By John Furman, PhD, MSN, CIC
Healthcareorganizations are constantly challenged to provide a safe environment for thoseto whom they deliver care and for healthcare personnel. Since 1983, when theCenters for Disease Control and Prevention (CDC) released its first"Guideline for Infection Control in Healthcare Personnel," there hasbeen increased awareness of the occupational health hazards to healthcarepersonnel. Due to advances in occupational medicine, such as HIV post-exposureprophylaxis recommendations, in 1998 the CDC updated its guideline.1This article sets forth the minimum qualifications for an occupational healthprogram in the healthcare setting.
Infection control professionals have a critical role within the healthcaresetting in interfacing with occupational health, identifying risks to healthcarepersonnel, assessing potential adverse outcomes, implementing protectivepolicies and procedures, and evaluating the effectiveness of measures taken.Factors such as increasing regulation, rising patient acuity, and staffingshortages combine to make these responsibilities ever more complex anddemanding. The infection control professional must keep abreast of currentregulations and literature in the occupational health arena to ensure thatappropriate measures are being taken to reduce the risks of nosocomialinfections in healthcare personnel.
The following is an overview of recent occupational health issues inhealthcare:
Occupational Health and Safety
In September 2001, the American Nurses Association (ANA) released the resultsof its Nursing World Health and Safety Survey.2 More than 4,800nurses from across the US responded to this online survey. Eighty-eight percentof the nurses said safety and health concerns influence their decisions tocontinue working in the field of nursing and the kind of nursing work theychoose to perform. Fear of contracting an infectious disease at work was acommon thread in the survey responses.
In addition to the No. 1 concern of stress and overwork, nurses citedcontracting HIV or hepatitis from a needlestick injury (45%) among their topthree health and safety concerns. Other concerns included being infected withtuberculosis or another disease (37%), developing a latex allergy (20.9%), toxiceffects from exposure to hazardous chemicals such as glutarahdehyde or ethyleneoxide (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 andrelated working conditions.3 The results from this survey indicated arelationship between the current nursing shortage and the risk of occupationalillness. Factors such as increased stress, mandatory overtime, and lost sleepadversely affect the immune system making healthcare personnel more susceptibleto infectious disease. Staffing deficits have a direct relationship to thepractice of infection control and occupational health. Practicing appropriatehand washing, antisepsis, and isolation practices suffer under adverse workingconditions. Forty eight percent of the respondents reported they had contractedjob-related illnesses or their illnesses have been made worse at work.
The National Institute of Occupational Safety and Health (NIOSH) is concernedabout occupational health issues in the healthcare industry. NIOSH's NationalOccupational Research Agenda (NORA) has recognized that bloodborne (HBV, HCV,and HIV) and airborne pathogens (TB and influenza) represent a significant classof exposures for the 6 million US healthcare workers. The goals of ongoingresearch are to determine the extent of occupational transmission of theseinfectious diseases, to understand the barriers to the use of safe workpractices and vaccines, and to develop and evaluate new control methods.
In addition, NIOSH has established a research focus on the occupationalsafety and health needs of working women. Ninety two percent of the 4.3 millionnurses 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 willbe 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 thelookout for announcements of the meetings, as this will be a great opportunityfor infection control and occupational health professionals to provide directinput.
The Occupational safety and Health Administration (OSHA) has revised itsBloodborne Pathogens Standard to conform to the requirements of the federalNeedlestick Safety and Prevention Act.4 The revisions include (a) newexamples in the definition of engineering controls along with definitions of"needleless systems" and "sharps with engineered sharps injuryprotections (SESIP);" (b) to require that Exposure Control Plans (ECPs)reflect how employers implement new developments in control technology; (c) torequire employers to solicit input from employees responsible direct patientcare in the identification, evaluation, and selection of engineering and workpractice controls; and (d) to establish and maintain a log of percutaneousinjuries from contaminated sharps.
