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By Willam Duffy, RN, MJ, CNOR
This article discusses several key clarifications made to the BloodbornePathogens Standard, such as employee training, physician and temporary nursing personnel,the annual review of the bloodborne pathogen program, the use of safer medical devices,personal protective equipment, and administrative controls that are all addressed by OSHAin its revised directive and varying interpretation letters.
Author'sNote: The information contained in this article is not intended to substitute for anyprovisions of the Occupational Safety and Health Act of 1970 or the requirements of theOccupational Exposure to Bloodborne Pathogens Standard.
In December 1991, the Occupational Safety and Health Administration (OSHA) issued theOccupational Exposure to Bloodborne Pathogens Standard. This standard was designed toprotect nearly six million healthcare workers from the risk of exposure to pathogens suchas the HIV and hepatitis B viruses.1 Since that time, employers have beenscrambling to meet the requirements of the standard, so they may adequately protect theirworkers and avoid the fines associated with noncompliance.
Recently, OSHA surveyed healthcare institutions to assess the impact of the BloodbornePathogens Standard. The survey showed that progress has been made in reducing injuries andexposures to employees, but areas of concern and confusion still exist.2 Onearea of concern related to the broad scope of the Bloodborne Pathogens Standards leavesareas that are subject to interpretation by each healthcare institution and the OSHAcompliance officers. OSHA has revised its Bloodborne Pathogens Compliance Directive tohelp institutions and their surveyors have a clearer understanding of the intent of thestandards and further reduce the risks of bloodborne pathogens.2 Frequently,Infection Control Practitioners are key members in a hospital's efforts to institutesafety measures and meet the intent of the standards.
Institutionscontinue to be confused on who is covered by the standard. Temporary workers andphysicians are a major cause of the confusion, but the eligibility of other healthcareworkers appears to be a problem also. In general, OSHA views any employee who has thereasonable potential for occupational exposure to bloodborne pathogens to be includedwithin the scope of the standard. The standard states that occupational exposure isdefined as "reasonably anticipated skin, eye, mucous membrane or parenteral contactwith blood or [other potentially infectious material] OPIM.3
The standard does provide a list of jobs that may be associated with occupationalexposure, but OSHA is clear that the list does not necessarily include or exclude anyemployee. The key to coverage is the employee's potential for occupational exposure.4
OSHA has notified its surveyors that part-time, temporary, and per diem healthcareworkers are covered by the standard if their job duties present potential risks. Although,OSHA's jurisdiction does not appear to extend to students, the self-employed, orhealthcare professionals who are sole practitioners. Additionally, any employee who istrained in first aid and has the responsibility to render aid as an expectation of theirjob is also within the scope of the standard.4
Employers must ensure that their employees who have the risk of occupational exposureparticipate in the training program that is provided during the employee's normal workinghours. The program's structure must include training at the time of initial assignment andthen at least annually thereafter. The standard specifies that the annual training must beprovided within one year of the previous training date.4
Healthcare professionals have questioned the annual training requirement as beingexcessive in light of their high awareness of the risks associated with bloodbornepathogens. OSHA states it understands this level of knowledge and allows institutions tocustomize the annual training to focus on a "quick review" of previous trainingmaterial and more importantly to inform employees regarding new healthcare worker issuesand the policies implemented to address these issues.5
Additional training separate from the initial or annual training must be providedwhenever there are changes in work tasks or procedures that may affect the potential foran occupational exposure.6 This training may be limited to addressing the newrisks created by the changes, but employers should note that this is an interpretationpoint that OSHA has left to employers' control. Employers must assess each practice changefor its potential to affect the employee and be prepared to demonstrate to OSHA whyadditional training was not required.
OSHA expects the training program to be adapted to varying levels of education,literacy, and language capabilities of the employees. This expectation requires employersto adjust their programs to ensure their employees can understand the materials presented.OSHA may question the efficacy of a training program designed for registered nurseprofessionals if it is used to train environmental personnel. Employers should be preparedto demonstrate their efforts to structure their training to meet their employee's needs.Some examples may include creating different programs for various groups, documenting thereadability and educational grade level of the program, and the creation of multilingualprograms.
