2.3 Controlling Hazards

Once potential exposures and safety problems in the hospital have been identified and evaluated, priorities should be established for controlling the hazards. Identified safety hazards should be promptly corrected, and educational programs should be developed on subjects such as correct lifting procedures and the handling of electrical equipment. Workers who are potentially exposed should be fully informed and trained to avoid hazards, and controls should be instituted to prevent exposures. Control methods that can be used for environmental hazards include substitution, engineering controls, work practices, personal protective equipment, administrative controls, and medical surveillance programs. Each of these methods is discussed in the following subsections.

2.3.1 Warning Systems

Any system designed to warn worker of a hazard should

• Provide immediate warnings of potential danger to prevent injury, illness or death

• Describe the known acute (short-term) or chronic (long-term) health effects of physical, chemical, and biologic agents

• Describe any safety hazards that might be encountered, including chemical exposures that might result in traumatic injuries

• Indicate actions for preventing or reducing exposure to hazards

• Provide instructions for minimizing injury or illness in the event exposure has already occurred

• Include a plan for dealing with emergency situations

• Identify the population at risk so that information is provided to the correct group of workers

• Identify actions to be taken in the case of illness or injury

2.3.2 Substitution

The best way to prevent occupational safety and health problems is to replace the offending agent or hazard with something that is less hazardous. For example, highly explosive anesthetic gases have been replaced by nonflammable gases. Replacements for asbestos are being used in new construction, and cleaning agents are often changed when workers complain of dermatitis.

2.3.3 Engineering Controls

Engineering controls may involve modifying the workplace or equipment to reduce or eliminate worker exposures. Such modifications include both general and local exhaust ventilation. Isolating patients or work processes from the hazard, enclosing equipment or work processes (as in glove-box cabinets), and altering equipment (such as adding acoustic padding to reduce noise levels).

2.3.4 Work Practices

How workers carry out their tasks may create hazards for themselves and others. For example, staff, nurses, or doctors who do not dispose of used needles safely create a severe hazard for housekeepers, laundry workers, and themselves. Workers sometimes perform tasks in ways that create unnecessary exposures. This includes staff members who try to life patients without assistance and laboratory workers who pipette by mouth rather than by rubber bulb, thereby increasing their risk of injury or contamination.

2.3.5 Personal Protective Equipment

Personal protective equipment includes gloves, goggles, aprons, respirators (not surgical masks), ear plugs, muffs, and boots. Although the use of such equipment is generally the least desirable way to control workplace hazards because it places the burden of protection on the worker, the equipment should be available for situations when an unexpected exposure to chemical substances physical agents, or biologic materials could have serious consequences.

Personal protective equipment is frequently uncomfortable and difficult to work in, and it must be adequately maintained. Maintenance requires constant supervision and training. The use of respirators also requires frequent testing to ensure adequate fit for each wearer. For this reason, the policy of OSHA and NIOSH has been to use personal protective equipment for preventing inadvertent exposures that are threatening to health or life only when (1) engineering and administrative controls are not feasible, (2) such controls are being developed or installed, (3) emergencies occur, or (4) equipment breaks down.

The proper selection of chemical protective clothing (CPC) requires an evaluation by a trained professional such as an industrial hygienist. The selection process must include

• Assessing the job or task

• Determining the body parts that need to be protected

• Determining the necessary flexibility and durability that will allow the worker to perform the job or task

• Assessing the exposure situation in view of the chemicals present, the toxicity of those chemicals, and the concentrations to which workers will be exposed

• Assessing existing laboratory data on the capacity of CPC to withstand contact with the chemicals during use and to prevent penetration by those chemicals (permeation data are available for many chemical and CPC materials (ACGIH 1985) and should be consulted)

• Evaluating candidate materials in the laboratory and, if possible, at the worksite

Standard operating procedures for the proper use of CPC should be established and should include

• Training in proper ways to put on and take off CPC

• Training in proper disposal methods

• Periodic evaluation of the effectiveness of the CPC

NIOSH does not recommend reuse of CPC unless data are available that demonstrate the efficacy of decontamination procedures in maintaining the effectiveness of the CPC against the chemicals used.

