Health care facilities present workers with a myriad of potential health and safety hazards. Compared with the total civilian workforce, hospital workers have a greater percentage of workers’ compensation claims for sprains and strains, infectious and parasitic diseases, dermatitis, hepatitis, mental disorders, eye diseases, influenza, and toxic hepatitis.

This document contains guidelines for reducing the incidence of injury and disease among health care workers. Although much of the information here was obtained from studies conducted in hospitals, it can also be applied to health care workers in other settings, including outpatient clinics, nursing homes, acute care centers, physicians’ and dentists’ office, blood banks, and private residences. Workers who provide emergency medical services outside health care facilities have not been addressed because of the unique nature of their work, but medical technicians and others who occasionally provide emergency medical treatment (first aid) may benefit from these guidelines.

Hospitals are regulated and guided in their operations by a wide variety of local, State, and Federal agencies and organizations. As a consequence, no single set of health and safety regulations applies to all aspects of hospital work or health care delivery. The health and safety guidelines in this document were compiled from many sources, including the National Institute for Occupational Safety and Health, the Centers for Disease Control (CDC), the Occupational Safety and Health Administration, the Joint Commission on Accreditation of Healthcare Organizations, the National Fire Protection Association, and the US Environmental Protection Agency.

The document has seven sections. Section 1 is an overview of hospital hazards, and Section 2 contains methods for developing hospital safety and health programs. These sections are organized so that the user can follow a logical progression of recognition, evaluation, and control of hazards. Section 3 focuses on safety hazards such as fires, flammable and explosive materials, electricity, and assaults. Section 4 refers readers to CDC guidelines for protection workers from selected infectious diseases, including acquired immunodeficiency syndrome (AIDS). The applicable CDC guidelines are reprinted in the Appendices. Section 5 contains discussions of noninfectious health hazards, including chemical agents and dusts, physical agents, mutagenic and teratogenic agents, skin irritants, and stress. Section 6 outlines procedures for hazardous waste disposal, and Section 7 contains a directory of occupational safety and healthy agencies and resource organizations.

1. Overview of Hospital Hazards

1.1 Occupational Injury and Illness Among Hospital Workers

Hospitals employ approximately 4.5 million of the 8 million health care workers in the United States, or about 4% of the total US workforce (BLS 1988). The percentage distribution of hospital workers by occupation is shown in Appendix 1.

Few workplaces are as complex as the hospital. not only does it provide the basic health care needs for a large number of people, but it is often a teaching and research center as well. As a result, the list of potential hazards includes radiation, toxic chemicals, biological hazards, heat, noise, dusts, and stress.

Maintenance workers are potentially exposed to solvents, asbestos, and electrical hazards. Persons working in or around boiler rooms are regularly exposed to high levels of noise and heat.

Housekeepers are exposed to detergents and disinfectants that can cause skin rashes and eye and throat irritation. They risk exposure to hepatitis and other diseases from hypodermic needles that have not been discarded properly. Sprains and strains are also common problems for housekeepers.

Food service workers face problems such as cuts from sharp-edged equipment, burns from hot surfaces and steam lines, falls on slippery floors, and fatigue and stress from long periods of standing on hard surfaces. Nonionizing radiation from improperly maintained microwave ovens is a potential hazard. Skin rashes from fresh foods, detergents, and humidity are also common, and excessive exposure to noise has been documented.

Registered nurses, (RN’s), nurse practitioners, and licensed vocational/licensed practical nurses (LVN’s/LPN’s) confront such potential problems as exposure to infectious diseases and toxic substances, back injuries, and radiation exposure. Nurses also deal with less obvious hazards resulting from stress and shift work.

Radiology technicians are potentially exposed to radiation from X-rays and radioactive isotopes. Even with the adequate maintenance of equipment, risks can result from incorrect work practices (such as holding infants under a radiation beam without adequate self-protection) or from infectious diseases transmitted by patients. Radiology technicians may also be exposed to chemical hazards.