Training programs should address how employees may access a copy of the standard, ageneral explanation of the symptoms and epidemiology of bloodborne diseases, modes ofdisease transmission, and the institution's exposure control plan and its accessibility.For example, the standard requires that while such viruses as HIV and HBV must bedescribed employees also need to be educated regarding other bloodborne diseases likehepatitis C and syphilis.6 The training information on exposures must includemethods to recognize activities that may lead to exposure, methods to limit exposures, thebasis for selection of personal protective equipment, and information on hepatitis Bvaccine and its availability. Additional information should address actions to take innotifying appropriate personnel regarding situations involving potentially infectiousmaterial, information on exposure reporting procedures, and post exposure follow-up andevaluation.7
The training program must also cover the types, use, location, removal, handling,decontamination, and disposal of personal protective equipment. An OSHA compliance officerwill also look for explanations of the signs, labels, and color-coding used to identifyhazardous or contaminated materials. Finally, the program must include an opportunity forinteractive questions and answers with the trainer who must be knowledgeable of allmaterial contained in the training programs.8
OSHA does allow the employer latitude to develop training programs to meet theinstitutions specific needs. The key is for the employer to be prepared to address howtheir training programs meet the requirements of the standard. Employers may write OSHAfor clarification of questions regarding their training programs, and OSHA will respondwith a detailed letter. Additionally, employers can access information contained inprevious letters OSHA has answered by visiting OSHA's website at
There seems to be debate in institutions across the country regarding potentialliability resulting from physicians not following the Bloodborne Pathogens Standard. OSHAattempted to clarify its position on physicians in a 1993 interpretation letter.9Generally, institutions can face fines due to the lack of compliance with the standards byphysicians. The two significant areas of risk are practice patterns of physicians who areemployees of the institution and unsafe practices by physicians who are independentpractitioners.
The employee provisions of the Bloodborne Pathogens Standard covers physicians who areemployees of an institution. Employing institutions must provide the physician with thesame safety devices and workplace controls that they provide to traditional employees.9Employers should also address having employee physicians attend the required trainingprogram. Physicians may resist the training, but it will be the employers who are liablefor fines from OSHA if a physician is injured from exposure to a bloodborne pathogen.
Additionally, employers may be exposed to civil liability if they do not requireemployee physicians to attend training sessions or follow the institution's exposure plan.The potential exists for an injured physician to initiate legal action as a result of hisor her injury and argue that the institution had a duty under the Bloodborne PathogensStandard to protect him or her from these hazardous materials. Under this scenario, asurgeon, who is an employee of a hospital-owned medical group, theoretically can exposethe hospital to potential fines and civil liabilities for violating the requirements ofthe Bloodborne Pathogens Standard if he or she does not wear appropriate eye protectionduring surgery, and the institution allows this behavior.
On the other hand, institutions are not responsible for enforcing the requirementscovering employee protections for physicians who are independent practitioners. OSHA viewsthese physicians as outside the employer-employee relationship. However, these physicianscan still create problems for institutions. Hospitals are exposed to potential fines if anindependent practitioner physician creates a hazardous environment for the hospital'semployees.9 In these instances, OSHA expects the institution to intercede onbehalf of their employees and correct the situation. Therefore, while a hospital does nothave a duty to force an independent practitioner to follow the standard for him orherself, it does have a duty to force a physician to change practice patterns if his orher practice creates an unsafe environment.
Agency nurses also have an unusual standing under the Bloodborne Pathogen Standard. Theresponsibility for temporary workers was challenged in the case of the American DentalAssociation v. Martin.10 Under the theory of borrowed servants, the employingagency has a duty to perform initial and annual training of its employees in bloodbornepathogen protections. The hospital has the duty to provide them with the same safetydevices and workplace controls that it would to its regular employees.11 Inthese situations, regular employees must be aware of the practice patterns of agencypersonnel and notify their supervisors of practices that do not satisfy the standard.