Recommendations for personal protective equipment for chemical hazards are also discussed in the NIOSH Pocket Guide to Chemical Hazards (NIOSH 1`985) and the NIOSH/OSHA Occupational Health Guidelines for Chemical Hazards (NIOSH 1981a).

2.3.5.1 Eye and Face Protection

Eye protection or face shields are required when the worker may be injured by flying particles, chips, or sparks or splashed by such liquids as caustics, solvents, and blood or body fluids. Workers should wear protective equipment and clothing when they use machinery that produces dusts and chips or when they handle toxic and corrosive substances. Eye and face shields should provide adequate protection against the particular hazards to which the worker is exposed. The equipment should be easy to clean and disinfect. If workers who wear glasses must also wear goggles, the goggles should fit over the glasses, or the corrective lenses should be mounted behind the protective lenses.

2.3.5.2 Head Protection

Protective head coverings (hard hats) should be required in situations where workers may be struck on the head by falling or flying objects.

2.3.5.3 Foot Protection

Safety shoes are recommended to prevent injury to the feet from falling objects and other hazards. They are particularly important where heavy materials or parts are handled and during shipping and receiving operations. Appropriate footwear with good traction should be worn for wet or slippery areas. Periodic conductivity checks should be made on footwear worn in surgical areas, and disposable shoe covers should be readily available to minimize the potential for static electricity in surgical areas.

2.3.5.4 Gloves, Aprons, and Leggings

Aprons and leggings may be necessary for workers in some operations, depending on the type of hazard. Gloves and arm protectors should be used to prevent lacerations from sharp edges, to prevent contact with chemical and biologic materials, to prevent burns, and to provide shielding from radiation.

2.3.5.5 Hearing Protection

If noise levels exceed current standards, workers must be provided with hearing-protection devices and directed to wear them (29 CFR 1910.95).

2.3.5.6 Respiratory Protection

The employer must provide approved respiratory protection (not surgical masks, which do not provide respiratory protection) when the air is contaminated with excessive concentrations of harmful dusts, fumes, mists, gases, vapors, or microorganisms. Respiratory protection may be used as a control only when engineering or administrative controls are not feasible or while these controls are being developed or installed.

Respirators must be selected by individuals knowledgeable about the workplace environment and the limitations associated with each class of respirator. These individuals must also understand the job tasks to be performed. The correct use of a respirator is as important as the selection process. Without a complete respiratory protection program, workers will not receive the protection anticipated even if the respirator has been correctly chosen. Training, motivation, medical evaluation, fit testing, and a respirator maintenance program are critical elements of an adequate respiratory protection program.

NIOSH has recently updated its "Guide to Industrial Respiratory Protection", which covers the selection, use, and maintenance of respiratory protective devices (NIOSH 1987a). NIOSH has also developed a respirator decision logic (RDL) (NIOSH 1987b) to provide knowledgeable professionals with a procedure for selecting suitable classes of respirators. The RDL identified criteria necessary for determining the classes of respirators that provide a known degree of respiratory protection for a given work environment, assuming the respirators are used correctly.

The criteria and restrictions on respirator usage in the following two subsections were adapted from the NIOSH RDL (NIOSH 1987).

2.3.5.6.1 Criteria for selecting respirators

The first step is to determine which contaminants the worker are exposed to and then to assemble the necessary toxicologic, safety, and other relevant information for each. This information should include

• General use conditions

• Physical, chemical, and toxicologic properties

• Odor threshold data

• NIOSH recommended exposure limit (REL) or OSHA permissible exposure limit (PEL), whichever is more protective; if no REL or PEL exists use another recommended exposure limit

• The concentration of the contaminant believed to be immediately dangerous to life or health (IDLH)

• Potential for eye irritation

• Any service life information available for cartridges and canisters

2.3.5.6.2 Restrictions and requirements for all respirator use

The following requirements and restrictions must be considered to ensure adequate protection by the selected respirator under the intended conditions for use:

1. A complete respiratory protection program should be instituted and should include information on regular worker training, use of the respirator in accordance with the manufacturer’s instructions, fit testing, environmental monitoring, and maintenance, inspection, cleaning, and evaluation of the respirator. Whenever possible, quantitative evaluation of the protection factor should be performed in the workplace to confirm the actual degree of protection provided by the respirator to each worker. minimum respiratory protection requirements for air contaminants can be found in the OSHA Safety and Health Standards (29 CFR 1910.134) and in separate sections for specific contaminants (e.g. 1910.1001 for asbestos, and 1910.1025 for lead {see Section 5 of this document}).

