Risky Business

September 1, 2005

Risky Business
Occupational Hazards & The Healthcare Worker

By Kelly M. Pyrek

While hospitals are designed to beplaces of treatment and healing for patients, they present a significant numberof occupational hazards to healthcare workers (HCWs).

A survey1 of registered nurses by the American NursesAssociation revealed that stress/overwork, disabling back injuries, andcontracting a bloodborne disease were the top three health and safety concerns.

A National Institute for Occupational Safety and Health(NIOSH) report indicated that an estimated 600,000 to 800,000 percutaneousinjuries occur annually to HCWs,2 and that nurses sustain the majority of these injuries.3The Association of periOperative Registered Nurses (AORN) saysin its position statement on workplace safety, Nurses practicing in theperioperative environment are at distinct risk for percutaneous injury due toprolonged exposure to open surgical sites, frequent handling of sharpinstruments, and the presence of large quantities of blood and other potentially infectious body fluids.4

Of particular concern to an aging nursing population areergonomic-related injuries. Back injuries pose a significant risk to perioperative nursesand are the most prevalent occupational injury in the healthcare industry.5 Direct costs associated with occupational back injuries ofHCWs average $37,000, while indirect costs associated with back injuries can range from $147,000 to $300,000.6

We must consider the needs of an older nursing population,says Denise Strode, RN, BSN, COHN-S/CM, president of the Association ofOccupational Health Professionals in Healthcare (AOHP). Its a real concernto occupational health professionals (OHPs) who see the potential for a seriousproblem in the future. OHPs must conduct analyses of injuries, looking closelyat workers patient-handling and transfer practices, stopping as much manuallifting as possible, and taking appropriate safety measures in the healthcareenvironment. Facility administrators must look at the return on investment theycan achieve from equipment such as patient lifts and positioning devices.

Strode says emphasis on proper ergonomics must be made tonon-nursing hospital employees, too, who are at risk of injury. Dontforget to educate individuals such as housekeepers, radiologists, or members ofthe dietary department, because almost no one is immune to occupationalaccidents and injuries, Strode adds. Its critical to ensure that allstaff members understand proper workplace safety protocols and practices, andthat there is buy-in from all employees of all hospital departments.

According to AORNs workplace-safety position statement, Keyindicators to an organizations culture and commitment to ensure a safeworkplace include maintaining safe equipment, providing adequate nurse staffinglevels, and fostering safe work practices. An unsafe workplace contributes to work-related injuries anddiseases that often result in physical, emotional, and financial difficultiesfor perioperative nurses. Occupational injuries resulting from an unsafe workplaceimpact the healthcare organization by increased costs and a reduced ability toprovide services. Occupational hazards in the workplace have been identified asa major contributor to nurses leaving the profession, contributing to the growing nursing shortage.7-8

The aforementioned nursing shortage has tangible implicationsfor occupational health. AORN states that the ongoing shortage of skilled RNs and otherallied health personnel has not only impacted the delivery of safe, qualitypatient care, but has affected these workers decision to continue theirpursuit of nursing as a vocation. AORN states, A safe workplace will have apositive impact on the retention and recruitment of qualified nurses to provide safepatient care.

Healthcare organizations play a critical role in influencingemployee compliance with safe work practices. A commitment to cultivating aculture of safety in the workplace is increasingly import as workloads andemphasis on productivity increase, and patient-acuity levels increase.9 Onestudy demonstrated that strong support from senior management resulted in areduced rate of occupational exposure to blood and body fluids.10

One of the key factors of creating a safe workplace isemployee buy-in and compliance with safety measures. You would like to assumethat all HCWs know the basics of proper hand hygiene or PPE usage, Strodecomments, but you cant. You must continually communicate and educate,taking into consideration factors such as staffs cultural diversity anddifferences in learning styles. Its also important to provide good rolemodels and strong leadership from the top. You want to walk the walk if you talkthe talk.

AORN suggests the following strategies for developing andmaintaining a safe workplace:

  • The facility has the responsibility to establish andpromote a safe work environment and strive to use best practice models (e.g.,magnet hospital status criteria, workplace of choice)

  • Each facility shoulddevelop a comprehensive workplace safety program that includes a written planfor each topic covered in the program, a written plan to provide education onsafety initiatives, and monitoring of compliance for employees and otherhealthcare providers

  • Every perioperative nurse is responsible for followingsafety policies and participating in the safety programs

  • The perioperativenurse has a responsibility to identify safety hazards, take appropriate action,and report them through the appropriate channels

The Hazards

AORN acknowledges that there are multiple occupational hazardsthat create a risk of personal injury; they are:

  • Biological: Exposure to bloodborne pathogens frompercutaneous injuries, splashes, and other contact; exposure to infectiousmicroorganisms; exposure to biological components of surgical smoke from use oflasers and electrosurgical units; and exposure to the chemical and proteinallergens in latex gloves

  • Ergonomic: Static or awkward posture; standing for long periods of time in one position; back injuries; repetitive motion; and moving patients orcarrying heavy instruments and equipment

  • Chemicals: Anesthesia gases,disinfecting/ sterilizing agents, and cleaning agents

  • Physical hazards:Fire, electrical, radiation, lasers, smoke plume, and compressed gases

  • Psychosocial: Long hours, mandatory overtime, demographic diversity, nursingshortage, trauma, burnout, verbal and physical abuse

  • Cultural: Tolerance ofabuse from physicians; lack of commitment by management to adhere to an optimalworkplace safety program; absence of respect from peers and other healthcareprofessionals; absence of a code of conduct for all team members; and workplacesafety strategies.

Bloodborne Pathogens

OSHA estimates that 8 million HCWs are at risk of occupationalexposure to bloodborne pathogens including Human Immunodeficiency Virus(HIV), hepatitis B Virus (HBV), hepatitis C Virus (HCV) as well as otherpotentially infectious materials (OPIM). HCWs are at risk when handling sharpdevices or equipment such as scalpels, sutures, hypodermic needles, andblood-collection devices. EPINET data shows that needlestick injuries occur mostfrequently in patient rooms, and various hospital studies indicate that as manyas one-third of all reported sharps injuries are related to the disposalprocess.

To help prevent exposure to blood and OPIM from contaminatedsharps, HCWs should follow the requirements of OSHAs Bloodborne PathogensStandard and implement engineering and work-practice controls. According to OSHA, engineering and workpractice controls mustbe the primary means used to eliminate or minimize exposure to bloodbornepathogens. Engineering controls are measures, such as sharps disposalcontainers, self-sheathing needles, or needleless systems, that isolate orremove the bloodborne pathogens hazard from the workplace. OSHA describeswork-practice controls as measures that reduce the likelihood of exposure byaltering the manner in which a task is performed, such as prohibiting recappingof needles by a two-handed technique.

The revised Bloodborne Pathogens and NeedleStick PreventionStandard requirements that went into effect in April 2001 include the followingpoints:

  • Employers must implement the safer medical devices thatare appropriate, commercially available, and effective, and documentconsideration and implementation of safer medical devices annually.

  • Employers must get input for these devices from thoseresponsible for direct patient care; this input must be documented.

  • Employers must train employees to use new devices and/orprocedures and document training in the facilitys OSHA-mandated exposurecontrol plan.

  • Employers must maintain a log of injuries fromcontaminated sharps.

  • Compliance with standard precautions, an infection controlprinciple that treats all human blood and OPIM as infectious.

Exposure to bloodborne pathogens and OPIM can be limitedthrough the proper use of personal protective equipment (PPE) as well as properhandling and containerization of sharps.

Needlestick Injuries

According to 1996 data from EPINET, in an average hospital,workers incurred approximately 30 needlestick injuries for 100 beds per year.HCWs are at risk of exposure to blood and OPIM due to unsafe needle devices andimproper handling and disposal of needles. It is recommended that HCWs:

  • Do not bend, recap, or remove contaminated needles andother sharps unless such an act is required by a specific procedure or has nofeasible alternative.

  • Do not shear or break contaminated sharps (OSHA definescontaminated as the presence or the reasonably anticipated presence of blood orOPIM on an item or surface).

  • Have needle containers available near areas where needlesmay be found.

  • Discard contaminated sharps immediately or as soon asfeasible into appropriate containers.

According to OSHA, appropriate containers must be:

  • Closable, puncture-resistant, and leak-proof on sides andbottom

  • Accessible, maintained upright, and not allowed to overfill

  • Labeled or color coded

  • Colored red or labeled with the biohazard symbol

  • Labeled in fluorescent orange or orange-red, with lettering and symbols in acontrasting color; red bags or containers may be substituted for labels

Other Sharps Injury

Other contaminated sharps, including scalpels, broken glass,or broken capillary tubes, are a hazard to HCWs. For example, glass capillarytubes may break when handled incorrectly, resulting in a penetrating wound tothe HCW, or used disposable razors could be contaminated with blood. In a 1999joint document, Glass Capillary Tubes: Joint Safety Advisory About PotentialRisks, OSHA and NIOSH recommend using:

  • Capillary tubes that are not made of glass

  • Glasscapillary tubes wrapped in punctureresistant film

  • Products that use a methodof sealing that does not require manually pushing one end of the tube into puttyto form a plug

Another sharps-related hazard is IV connector systems. OSHA andNIOSH recommend the use of needleless connector systems with IV set-ups tominimize occupational exposure.