OSHA neither mandates specific work place controls nor states that employers mustpurchase expensive devices to prevent exposure. What the standard says is that employersmust analyze the situation and take reasonable action to put into effect workplacecontrols that would limit the risk of exposure. OSHA has discovered that employers haveachieved varying levels of success in instituting workplace controls. Most institutionsresponding to OSHA's request for information stated that they have instituted safermedical devices for IV line access (87%); however, use of safer medical devices in otherareas was less extensive.12
Table 1 acknowledges that safer medical devices are being used in these applications,but it does not represent the extent of device utilization. OSHA has reported that manyfacilities have not adopted safer medical devices on a facility-wide scale.12
Other organizations have noted the varying levels of success in implementing work placecontrols. For example, in a recent survey of operating room leaders, more than half of therespondents reported that they have adopted strategies to reduce employee injuries andhave vaccinated their at-risk staff against Hepatitis B, but many still have issues withemployees and physicians wearing appropriate eye protection.13 Additionally, astudy conducted by the Association of periOperative Registered Nurses (AORN) and theInternational Health Care Worker Safety Center at the University of Virginia documentedmultiple sources and types of injuries associated with exposure to blood or otherpotentially infectious material (OPIM).14
Control of the workplace would start with the exposure control plan. Each facilityshould have a written exposure control plan that identifies the tasks and procedures inwhich potential occupational exposure may occur and to identify the job positions whoseduties encompass the performance of these tasks. OSHA compliance officers are instructedto review a facility's plan for its accessibility to employees and its ability tocommunicate the overall goals and references of the plan. Accessibility is a keycomponent. Employers may adapt the location of a plan and even have the plan computerizedas long as employees either have the training to access the plan in the computer or haveaccess to the plan on their work shift.15
The officer will also look to see if the plan is updated annually or whenever necessaryand that the plan contains information regarding the changes in technology that willreduce exposures. OSHA believes a periodic review of the plan will help protect employeesby keeping them current with the latest information and knowledge regarding bloodbornepathogens. OSHA considers the lack of a control plan or an outdated plan a seriousviolation of the standard.
Facilities must institute a progressive action plan to implement their safety program.First, OSHA will monitor the facility for the practice of universal precautions.Alternative concepts such as Body Substance Isolation (BSI) and Standard Precautionsdefine all body fluids and substances as infectious and are acceptable alternatives touniversal precautions as long as the facility adheres to all other provisions of thestandard.15 Next, the Compliance Officer will look for the engineering and workpractice controls that the facility has put into place to reduce employee exposures. Theuse of needleless devices, shielded needles, plastic capillary tubes, no-hands handlingcontaminated sharps, and hands-free passing of surgical instruments are all examples ofengineering or work practices that could reduce employee injuries. It is important that afacility include its employees in the selection of these safety devices. OSHA's researchhas shown that utilization of these devices is higher in institutions that have involvedtheir employees in the decision-making process.16
Facilities must have this practice documented in their Exposure Control Plan to avoid acitation. OSHA has changed the language of the compliance instruction to state that theexposure control plan must be updated to reflect new technology to control occupationalexposure. If engineering and work practice controls are not successful at eliminating thepotential exposure, then personal protective equipment must be used. OSHA has instructedthe Compliance Officer to interview employees and observe work practices in areas whereoccupational exposure occurs. The compliance officer will review the facility's records tofind the areas that are more likely to be the site of exposures. OSHA has alreadyidentified that exposures occur most often in patient rooms, operating rooms, emergencydepartments, and the ICU areas. Nurses are the most likely healthcare workers to beinjured, and the injury is most likely to be caused by a non-safety device. The complianceofficer will then look to see if there is a pattern of repeating injuries and evaluate theinstitution's efforts to institute engineering or work practice controls.17
Progress has been made in reducing injuries to employees in the eight years since theBloodborne Pathogen Standard have been issued, but areas of concern still remain. Safermedical devices are making headway in the medical market, but their use is still sparse inmany areas. OSHA has decided to take the step of revising its compliance directive toencourage employers to use new medical devices to control exposures. The OSHA compliancedirective can be beneficial to healthcare professionals charged with maintaining aninstitution's exposure control plan. The compliance directive will provide the healthcareworker into OSHA's insights regarding the assessment and enforcement of the standard. Thedocument can be obtained from OSHA or accessed from their Web site at
Protecting workers from injuries is a key goal for any employer. However, now theemployer has to meet certain expectations that are set by a third party who is in essencethe judge and jury in determining compliance. It would seem reasonable that employers useevery means available to understand and satisfy the expectations of the OSHA.
William J. Duffy, RN, MJ, CNOR, is the Director of Perioperative Services, atEvanston Northwestern Healthcare Corp. (Evanston, Ill).
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