2. Qualitative or quantitative fit tests should be conducted as appropriate to ensure that the respirator fits the individual. Periodic evaluations should be made of the effectiveness of each respirator during workplace use. When quantitative fit testing is used, the fit-factor screening level should be chosen with caution, recognizing the uncertainty of its effectiveness (no studies have demonstrated which fit factor values provide adequate acceptance of rejection criteria for quantitative fit screening).

3. Negative-pressure respirators should not be used when facial scars or deformities interfere with the face seal.

4. No respirator (including positive-pressure respirators) should be used when facial hair interferes with the face seal.

5. The respirators should be maintained properly, used correctly, and worn conscientiously.

6. The usage limitations of air-purifying elements (particularly gas and vapor cartridges) should not be exceeded.

7. All respirators must be approved by the National Institute for Occupational Safety and Health (NIOSH) and the Mine Safety and Health Administration (MSHA).

8. Workers should be instructed to leave a contaminated area immediately if they suspect that the respirator has failed.

9. Workers are usually not exposed to a single, unvarying concentration of a hazardous substance, but exposures may vary throughout a workshift and from day to day. Thus the highest anticipated concentration should be used to compute the required protection factor for each respirator wearer.

10. Respirator wearers should be aware of the variability in human response to the warning properties of hazardous substances. Thus when warning properties must be relied on as part of a respiratory protection program, the employer should screen each prospective wearer for the ability to detect warning properties of the hazardous substance(s) at exposure concentrations below the REL or PEL, whichever is more protective.

2.3.6 Administrative Controls

Administrative controls involved reducing total daily exposure by removing the worker from the hazardous area for periods of time. These controls are used when it is impractical to reduce exposure levels in the workplace through engineering controls. Administrative controls include
(1) rescheduling work to reduce the necessity of rotating shifts, and
(2) increasing the frequency of rest period for persons who work in hot environments.

2.3.7 Medical Monitoring Programs

2.3.7.1 Designing the Program

Appropriate medical procedures exist to evaluate the extent of some workplace exposures (e.g. measuring lead levels in blood) or the effects of exposure on the worker’s health (e.g. measuring hearing loss).

Section 5 contains the specific tests appropriate for some common hospital hazards. A medical monitoring program should be designed for each department based on information from safety and health walk-through surveys and industrial hygiene evaluations.

The following questions should be considered for designing medical monitoring programs:

• Are the selected tests specific to the potential exposures? Multiphasic or other general examinations do not target specific hazards.

• Are the selected tests likely to detect adverse health effects? A chest X-ray may detect asbestosis, but asbestosis does not usually develop until 10 or more years after first exposure. Thus a yearly chest X-ray for asbestosis would not help new workers.

• Are there any side effects from the selected test? A chest X-ray may detect some diseases, but it also exposes a worker to radiation. The potential test benefits must be weighed against potential harm.

Specific tests for each job category should be incorporated into the monitoring program of the worker health service. Appendix 2 contains NIOSH recommendations for general safety and health programs, including pre-employment, preplacement and periodic worker health examinations. In addition, the worker health service may test for conditions that are not necessarily job related but are important for promoting general worker health (e.g. high blood pressure) or are specific to the region (e.g. some hospitals in the southwestern United States routinely administer skin tests for coccidioidomycosis in preplacement physicals).

2.3.7.2 Consent and Confidentiality

Before certain immunizations (e.g. M-M-R {measles, mumps, rubella} and Heptavax-B vaccinations) are given, workers should read, sign, and date informed consent forms designed to alert them to potential side effects. The results of medical testing should be provided directly and confidentially to individual workers. The workers and the safety and health committee should receive group results of testing by work unit (e.g. a table of audiometry result for maintenance worker) to assess the adequacy of worker protection in each unit; individual workers should not be identified.