Operating-room workers (both female and male, and the wives of male workers) may face the increased risk of reproductive problems as a result of exposure to waste anesthetic gases. They are also subject to cuts and puncture wounds, infection, radiation, and electrical hazards.

1.1.1 Published Data

A 1972 national survey of occupational health services in more than 2,600 hospitals reported an annual average of 68 injuries and 6 illnesses among workers in each institution (NIOSH 1974-1976). The most frequent injuries were strains and sprains, followed by puncture wounds, abrasions and contusions, lacerations, back injuries, burns, and fractures. The most frequent illnesses were respiratory problems, infections, dermatitis, hepatitis, and drug or medication reactions. Although studies have shown the adverse effects of some hospital hazards such as anesthetic gases, ethylene oxide, and certain cytotoxic rugs, the effects of many others are not well understood. Hazard surveillance data in the hospital industry (NIOSH 1985) have identified 159 known primary skin or eye irritants used in hospitals and 135 chemicals that are potentially carcinogenic, teratogenic, mutagenic, or a combination of these (see Appendix 4).

In 1978, the California State Department of Industrial Relations published injury and illness data for 1976-1977 from an intensive study of hospital personnel (California Department of Industrial Relations, 1978). The work injury rate in convalescent hospitals (8.4 lost workday cases per 100 full-time workers) was almost double that in acute-care hospitals and in all California industries. Major causes of disabling injury and illness were strain or overexertion, falls or slips, being struck by or striking against objects, burns, and exposure to toxic or noxious substances. Workers with the highest reported number of injuries and illnesses were aides, nursing attendants, orderlies, kitchen workers, housekeeping and maintenance workers, laundry room workers, RN's, LVN's/LPN's, clerks and office workers, and technicians. In Florida, the annual rate of illness and injury reported for hospital workers was 10.0 per 100 workers -- about the same as that recorded for sheet metal workers, auto mechanics, and paper mill workers (American Journal of Nursing 1982).

Two national data systems have been analyzed by Gun (1983): (1) the National Health Interview Survey (1970-1977), which describes the hospital workforce and compares the rates of acute and chronic conditions for hospital workers with those for the total workforce, and (2) compensation data from the Bureau of Labor Statistics. The study compared disease rates for hospital workers with data for all workers combined from the National Health Interview Survey.

1.1.2 Chronic Conditions

Gun (1983) noted that an excessive incidence of some chronic conditions among hospital workers was clearly due to primarily female medical conditions in a predominantly female workforce. After allowance was made for this factor, six conditions of interest were found:

1. Hypertension, among service and blue collar workers

2. Varicose veins, among nearly all categories of hospital workers

3. Anemia, mostly among females, but sex bias was not the sole cause of excess incidence

4. Diseases of the kidneys and urinary system, mostly among females (69%), but an excess incidence appeared in all categories of hospital worker

5. Eczema, dermatitis, and urticaria, mostly among females (57%), but an excess incidence appeared in most categories of hospital workers

6. Displacement of intervertebral disc (low-back injury), mostly among females (166% relative risk)

No data were provided on the risks of diseases such as cancer or reproductive impairment.

1.1.3 Acute Conditions

Hospital workers had a significantly greater incidence of acute conditions compared with all workers in all categories of sex, race, age, and occupational status (Gun 1983). Respiratory problems accounted for more than half of all acute conditions in both hospital workers and all workers. The incidence of every major category of acute condition was higher in hospital workers than in all workers. The risk for hospital workers was about 1.5 times greater than that for all workers, and it was statistically significant for all conditions, including infectious and parasitic diseases, respiratory conditions, digestive system conditions, and "other" conditions (diseases of the ear, headaches, genitourinary disorders, problems associated with childbirth, disorders of pregnancy and the puerperium, and diseases of the skin and musculoskeletal system). The risk of injury for hospital workers was only slightly greater than for all workers.

