By Amber Hogan Mitchell, DrPH, MPH, CPH
According to 2014 occupational incident surveillance data from nearly 30 U.S. hospitals, when an employee experiences a splash or splatter of blood or body fluid (e.g. blood or bloody urine) into the eye they are only wearing eye-appropriate personal protective equipment (PPE) 3.5 percent of the time. These mucotaneous exposures are extremely high risk. Just as the eyes are the windows to the soul, they are the frontlines for risk of disease transmission from patient to worker. If we experience fatigue, allergies, irritation, or infection our eyes become even more susceptible to microorganisms that come into contact with them.
With the emergence of global infectious disease like Ebola and Zika, we would expect compliance with PPE to be at an all-time high given healthcare facilities focus on public health preparedness. In fact, the opposite seems to be true. Compared to 2014, in 2013 20.9 percent of all eye exposures reported were employees wearing eye-appropriate PPE (i.e., goggles, faceshield). In 2012, 9.6 percent were wearing eye-appropriate PPE during an eye exposure.
PPE use is sporadic from year to year, despite growing infectious risk associated with the same types of exposures. When thinking about how to improve occupational protection with the use of PPE specifically, and as it relates to blood and body fluid exposures (BBFE), what guidance, standards, or controls are good enough?
To note, for the purposes of this article, we will be focusing on eye exposures as a means to focus on some of the highest risk exposures first. This isn’t to say that other types of exposures are not frequent or can’t be high risk, they are and they can -- but this gives us a definitive place to start.
Is Infection Prevention Guidance Good Enough?
No. When turning to CDC for their definition of “standard precautions,” eye protection is not mentioned explicitly.
Standard Precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or con-firmed infection status of the patient, in any setting where healthcare is delivered. These evidence-based practices are designed to both protect healthcare personnel and prevent the spread of infections among patients. Standard Precautions replaces earlier guidance relating to Universal Precautions and Body Substance Isolation.
Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, facemasks), depending on the anticipated exposure, 3) respiratory hygiene and cough etiquette, 4) safe injection practices, and 5) safe handling of potentially contaminated equipment or surfaces in the patient environment.
Additionally, in CDC’s 1998 Guideline for infection control in healthcare personnel. PPE and eye protection used for patient care are not mentioned at all. In their 2003 guidance Guidelines for Environmental Infection Control in Health-Care Facilities we do begin to see mention of eye protection for airborne viral diseases only, more specifically they recommend “(f)ace shields or goggles will help to prevent mucous-membrane exposure to potentially-aerosolized infectious material in these situations.”
Could lack of specification about PPE use in infection prevention guidance contribute to why compliance with eye protection during what could be the highest risk type of occupational exposures is so low? Let’s explore this further.
Are Behavioral Models Enough?
No. In Powers, et al.'s 2016 paper and highlighted in detail in ICT’s May Issue by Kelly Pyrek, we wonder if we create enough “cues” to mo-tivate behavior among healthcare practitioners to improve PPE compliance. This concept is fundamental to the Health Belief Model (HBM) fea-tured by Powers, Rosenstock, and others over the past several decades.
Healthcare facilities are paid for performance or punished for not preventing healthcare acquired conditions (HACs) like HAIs, but is there any incentive or motivation to influence worker wellbeing? Is the contrary true? If healthcare workers are motivated to wear PPE because they perceive it to be beneficial to reduce becoming ill, but their employer does not make it available where and when it is needed – meaning there is no access to it – have we actually created cues for inaction? Does that actually demotivate a preferred behavior or action?
Are OSHA Standards and NIOSH Guidance Enough?
No. While OSHA does require the use PPE in both its Bloodborne Pathogens Standard (BPS) (29 CFR 1910.1030) and its Personal Protective Equipment Standard (29 CFR 1910.132), its language is intentionally generic and performance-based. Specifically, the BPS standard states: When there is occupational exposure, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered appropriate only if it does not permit blood or oth-er potentially infectious materials to pass through to or reach the employee's 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.