If a worker must be temporarily or permanently removed from a job for occupational safety or health reasons, the employer should be informed without receiving actual medical information. For example, the notification should read, "Jane Doe may not continue to be exposed to solvents and must be transferred out of the histology section", rather than, "Jane Doe has liver disease and must be transferred out of histology".

2.3.7.3 Recordkeeping

adequate recordkeeping is very important: (1) to track the safety and health of individual workers and work groups over time, (2) to provide documentation for future evaluations, (3) to help the hospital administration and the safety and health committee identify problem areas, and (4) to measure the effectiveness of safety and health programs.

Many specific OSHA standards (e.g. for ethylene oxide and asbestos) contain detailed provisions for recordkeeping, monitoring, and medical surveillance. These standards should be consulted. In 29 CFR 1904, the Department of Labor also requires all employers covered by the Occupational Safety and Health act of maintain logs of all occupational injuries and illnesses that have occurred in their workplaces over the last calendar year. These logs (usually OSHA form 200) must be posted in conspicuous places where notices to worker are usually posted. The employer must maintain these records for at least 5 years and provide access to these records for the Secretary of the Department of Health and Human Services. Workers and their representatives also have the right to access these records. When there is a specific standard for a substance, OSHA generally requires that records be maintained for at least the duration of employment plus 30 years.

2.3.7.4 Preplacement Evaluations

Preplacement physical examinations are very important for establishing baselines (pre-exposure measurements of health) and for ensuring that the worker is physically able to perform the job. The Centers for Disease control (CDC), the American Hospital Association (AHA), and State hospital codes have developed guidelines for screening new hospital workers. The results of the hazard identification procedures outlined in this section should be used to design appropriate preplacement programs. For example, when a person is hired for a position that may require the use of respiratory protection, the preplacement examination should include an evaluation of the worker’s physical ability to wear a respirator.

Because many workers do not have general medical examinations regularly, some worker health services in hospitals include a simplified general medical questionnaire and examination when tests are given for more specific reasons. A report of 3,599 preplacement examinations in a large teaching hospital indicated that the most frequent problems involved (1) susceptibility to communicable diseases such as diphtheria or rubella, or (2) the potential for disease transmission, as indicated by tuberculin-positive skin tests, intestinal parasites in stool examinations, positive serological tests for syphilis, or the presence of the hepatitis B surface antigen. The most frequent noninfectious illnesses were hypertension and anemia (Schneider and Dykan 1978).

2.4 Occupational Safety and Health Agencies and Organizations .

Several agencies and organizations are involved in promoting safety and health in hospitals, and significant differences exist among state agencies that hold enforcement powers. Federal agencies such as NIOSH help assess potential hazards and make recommendations for correction without the threat of citation or penalty. Private organizations such as the AHA and the National Safety Council (NSC) also develop recommendations and provide materials and assistance. The major agencies and organizations that develop regulations, standards, recommendations, and codes for occupational safety and health in hospitals are described briefly below. Other organizations addressing more specific groups of health professionals (e.g. the College of American Pathologists) are listed in Section 7.

2.4.1 Occupational Safety and Health Administration

The Occupational Safety and Health Administration (OSHA) is responsible for promulgating and enforcing standards in most workplaces, including Federal and private sector hospitals. About half of all States have approved State OSHA plans, which must be at least as effective as Federal plans in providing for safe and healthful employment. State plans may also cover hospitals operated by State and local governments. OSHA offices are listed in Section 7.

OSHA has developed specific standards for hazards such as noise, mercury, ethylene oxide, and asbestos. Also, a general duty clause states that employers must provide their worker with "employment and a place of employment which are free from recognized hazards that rare likely to cause death or serious physical harm...."(Public Law 91-596).

OSHA has the authority to inspect workplaces in response to requests form workers or as part of targeted or routine inspection schedules. Citations and fines may be imposed for violations discovered during these inspections. OSHA also has a free consultation service that provides employers with evaluations of workplace hazards and advice on control methods without the risk of citations or fine -- provided the employer agrees to abate any serious hazards identified during a consultation. OSHA has a referral system for serious violations that are not abated after a consultation visit.