Studies have demonstrated that most needlestick injuriesresult from unsafe needle devices rather than carelessness by HCWs. Safer needle devices have built-in safety control devices,such as those that use a self-sheathing needle, to help prevent injuries before,during, and after use through safer design features. In 2000, the CDC estimatedthat 62 percent to 88 percent of sharps injuries in the hospital setting couldbe preventing by using safer medical devices. According to the revisedBloodborne Pathogens Standard, employers with the help of employees, must selectsafer needle devices to use in work environments.

Safety features being incorporated into medical devicesinclude:

  • Passive safety features that remain in effect before,during and after use

  • Active safety devices that require the HCW to activatethe safety mechanism

  • Integrated safety design which incorporates a safetyfeature as an integral part of the device and cannot be removed

  • Accessorysafety devices have safety features that are external to the device and must becarried to, or be temporarily or permanently fixed to, the point of use

According to OSHA, desirable characteristics of safety devices include:

  • The device is needleless

  • The safety feature is anintegral part of the device

  • The device is easy to use and practical

  • Thedevice performs reliably

  • The safety feature cannot be deactivated andremains protective through disposal

  • The devices work effectively andreliably, and are acceptable to the healthcare worker, and do not adverselyaffect patient care

The Food and Drug Administration (FDA), which is responsiblefor clearing medical devices for marketing in the U.S., recommends safer needledevices with a fixed safety feature that:

  • Provides a barrier between the hands and the needle afteruse; the safety feature should allow or require the workers hands to remainbehind the needle at all times

  • Is an integral part of the device and not anaccessory

  • Is in effect before disassembly and remains in effect afterdisposal to protect users and trash handlers, and for environmental safety

  • Is as simple as possible, and requires little or no training to use effectively

There are many types of safety devices, including needleless connector systemssuch as blunt cannula for use with pre-pierced ports and valved connectors thataccept tapered or luer ends of IV tubing; sliding needle shields attached todisposable syringes and vacuum tube holders; disposable scalpels with safetyfeatures such as a sliding blade shield; needles or sharps that retract into asyringe, vacuum tube holder, or back into the device; syringes with aretractable needles; retractable finger/heel-stick lancets; self-bluntingphlebotomy and winged-steel butterfly needles; and hinged or sliding shields attached to phlebotomy needles,winged steel needles, and blood-gas needles.

According to NIOSH, when selecting and evaluating needledevices with safety features, the healthcare facility should form amultidisciplinary team that includes HCWs to develop, implement, and evaluate aplan to reduce needlestick injuries in the institution, and evaluate needledevices with safety features. NIOSH further recommends that facilities identify prioritiesbased on assessments of how needlestick injuries are occurring, patterns of deviceuse in the institution, and local and national data on injury- and disease-transmission trends. The highest priority should be given to needle devices withsafety features that will have the greatest impact on preventing occupationalinfection, such as hollow-bore needles used in veins and arteries. Facilitiesshould identify a safety devices intended scope of use and any specialtechnique or design factors that will influence its safety, efficiency, and useracceptability. Conduct a product evaluation, ensuring that the participantsrepresent the scope of eventual product users.

Airborne Transmission of Pathogens

One of the more hazardous risks in hospitals is the airbornetransmission of infectious organisms, such as tuberculosis, influenza, andsevere acute respiratory syndrome. The debate still rages in hospitals overrevised mask fit-testing requirements mandated by OSHA. A number of hospitalsand healthcare professionals think there is no true science behind fit-testing,or that because they have had no conversions, why must they change the way theyhave been doing things for a long time, says Strode. But sometimes youmust re-examine what you have been doing because its all about championingHCW safety and patient wellbeing.

The most effective way to control respiratory hazards is tofollow correct work practices and prescribed engineering controls. When additional protection is needed, respiratory protection(masks/respirators) is used to further ensure that individuals are not exposedto hazardous airborne contaminants. Masks/respirator must be approved by NIOSH, and personnel areto be fit tested for different facial sizes/characteristics. HCWs are instructedto perform a fit check, in accordance with OSHA standards and good industrialhygiene practice, each time the mask/respirator is worn.

Latex Allergies

HCWs face a significant risk of developing latex sensitivityor latex allergy from exposure to latex in products such as examination andsurgical gloves. It has been estimated that 8 percent to 12 percent of HCWs arelatex-sensitive, with reactions ranging from irritant contact dermatitis andallergic contact sensitivity, to possibly life-threatening, sensitivity. Manyother hospital employees who are not patient-care providers, such as housekeepersor laundry workers, also are exposed to latex products and latex-allergy risks.Employees exposed to latex gloves and other products containing natural rubberlatex may develop allergic reactions such as skin rashes, hives, nasal, eye, orsinus symptoms, and asthma. Atopic individuals and those with spina bifida areat increased risk for developing latex allergy.

