O.P. (EXPOsure Survey of Trends in Occupational Practice), the largest annual survey of its kind conducted in the United States, was initially conducted in 2011 to establish the first nationally representative blood exposure database and benchmark resource.
“Blood exposure among healthcare workers (HCW) continues to be a serious occupational risk that healthcare facilities strive to reduce,” says Linda Good, PhD, RN, COHN-S, director of employee occupational services for Scripps Health in San Diego, and EXPO-S.T.O.P. co-author. “Currently in the United States, EXPO-S.T.O.P. is the only active national blood exposure data collection system.”
A 15-item electronic survey pertaining to 2012 calendar-year data was developed and distributed to AOHP members across the nation to ascertain blood exposure incidence and denominator data. The survey, which will be conducted annually by AOHP going forward, provides results to help healthcare facilities enumerate and categorize blood exposures to better understand how they occur and what resources are required to reduce them. The survey also identifies best practices in hospitals with low incidence rates of blood exposures.
“AOHP members from 157 hospitals in 32 states participated in EXPO-S.T.O.P.-2012, a significant increase from 2011,” says survey co-author Terry Grimmond, director of Grimmond and Associates in New Zealand. “The survey shows a sharps injury (SI) rate of 28.2 per 100 occupied beds, or 2.2 per 100 full-time equivalent (FTE) staff. This incidence of SI is significantly higher than in other contemporary U.S. surveys and shows that little reduction in SI rates has occurred in the last decade. These results indicate that simply mandating the use of safety-engineered devices through the Needlestick Safety and Prevention Act of 2001 has not achieved our reduction goals, and a new vigor must be found to protect healthcare workers.”
The survey examined the 9,494 blood exposures reported from 157 hospitals in 32 states; the 7,119 sharps injuries (SI) and 2,375 mucocutaneous exposures (MC) resulted in incidence rates of:
- 28.2 SI / 100 occupied beds; 2.2 / 100 staff; 3.3 / 100 nurses; and 0.43 100 adjusted patient days
- 10.1 MC / 100 occupied beds; 0.8 / 100 staff; and 0.15/100 adjusted patient days
- of total reported SI, 42 percent were among nurses and 36 percent among doctors
- 44 percent of reported SI occurred during surgical procedures
The AOHP points to practices that have led to a more than 60 percent reduction in SI incidents in some hospitals:
- Prevention through education.
- Data-driven communication.
- Immediate root cause investigation of all exposures.
- Adoption of safer safety engineered devices.
- Engagement of staff on all levels.
- Acceptance by staff that safety is their responsibility
Association for Professionals in Infection Control and Epidemiology (APIC). Position Paper: Influenza Vaccination Should Be a Condition of Employment for Healthcare Personnel, Unless Medically Contraindicated. Available at: http://www.apic.org/Resource_/TinyMceFileManager/Advocacy-PDFs/APIC_Influenza_Immunization_of_HCP_12711.PDF
Black CL, Yue X, Ball SW, Donahue SMA, Izrael D, de Perio MA, A. Laney AC, Lindley MC, Graitcer SB, Lu P, Williams WW, Bridges CB, DiSogra C, Sokolowski J, Walker DK and Greby SM. Centers for Disease Control and Prevention (CDC). Influenza Vaccination Coverage Among Health Care Personnel — United States, 2013-14 Influenza Season. MMWR. Sept. 19, 2014 / 63(37);805-811.
Infectious Disease Society of America (IDSA). IDSA, SHEA, and PIDS Joint Policy Statement on Mandatory Immunization of Healthcare Personnel According to the ACIP-Recommended Vaccine Schedule. December 2013. Available at: http://www.shea-online.org/Article/smid/428/ArticleId/246.aspx
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Joint Commission. Implementing Hospital Respiratory Protection Programs: Strategies from the Field. Oakbrook Terrace, IL: The Joint Commission, Dec 2014.
Peterson K, et al. Hospital respiratory protection practices in six U.S. states: A public health evaluation study. American Journal of Infection Control. 43, 63-71. 2015.
U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). Caring for Our Caregivers: Safety and Health Management Systems: A Road Map for Hospitals.
U.S. Department of Labor. Occupational Safety and Health Administration (OSHA). Hospital Respiratory Protection Toolkit: Resources for Respirator Program Administrators. 2015.