OSHA does not provide specific requirements for when and where, using the example above, that eye protection should be used. It also does not dictate where it should be kept and how quickly it should be accessible to employees. Again, the purpose of OSHA standards is to keep the employer at an institutional level accountable for the safety and health of its workers.
Is depending on individual worker behavior, training, and education enough to increase the use of and compliance with wearing PPE? Many would argue, no. Are having standards in place that are designed to protect individual workers but that focus on compliance, program plans, annual reviews, recordkeeping, and abatement on a higher facility or employer level contributing to lower than ideal PPE use?
Granted, compliance is based on performing exposure assessments and documenting those in the employer’s Exposure Control Plan, but in a changing healthcare environment with constantly changing parameters, cost structures, employee turnover, new technologies, and expansion of healthcare out into communities – is that review really possible on an annual basis? Is it possible enough that individual worker controls – having access to and wearing PPE in dynamic times – trickles down to those at-risk employees in real time?
NIOSH recommends the following in its 2009 Information for Employers
Complying with OSHA’s Bloodborne Pathogens Standard: Provide and ensure the use of appropriate personal protective equipment, such as gloves, gowns, lab coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.
This language is identical to OSHA language and offers little in the way of recommendations for what to use during what procedures or for what patients. Again, these recommendations are workplace-specific and risk-based. In NIOSH’s 2011 Occupational HIV Transmission and Prevention among Health Care Workers, the agency recommends, “routinely using barriers (such as gloves and/or goggles) when anticipating con-tact with blood or body fluids.”
Again, this is not prescriptive enough to be as useful as we need it to be to improve compliance and PPE use for the workers that need it. Many are hoping that the new OSHA Infectious Disease Standard will help clarify and specific direction and controls. More likely, however is that the standard will also be as generic regarding PPE as its predecessor – the CalOSHA Aerosol Transmissible Disease (ATD) Standard.
Is the Occupational Hierarchy of Controls Enough?
Maybe. Since traditional infection prevention guidance is not good enough to improve compliance with PPE and prevent occupational transmission of infectious disease; and since behavioral models, OSHA standards, nor NIOSH guidance seem to do enough in their separate components – what is enough? Is it a combination of all of those things? Absolutely. But let’s think about this hierarchically. Can we change behavior – in this case increase PPE use by workers – focusing at a level higher than the worker themselves?
The idea behind the industrial hygiene or occupational hierarchy is that the control methods at the top are potentially more effective and protective than those at the bottom. Following this hierarchy normally leads to the implementation of inherently safer systems, where the risk of illness or injury to the worker has been substantially reduced.
Elimination and substitution, while most effective at reducing hazards, also tend to be the most difficult to implement in an existing process because major changes in equipment and procedures may be required to eliminate or substitute for a hazard. Consider here, eliminating all skin sutures in place of skin adhesives where possible or substituting glutaraldehyde (“glute”) used for instrument high level disinfection for its less hazardous counterpart -- ortho-phthalaldehyde (OPA) or substituting glass for plastic used in diagnostics.
Engineering controls are favored over administrative controls and PPE for controlling existing worker exposures in the workplace because they are designed to remove the hazard at the source, before it comes in contact with the worker. Well-designed engineering controls can be highly effective in protecting workers.
Examples of engineering controls used to protect workers from BBFEs are safety engineered medical devices (or sharps with engineered sharp injury protection “SESIPS” in OSHA terms). While safety devices (e.g., retracting needles or sheathing features on disposable syringes) have been effective in reducing needlesticks in the last 15 years, they still rely on the worker to activate the safety feature.
According to International Safety Center Exposure Prevention Information Network (EPINet®) 2014 data, 42.3 percent of employees are injured with devices that have an incorporated safety design. Of those using a safety device, only 36 percent actually fully or partially activate the safety feature. This can be interpreted to mean that even engineering controls can rely heavily on components of administrative or individual action that fall lower on the hierarchy.
We still have a ways to go on building better and safer practices, and on building new and different safety designs for sharp medical devices. This includes not just training and education, but also identification, evaluation and selection of effective devices by frontline non-managerial employees as required by OSHA.