2.4.2 National Institute for Occupational Safety and Health

The National Institute for Occupational Safety and Health (NIOSH) conducts research on workplace hazards and recommends new or improved standards to OSHA. NIOSH also investigates specific workplace hazards in response to requests by worker or employers. Although NIOSH has the same right of entry as OSHA to conduct health hazard evaluations (HHE’s), NIOSH can only recommend hazard controls and has no enforcement authority. HHE’s can be particularly useful where the causes of workplace hazards are unknown, where a combination of substances may be causing a problem, or where a newly recognized health effect is suspected for a substance that is already regulated. NIOSH also investigates potential health hazards on an industry wide basis, performs research on methods for controlling safety and health hazards, recommends standards to OSHA for promulgation, publishes and distributes NIOSH studies and investigations, and provides training programs for professionals. For more detailed information on the NIOSH HHE program, refer to a Worker’s Guide to NIOSH (NIOSH 1978). NIOSH also assesses and documents new hazards control technology for processes and specific hazards. An article by Kercher and Mortimer (1987) is an example of such an assessment.

In addition to conducting HHE’s and control technology assessments, NIOSH investigates the circumstances of fatal accidents and recommends safe work practices and controls to reduce or eliminate hazards.

2.4.3 Centers for Disease Control

The Centers for Disease Control (CDC) is a Federal public health agency based in Atlanta, Georgia. Among other responsibilities, CDC is charged with the surveillance and investigation of infectious diseases in hospitals. CDC collects weekly, monthly, and yearly statistics on many infectious diseases, on control programs and activities for hospital infections, and on new problems as they appear. The Agency is also charged with making recommendations necessary for disease control.

2.4.4 Health Resources and Services Administration

Under the Hill-Burton legislation (Public Law 79-725, as amended), the health Resources Administration (HRA) (now the Health Resources and Services Administration {HRSA} published Minimum Requirements of Construction and Equipment for Hospital and Medical Facilities (HRS 1979). Hospitals receiving Federal assistance must comply with these regulations.

2.4.5 Nuclear Regulatory Commission

The Nuclear Regulatory Commission (NRC) adopts and enforces standards for departments of nuclear medicine in hospitals, although some states have agreements with the federal government to assume these responsibilities. In these cases, the responsible state agency is usually the state health department. NRC regulates roentgenogram sources (title 21) and all radioactive isotope sources except radium (Title 10) (21 CFR 100-1050 {1958}; 10 CFR 20 and 34 {1985} but does not have authority to regulate naturally occurring radioactive materials such as radium or radon. The Food and Drug Administration (FDA) is responsible for those regulations. NRC publishes and continuously revises guides to describe methods acceptable for implementing specific parts of the Commission’s regulations. These guides are published and revised continuously.

2.4.6 State, County, and Municipal Health Agencies

With some variation, state health departments adopt and enforce regulations in the following areas: radiation, nuclear medicine, infectious disease control, infectious disease and hazardous waste disposal, and food handling. In some states, the health department and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (formerly the Joint Commission on Accreditation of Hospitals (JCAH) accredit hospitals jointly. Both the JCAHO and the State health departments have the patient’s rather than the worker’s safety and health as their primary concern. Thus the accreditation requirements are not fully developed in the area of worker health protection. County and city health departments also have jurisdiction over food handling and some other hospital functions, and they help evaluate many potential hazards regulated at the state level.

2.4.7 Joint Commission on Accreditationof Healthcare Organizations

The Joint Commission on Accreditation of Healthcare Organization (JCAHO) re-evaluates the accreditation every 3 years for hospitals that choose to apply. The accreditation inspections reflect a primary concern for patients’ safety and health, but JCAHO does require hospitals to establish policies and procedures for monitoring and responding to safety and health hazards.

2.4.8 National Fire Protection Association

The National Fire Protection Association Code for Safety to Life from Fire in Buildings and Structures (NFPA 1985) is the most basic and complete code for fire safety in hospitals. OSHA, JCAHO, and HRSA have adopted portions of this and other NFPA codes, although the specific references are often to earlier versions.

2.4.9 National Safety Council

The National Safety Council (NSC) recommends general safety and (in the case of ethylene oxide) health recommendations. The hospital section of NSC is responsible for preparing recommendations for hospitals, whereas the research and development and chemical sections are responsible for laboratory safety guidelines.