The revisions to the Bloodborne Pathogens Standard became fully effective inall federal and state health and safety plan states Oct. 18, 2001 (if you are ina state with its own occupational heath and safety plan, additional requirementsmay apply). The standard requires employers to establish written ECPs tominimize employee exposures to bloodborne pathogens through the use ofengineering and work practice controls. Employers are required to update ECPs todocument consideration and implementation of appropriate and effectiveengineering controls, which includes the use of safer medical devices. Forpurposes of the standard, an "appropriate" safer medical deviceincludes only devices whose use, based on reasonable judgment in individualcases, will not jeopardize patient or employee safety or be medicallycontraindicated. An "effective" safer medical device is a device that,based on reasonable judgment, will make an exposure incident involving acontaminated sharp less likely to occur in the application in which it is used.4
The requirements of the Bloodborne Pathogens Standard are enforced throughgeneral OSHA and state plan inspection procedures. Citations and monetary finesmay be issued for:
The standard now clearly requires that any time an employee may be exposed toblood or other potentially infectious material, the employer must evaluate andimplement safer medical devices that eliminate exposures to the lowest extentfeasible. No exemptions to this requirement are provided in the standard. Allemployers must evaluate the hazards present in their workplace. All employerswho have employees with exposure to bloodborne pathogens must review andimplement commercially available safer medical devices to the extent that theyreduce occupational exposure to the lowest possible extent feasible.
The Bloodborne Pathogens Standard requires that employers providepostexposure evaluations, follow-up, and prophylaxis according to the current USPublic Health Service recommendations. In June 2001, the CDC issued its"Updated US Public Health Service Guidelines for the Management ofOccupational Exposures to HBV, HCV, and HIV and Recommendations forPost-exposure Prophylaxis."5 The report updates an consolidatesall previous US Public Health Services recommendations for the management ofhealthcare personnel who have occupational exposure to blood or otherpotentially infectious material.
Recommendations include initiation of the hepatitis B vaccine series tosusceptible HCP, along with post-vaccination antibody screening. Provision ofthe hepatitis B immune globulin (HBIG) and/or the hepatitis B vaccine seriesshould be considered for all exposures after evaluation of hepatitis B surfaceantigen status of the source and the vaccination and vaccine response status ofthe exposed person.
When HBIG is indicated, it should be administered as soon as possible afterexposure (preferably within 24 hours). The effectiveness of HBIG if administered>7 days after exposure is unknown. When hepatitis B vaccine is indicated, itshould be administered as soon as possible (preferably within 24 hours) and canbe administered simultaneously with HBIG at a separate site.
Immune globulin and antiviral agents (e.g., interferon with or withoutribaviron) are not recommended for post-exposure prophylaxis of hepatitis C. ForHCV exposure management, the HCV status of the source and the exposed personshould be determined. For the person exposed to an HCV positive source baselinetesting for anti-HCV and ALT is recommended. Follow-up testing should be done at4 to 6 months.
Recommendations for HIV post-exposure prophylaxis (PEP) include a basicfour-week regimen of two drugs (zidovudine and lamivudine [3TC]; 3TC andstavudine [d4T]; or didanosine [ddI] and d4T) for most HIV exposures and anexpanded regimen that includes the addition of a third drug for HIV exposuresthat pose an increased risk for transmission. The likelihood of drug resistanceshould also be considered when selecting a drug regimen. PEP should beadministered as soon as possible. The CDC does not give any specific timerecommendations. But animal studies have shown increased benefits if PEP isstarted 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 severehepatotoxicity) the CDC is recommending consultation with local experts and/orthe National Clinician's Post-Exposure Prophylaxis Hotline at (888) 448-4911before prescribing PEP.
Injury and Illness Record-keeping
OSHA's revised Occupational Injury and Illness recording and ReportingRequirements rule6 became effective Jan. 1, 2002. OSHA will delay theeffective dates of sections involving the recording of cases involvingoccupational hearing loss, and the recording of cases involving work-relatedmusculoskeletal disorders, until Jan. 1, 2003. All other sections of the rulepublished Jan. 19, 2001, remain unaffected. The record-keeping rule seeks toimprove how the government tracks occupational injuries and illness throughincreased employee involvement, simplified forms, and allows employers to usecomputers to meet OSHA record-keeping requirements. In addition to replacing theOSHA 200 logs with the new 300 and 301 forms, there are several revisions thatare of interest to infection control and occupational HCPs.
As discussed earlier the Bloodborne Pathogens Standard now requires theestablishment of a Sharps Injury Log. The record-keeping rule will requiresharps exposures to be recorded on the OSHA 300 and 301 forms.
Sharps injuries (along with HIV, hepatitis, and TB infection) will beconsidered "privacy cases," which means that no employeeidentification information will be included in the OSHA documentation. Sharpsexposures must also be documented separately from other injuries and illnesses.Requiring maintenance of a separate sharps injury log or use of a computerprogram that can sort sharps exposures from other injuries and illnesses.