Latex allergy should be suspected in anyone who developscertain symptoms after latex exposure, including nasal, eye, or sinusirritation; hives; shortness of breath; coughing; wheezing; or unexplained shock. Any exposed worker whoexperiences these symptoms should be evaluated by a physician, because furtherexposure could cause a serious allergic reaction. A diagnosis is made by usingthe results of a medical history, physical examination, and tests. Once a workerbecomes allergic to latex, special precautions are needed to prevent exposuresduring work, as well as during medical or dental care. Certain medications mayreduce the allergy symptoms, but complete latex avoidance is the most effectiveapproach. Many facilities maintain latex-safe areas for affectedpatients and workers.

Healthcare facilities should stock appropriate gloves forlatex-sensitive employees, as well as ensure that appropriate PPE is readilyaccessible. According to OSHA, hypoallergenic gloves, glove liners, powderlessgloves, or other similar alternatives must be readily accessible to thoseemployees who are allergic to the gloves normally provided. Among thealternatives are synthetic, low protein, and powder-free gloves.

NIOSH recommends the following practices:

  • Use good housekeeping practices to remove latex-containingdust from the workplace

  • Frequently clean areas contaminated with latex dust(upholstery, carpets, ventilation ducts, and plenums)

  • Frequently changeventilation filters and vacuum bags used in latex-contaminated areas

  • Useappropriate work practices to reduce the chance of reactions to latex:

  • When wearing latex gloves, do not use oil-based hand creamsor lotions (which can cause glove deterioration) unless they have been shown toreduce latex-related problems and maintain glove barrier protection.

  • After removing latex gloves, wash hands with a mild soapand dry thoroughly.

  • Do not use latex gloves when there is no risk of exposureto blood or OPIM.

Environmental Pollution

According to the organization Healthcare Without Harm,hospitals generate more than 2 million tons of waste each year. In the past,many hospitals simply dumped all waste streams together, from reception-areatrash to operating-room waste, and burned them in incinerators. Now there is agreater realization that incineration is a leading source of highly toxicdioxin, mercury, lead, and other dangerous air pollutants. Much of the contentof a typical hospitals waste stream includes materials that prove to bedeadly. For example, a broken mercury thermometer might be tossed into a redbag. When incinerated, mercury is released into the environment as dioxins,potentially causing impaired vision, hearing, taste, and smell. In low doses,dioxins, which are known carcinogens, cause reproductive, endocrine, and immunesystems problems.

Hospitals also produce what some experts are calling asimmering chemical soup which contains fumes from high-level disinfectants such asglutaraldehyde, surgical smoke from tissue being cut, vaporized, or coagulated,and waste gases from anesthetic agents that compromise the quality of indoor airand the health of patients and HCWs.

Exposure to glutaraldehyde fumes can cause serious respiratoryand dermatologic problems, while surgical smoke or laser plume, can also causeand aggravate respiratory problems, along with causing burning, watery eyes,nausea, and viral contamination.

References:

1. Working conditions are major factor in retaining currentnurse workforce. Legislative Network for Nurses 18. Sept 10, 2001) 137; Online health and safety survey, September 2001, Key finding.http://nursingworld.org/surveys/keyfind.pdf.

2. Department of Health and Human Services, National Institutefor Occupational Safety and Health. NIOSH Alert: Preventing needlestick injuriesin healthcare settings. 1999. http://www.cdc.gov/niosh/2000-108.html (accessed7 Oct 2002).

3. Ibid.

4. Jagger, J., Bentley, M., and Tereskerz, P. Study of patterns and prevention of blood exposures in ORpersonnel. AORN Journal 67. May 1998. 979-996.

5. Blackmon, D. Back injury prevention. Surgical Services Management 5. July 1999. 43-46.

6. Ibid.

7. Clarke, S., et al. Organizational climate, staffing, andsafety equipment as predictors of needlestick injuries and near-misses inhospital nurses. Am J Infection Control 30. June 2002. 207-216.

8. Legislative Network for Nurses. Working conditions aremajor factor in retaining current nurse workforce.

9. Gershon, R., et al. Hospital safety climate and itsrelationship with safe work practices and workplace exposure incidents. AmJournal Infection Control 28. July 2001. 211-221.

10. Ibid.

11. Department of Health and Human Services, NationalInstitute for Occupational Safety and Health. Healthcare workers.http://www.cdc.gov/niosh/healthpg.html#tb.