Finally, administrative controls and PPE are frequently used with existing processes where hazards are not particularly well controlled, like BBFEs. Administrative controls and PPE programs may be relatively inexpensive but, over the long term, can be very costly to sustain. These methods for protecting workers have also proven to be less effective than other measures, requiring significant effort by the affected workers and as such less than desired compliance with their use.
Creating a New Level of Control
We know that the hierarchy of controls has been fundamental to both occupational health and industrial hygiene in healthcare and other industries for many decades. We also know that employees are motivated to use PPE based on their training, education, and perception of risk. Additionally, the action of putting on PPE has to be reinforced by physical access to and availability of PPE in order to continue to motivate the behavior. Not only does PPE need to be actively sought out, but it also needs to be donned and doffed correctly so as not to cross-contaminate oneself. How do we do that?
Perhaps we need to think about a new top-level control – Institution. Imagine a control that sits at the very top of the hierarchy, above “elimination.” It takes into account more than just culture and climate of safety, but places the highest level of worker protection at the core of its business success, economic viability, and customer service.
“Institution” is the incorporation of system-wide safety programs in employer, workplace, and healthcare facility mission and vision statements. “Institution” is combining worker and patient safety into an overall safety. It creates programs that incorporate worker-patient-community safety, security, wellbeing, and business/fiscal success into all of its functions, departments, and thought processes.
How Can Institutional Controls Improve PPE Compliance?
“Institutional Controls” within the hierarchy, sets the stage for all other controls; it becomes the fundamental driving force. In an ideal scenario, using institutional controls during new or re-construction of a healthcare facility means building in locations to store PPE based on where exposures are anticipated or likely. Since EPINet data indicates that the greatest percentage of BBFEs occur in patient rooms (40.4 percent), it means designing and building rooms to house PPE by or near the bedside. It includes making business and safety decisions using real data and hard evidence.
Institutional Controls are not just for new construction; they can be put in place retrospectively or in innovative ways. In a small community hospital, where space is limited and exposure to unknown risks in the community tends to be higher, Institutional Controls can be manifested in building better programs for training and education including for workers, patients, visitors, and the community. Campaigns can be designed to inform entire communities about infectious disease and what potential impact they may have on a small to mid-sized community if proper pre-cautions are not taken. Campaigns can be as simple as creating a social media page or event through Facebook, Instagram or Twitter.
Considerations can be made for shifting spaces to get creative or innovative about storing new PPE or making PPE carts mobile or adaptable, as well as identification of locations for discarded or soiled PPE. Institutional Controls may include hiring a third party vendor for all PPE needs or bringing in an occupational safety and health expert to help build plans and programs.
A new Hierarchy of Controls may look something like this:
Now that we have explored some new concepts and re-explored some tried and true ones, let’s explore whether new recordkeeping requirements – access to more data - might also help improve PPE use.
Will New OSHA Requirements Drive Better Compliance?
Maybe. Currently employers are required to record exposures (occupational injuries and illnesses) that result in medical treatment beyond first aid. This would be the case for mucotaneous exposures with blood, like those to the unprotected eye. However, as it relates to blood-borne disease or BBFEs there is only a specific call out for “any needlestick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material (OPIM)”. These injuries are maintained as a Sharps Injury Log and kept along with the OSHA 300 Logs. These records are not required to be reported anywhere external to the facility, except with very limited exceptions (NY, NJ, TX and MA).
Again, the current OSHA requirement in place requires employers - like those in healthcare - to record incidents internally, but not to report them externally.
Unless healthcare employers are using surveillance systems like EPINet, this unfortunately results in the inability for employee health and risk management professionals to share information with each other or to benchmark on exposures; type, reason, or outcome and PPE use. We don’t yet know if NIOSH’s Occupational Health and Safety Network (OHSN) new “blood and body fluid exposure” module will allow facilities to compare on any level of detail, exposures and PPE use across facilities (OHSN is the rebirth of CDC’s NaSH).