The criteria for recording TB cases includes three provisions designed tohelp 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 askin test conversion if (a) the worker is living in a household with a personwho has been diagnosed with active TB, (b) the public health department hasidentified the worker as a contact of a case of active TB unrelated to theworkplace, or (c) a medical investigation shows that the employee's infectionwas caused by exposure to TB away from work or proves the case was not relatedto TB exposure. The rule envisions a more active role by public healthdepartments in determining the cause of TB infections with a suspectedrelationship to the workplace. Many health jurisdictions already classify TBskin test conversions as reportable conditions.
OSHA has simplified its approach to determining whether care provided to anemployee is classified as medical treatment or first aid. In the past medicaltreatment was simply defined as "any medical cure or treatment beyond firstaid." The new rule contains a comprehensive list of treatments that isclassified as first aid; all other treatments not contained on this list will beconsidered "medical treatment." These include, but are not limited to,(a) visits to a healthcare provider limited to observation, (b) diagnosticprocedures, including the use of prescription medications solely for diagnosticpurposes (e.g., eye drops to dilate the pupils), (c) simpleadministration of oxygen, and (d) administration of tetanus or diphtheria shotsor boosters. Administration of any other vaccine (e.g., hepatitis B orrabies vaccine) after an injury or exposure even if prophylactic in nature isconsidered medical treatment and is a recordable event on the OSHA 300 log.
OSHA Record-keeping Rule provides partial exemptions for workplaces inStandard Industry Classification codes 801-807 & 809. These includeworkplaces such as physicians' offices, and dental and medical laboratories. Forthose states with their own safety and health plans, they must adopt rules asleast as effective as federal OSHA rules. These states do not need to exemptemployers from record-keeping requirements and may institute more stringentrequirements when justified. Refer to your state plan for specificrecord-keeping requirements.
The CDC has published its "Draft Guideline for Hand Hygiene inHealthcare Settings"7 and is presently soliciting publiccomment. You can review the draft guideline and provide comments via e-maildirectly 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 dealingwith hand washing and hand antisepsis. Recommendations to promote improvedhand-hygiene practices along with such issues as gloving, the use of handlotions, and wearing of jewelry and artificial fingernails are provided.
New studies support the efficacy of alcohol-based hand rubs and the lowincidence of dermatitis associated with their use. Alcohol-based hand rubs havebeen shown to be more effective than traditional soap and water hand washing inreducing the transient microbiological load on hands. Using a waterlessantiseptic product may overcome many of the factors (e.g., accessibility,time, skin irritation) associated with poor compliance with hand washingpractices.
The draft guideline recommends the use of an alcohol-based waterlessantiseptic agent for decontaminating hands when hands are not visibly soiled.This recommendation contradicts OSHA's requirement in the Bloodborne PathogensStandard that the use of a waterless product may only be used when hand-washingfacilities are not readily available. Hands must then be washed with soap andwater as soon as feasible thereafter. As more scientific, research-basedinformation becomes available, OSHA and other agencies will need to review theirregulations on hand hygiene in order to support the most current infectioncontrol practice.
Laser or electrocautery procedures result in the destruction of tissue andcreates a smoke byproduct. This surgical smoke can contain toxic gases andvapors such as benzene, hydrogen cyanide, and formaldehyde. Research has shownthat bioaerosols containing dead and live cellular material, blood components,and microorganisms such as viruses can also be present. Although there has beenno documented transmission of infectious disease through surgical smoke, thepotential exists.
OSHA has considered developing a standard on controlling the hazardsassociated with exposure to surgical smoke but has yet to release draftregulation. When a hazard is not covered by a specific standard, OSHA may chooseto cite the general duty clause when reasonable control measures are notutilized by employers to abate recognized hazards in the workplace. In thiscase, reasonable control measures could include the use of recommendations onventilation and respiratory protection by product manufacturers and groups suchas the American National Standards Institute (ANSI).
NIOSH has published a Health Hazard Alert on the dangers of exposure tosurgical smoke.8 NIOSH recommends that exposure to airbornecontaminates contained in surgical smoke be controlled through the use ofventilation and work practice controls. Recommended ventilation techniquesinclude the use of both general room ventilation and local exhaust ventilation.A high efficiency particulate air filter (HEPA) should be used to trap anyairborne particles. Recommended work practice controls include properpositioning of suctioning hoses and continuous use of local exhaust ventilationduring any procedure that may generate surgical smoke. Infection controlmeasures such as universal or standard precautions should also be used asappropriate.
John E. Furman, PhD, MN, CIC is an occupational health consultant for theDepartment of Labor and Industries, WISHA Policy and Technical Services inOlympia, WA.