1.1.4 Compensable Injury and Disease

A review of data from the Bureau of Labor Statistics (BLS 1983) for compensable injury and disease showed that sprains and strains (often representing low-back injury) were by far the most common type of condition, constituting 51.6% of the total. The data in Table 1-1 also show that cuts, lacerations, and punctures account for a significant number of hospital workers’ compensation claims. Because these injuries also have a potential for contamination with blood and other body fluids, they should be carefully monitored and recorded. Employers should provide medical consultation for workers who sustain puncture wounds involving potentially infectious materials.

The injuries and illnesses listed in Table 1-2 are reported more commonly on hospital workers’ compensation claims compared with those of all civilian workers. An excess percentage of hospital workers’ compensation claims resulted from the following conditions: strains and sprains, dermatitis, serum and infectious hepatitis, mental disorders, ill-defined conditions, eye diseases, influenza, complications peculiar to medical care, and toxic hepatitis.

	Claims
Condition	Number†	% of Total
Sprains, strains	35,405	51.6
Contusion, crushing, and bruising	7,635	11.1
Cuts, lacerations, and punctures	7,374	10.8
Fractures	3,865	5.6
Multiple injuries	1,473	2.1
Thermal burns	1,343	2.0
Scratches, abrasions	1,275	1.9
Infections and parasitic diseases	865	1.3
Dermatitis and other skin conditions	850	1.2
All other	8,484	12.4
Total	68,569	100.0

* Adapted from information published in the Supplementary Data System by the U.S. Department of Labor, Bureau of Labor Statistics (1983).
†Figures are adjusted to allow for States that do not provide a sample of their cases.

	Hospital workers		All civilian workers
Condition	Number†	%	Number†	%
Sprains, strains	35,405	51.63	649,685	37.76
Infectious and parasitic diseases:
Unspecified	35	.05	142	.01
Conjunctivitis	102	.15	366	.02
Tuberculosis	87	.13	183	.01
Other	641	.93	2,063	.12
Total	865	1.26	2,754	.16
Dermatitis:
Unspecified	68	.10	1,291	.08
Contact dermatitis	407	.59	9,180	.53
Allergic dermatitis	106	.15	2,042	.12
Skin infections	223	.33	812	.05
Other	22	.03	402	.02
Skin conditions not elsewhere classified	24	.04	191	.01
Total	850	1.24	13,918	.81
Serum and infectious hepatitis	362	.53	903	.05
Mental disorders	360	.53	5,775	.34
Ill-defined conditions	263	.38	4,880	.28
Eye diseases	250	.36	4,805	.28
Influenza	136	.20	2,389	.14
Complications peculiar to medical care	114	.17	295	.02
Toxic hepatitis	37	.05	95	.01
Total	38,642	56.35	685,499	39.85

*Adapted from information published in the Supplementary Data System by the U.S. Department of Labor, Bureau of Labor Statistics (1983).
†Figures are adjusted to allow for States that do not provide a sample of their cases.

Until recently, safety and health policies in hospitals were developed mainly for patients, not workers. Traditionally, hospital administrators and workers considered hospitals and health institutions safer than other work environments and recognized mainly infectious diseases and physical injuries as risks in the hospital environment. Administrators have therefor emphasized patient care and have allocated few resources for occupational health. The following factors have contributed to the lack of emphasis on worker health:

• Hospital workers have been viewed as health professionals capable of maintaining their health without assistance.

• The availability of informal consultations with hospital physicians reduces the use of worker health services.

• Hospitals are oriented toward treating disease rather than maintain health.

Although infectious diseases, like most hospital hazards, were first recognized as risks for patients rather than staff, early attempts to protect patients against hospital infections also benefited workers. For example, Florence Nightingale introduced basic sanitation measures such as open-window ventilation and fewer patients per bed; and the Austrian surgeon, Semmelweis, initiated routine hand-washing more than a century ago. New hazards began to appear in the 1900’s when physicians experimenting with X-rays were exposed to radiation, and operating-room personnel faced possible explosions during surgery involving anesthetic gases. These hazards finally called attention to the many dangers facing hospital workers, and hospitals began to monitor their workers for tuberculosis and other infectious diseases.