Powers mentions data sharing as an important stake that everyone must take to build better occupational infection prevention programs. Currently however, facilities are not designed to do this on any scale. This may change.
This spring OSHA announced its new requirements under the OSHA Recordkeeping Standard (20 CFR 1904) including – for the first time ever – requiring employers to submit (or report) their OSHA Injury and Illness Logs (300 Logs) to the Agency electronically.
For the first time, the nation will have access to occupational illness data in healthcare and public health settings giving opportunities to drive efforts for safer workplaces.
On its website, OSHA states: This simple change in OSHA’s rulemaking requirements will improve safety for workers across the country. One important reason stems from our understanding of human behavior and motivation. Behavioral economics tells us that making injury information publicly available will “nudge” employers to focus on safety. And, as we have seen in many examples, more attention to safety will save the lives and limbs of many workers, and will ultimately help the employer’s bottom line as well. Finally, this regulation will improve the accuracy of this data by ensuring that workers will not fear retaliation for reporting injuries or illnesses.
The new reporting requirements will be phased in over two years:
Year 1: Establishments with 250 or more employees in industries covered by the recordkeeping regulation must submit information from their 2016 Form 300A by July 1, 2017. These same employers will be required to submit information from all 2017 forms (300A, 300, and 301) by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.
Year 2: Establishments with 20-249 employees in certain high-risk industries must submit information from their 2016 Form 300A by July 1, 2017, and their 2017 Form 300A by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.
This new OSHA requirement will lead way to more accurate data that reflects real world risk and prioritize tasks and challenges based on real data. It will also provide a better picture of what is happening in US healthcare workplaces and how employers can work together to pre-vent occupational exposures, illness, and injury.
There is a great deal of hope that this requirement will shed light on occupational illness and infection so that we can collectively identify where they are occurring, what actions we need to take to control them, and how we can improve controls – notably PPE use. CDC, quality organizations and state departments of health have been collecting patient illness and infection data for years. For the first time, we can build our understanding of the impact of “healthcare associated infections” for both patient and worker. This is long overdue.
To summarize, as you build better and safer healthcare environments that protect workers and their patients from exposures to bloodborne and infectious disease, consider the following:
1. Identify if the guidance and standards you are using are specific enough to build sustainable PPE use and compliance programs.
2. Identify if the culture you have in place promotes employee reporting of exposure incidents, including details about the exposure and PPE use.
3. Determine if there are the right incident recordkeeping and data analysis processes in place that allow for immediate action or intervention. Identify if these will help you comply with the new OSHA Recordkeeping requirements. You’ll be ahead of the game!
4. Consider adding “Institutional Controls” to your hierarchy of controls. You will be a surefire trendsetter.
5. Build systems that promote overall facility-wide safety not just patient or worker safety. Imagine the time you’ll save and the impact you’ll have including both.
6. Think creatively about improving access to PPE by creating/changing space or mobility for both clean and soiled PPE.
7. Develop informational or training programs or campaigns that educate more than just the worker on risks associated with infectious disease and the overall importance of self-protection. Think about starting a Facebook page, Twitter feed, or Instagram account and have your staff, patients, and visitors log on and “friend” you. Your kids and grandkids will be proud.
Amber Hogan Mitchell, DrPH, MPH, CPH, is president and executive director of the International Safety Center.
D. Powers et al. Factors influencing nurse compliance with Standard Precautions. American Journal of Infection Control 44 (2016) 4-7
EPINet® Report for Blood and Body Fluid Exposures. International Safety Center. (to be released August 15, 2016) http://internationalsafetycenter.org/exposure-reports/
NIOSH Occupational HIV Transmission and Prevention among Health Care Workers
NIOSH Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, Hepatitis C http://www.cdc.gov/niosh/topics/bbp/genres.html
NIOSH Hierarchy of Controls https://www.cdc.gov/niosh/topics/hierarchy/
OSHA Bloodborne Pathogens Standard https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051
OSHA Recordkeeping Rule https://www.osha.gov/recordkeeping/finalrule/