1.2.2 Development of Worker Health Programs

In 1958, the American Medical Association (AMA) and the American Hospital Association (AHA) issued a joint statement in support of worker health programs in hospitals. In addition to describing the basic elements of an occupational health program for hospital workers, they stated that “hospitals should serve as examples to the public at large with respect to health education, preventive medicine, and job safety” (AMA 1958). NIOSH subsequently developed criteria for effective hospital occupational health programs (NIOSH 1974-1976) (see Appendix 2).

1.2.3 The NIOSH Hospital Survey

NIOSH undertook the first comprehensive survey of health programs and services for hospital workers in 1972 (NIOSH 1974-1976). Questionnaires sent to hospitals of all sizes throughout the country were completed at more than 2,600 hospitals. The results demonstrated important deficiencies in the worker health programs of most hospitals, especially hospitals with fewer than 100 beds.

Although 83% of the hospitals surveyed gave new workers at least a general orientation on safety and health, only about half of the hospitals had a regular safety and health education program. Only 35% of the small hospitals had regular safety and health education programs, whereas 70% of the large hospitals had them.

Other inadequacies uncovered by the survey included a lack of immunization programs for infectious disease control (only 39% of surveyed hospitals had such programs) and an absence of in-service training in critical areas (only 18% of surveyed hospitals provided training in six critical areas identified).

Since the NIOSH survey, the number and size of worker health programs in hospitals and health facilities have increased rapidly across the Nation. The number of trained professionals is still limited, however, and although some hospitals have expanded the roles of infection-control committees, others have assigned control duties to security or other administrative personnel who have little training or experience in occupational safety and health.

1.3 Worker Health programs and Safety and Health Committees

Only 8% of the hospitals reporting in the 1972 NIOSH survey (NIOSH 1974-1976) met all nine NIOSH criteria for comprehensive hospital safety and health programs (Appendix 2). Many hospitals have since taken steps to initiate or improve worker health service: (1) Professional organizations have been formed for hospital safety officers and worker health service personnel; (2) the number of articles, books, and other published resources on hospital safety and health have increased dramatically; and (3) several organizations now offer annual conferences on occupational health for hospital workers.

In 1977, NIOSH published a full set of guidelines for evaluating occupational safety and health programs in hospitals. Appendix 2 contains these guidelines. See also Kenyon for the practical design of a full safety and health program.

Some hospitals have established joint labor-management safety and health committees. Labor unions representing workers in other hospitals have formed safety and health committees that have made important contributions by identifying safety and health problems and by educating the workforce about safety and health issues.

Major functions of safety and health committees include the following:

• Inspecting workplaces regularly to identify safety and health hazards

• Regularly reviewing accident rates, results from prevention activities, and other relevant workplace data

• Preparing information for workers on identified hazards

• Organizing educational classes

• Reviewing safety and health aspects when planning new construction or renovating facilities

• Investigating accidents

• Establishing motivational programs (e.g. recognition, awards, and dinners) to stimulate worker participation in safety and health activities.

The safety and health committees of labor unions have played important roles in articulating worker concerns, identifying potential hazards, educating their members, and improving work practices. For example, a union safety and health committee in New York City that was investigating risks associated with handling infectious disease specimens identified clusters of hepatitis cases among personnel in the chemistry laboratory, the intensive care unit, and the blood-gases laboratory. After meeting with hospital representatives and studying the problem, the committee identified several potential problem areas. Specific actions were initiated to correct unsafe work practices and conditions. Such safety and health committees can help ensure safe work environments in hospitals.

1.4 REFERENCES

AMA (1958). Guiding principles for an occupational health program in a hospital employee group. Chicago, IL: American Medical Association, Council on Occupational Health.

American Journal of Nursing (1982). Hospital hazards to be examined by Florida nurses. American Journal of Nursing 1:9-10.

BLS (1983). Supplementary data system. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, Occupational and Health Statistics, NTIS Publication No. PB80-160567.

BLS (1988). Employment and earnings. Vol. 35, No. 3. Washington, D.C.: U.S. Department of Labor, Bureau of Labor Statistics, Office of Employment and Unemployment Statistics.

California Department of Industrial Relations (1978). Work injuries and illnesses in California (quarterly), 1975-1976. Sacramento, CA: The Department, Division of Labor Statistics and Research.

Gun RT (1983). Acute and chronic conditions among hospital workers: analysis of surveillance data. Unpublished paper presented at the 1983 American Public Health Association meeting, Dallas, Texas, November 1983. Kenyon DA (1979). How to organize a successful hospital safety committee -a model design. Professional Safety 32:16-22.

NIOSH (1974-1976). Hospital occupational services study. Volumes l-VII. Cincinnati, OH: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control, National Institute for Occupational Safety and Health, DREW (NIOSH) Publication Nos. 75-101, 75-154, 76-107, 76-115, 76-115A, and 76-116.

NIOSH (1977). Hospital occupational health and safety. Cincinnati, OH: U.S. Department of Health, Education, and Welfare, Public Health Service, r Center for Disease Control, National Institute for Occupational Safety and | Health, DREW (NIOSH) Publication No. 77-141.

NIOSH (1985). Report of the DSHEFS Task Force on Hospital Worker Health. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, NIOSH Internal Report.

Stellman JM, Stellman SD, et al. (1978). The role of the union health and safety committee in evaluating the health hazards of hospital workers - a case study. Preventive Medicine 7(3)332-337.

1.5 ADDITIONAL RESOURCES

AHA and NSC (1983). Safety guide for health care institutions. 3rd edition. Chicago, IL: American Hospital Association and National Safety Council.

Bell A (1975). Hospitals harbor hazards ignored in fight for life. International Journal of Occupational Health and Safety 44(5)26-29, 66.

Bluestone N (1975). Employee health services: one hospital's experience. Journal of Occupational Medicine 17(4)230-233.

Brown DG (1980). Environmental health and safety at the University of Michigan Medical Campus. Journal of Environmental Health 43(2)75-78. Brown MP (1979). Hazards in the hospital: educating the workforce through its union. American Journal of Public Health 69(10)1040-1043.

Brown TC, Kreider SD, Lange WR (1983). Guidelines for employee health services in hospitals, clinics, and medical research institutions. Journal of Occupational Medicine 25(10)771-773.

Chovil A, Jacobs P (1983). A guide to conducting an economic evaluation of an occupational health program. Occupational Health Nursing 31(2)37-40.

Clever LH (1981). Health hazards of hospital personnel. Western Journal of Medicine 135(2)162-165.

Douglass BE (1971). Health problems of hospital employees. Journal of Occupational Medicine 13(12)555-560.

Gestal JJ (1987). Occupational hazards in hospitals: accidents, radiation, exposure to noxious chemicals, drug addiction and psychic problems and assault. British Journal of Industrial Medicine 44:510-520.

Greene SB (1981). Frequency of hospitalization among hospital employees and their families. American Journal of Public Health 71(9)1021-1025.

Navarro V (1975). Women in health care. New England Journal of Medicine 292(8)398-402.

Neuberger JS, Kammerdiener AM, Wood C (1988). Traumatic injuries among medical center employees. American Association of Occupational Health Nurses Journal 36(8):318-325.

Omenn GS, Morris SL (1984). Occupational hazards to health care workers: report of a conference. American Journal of Industrial Medicine 6(2)129-137.

Osborn P (1979). Employee health service in a hospital. Supervisory Nursing 10(10)40-42.

Parker JE (1982). Basic components of a hospital employee health program. Occupational Health Nursing 30(5)21-24.

Parmeggiani L (ed.) (1983). Encyclopedia of occupational health and safety. 3rd (revised) ed. Geneva, Switzerland: International Labor Office, 1052-1055.

Patterson SIB, Craven DE (1985). Occupational hazards to hospital personnel. Annals of Internal Medicine 102(5)658-680.

Schneider WJ, Dykan M (1978). The pre-plac~ment medical evaluation of hospital personnel. Journal of Occupational Medicine 20(11)741-744.