2.1 Addressing Diverse Needs

The diverse safety and health concerns in hospitals are traditionally divided into hazards that pose an immediate threat and hazards that cause long-term health problems. Safety hazards include sharp-edged equipment, electrical current, and floor surfaces that can contribute to slipping or tripping. Health hazards are often more difficult to identify than safety hazards. They may result in an immediate illness or in the long-term development of disease. Although a needle puncture may result in hepatitis in 90 to 180 days, exposure to excess radiation or to some chemicals may not result in any noticeable health effects for 20 to 30 years. Thus workers may appear and feel healthy when, in fact, their health is being seriously threatened. Because workers are often exposed to hazards for which the effects are not well known, they may have difficulty associating a new illness with past workplace exposures.

This section contains steps for developing safety and health programs to identify and control occupational hazards within the hospital setting. These steps are summarized in Table 2-1. Personnel trained in occupational safety and health are needed to design, implement, and manage such a program. Many organizations listed in this manual offer courses designed specifically to train nurses, safety officers, physicians, and nonprofessional workers (see Section 7).

2.1.1 Enlisting Administrative Support

Developing an appropriate and useful safety and health program for a hospital or health facility requires the involvement of a safety and health committee that represents workers and supervisors from all departments in the hospital. Such involvement is essential because workers frequently observe real and potential hazards that supervisory staff, the employee health service, or other safety and health personnel do not recognize. To be effective, committee members should be knowledgeable in occupational safety and health and have explicit responsibilities and appropriate authorities.

2.1.2 Identifying Hazards

Hazard identification involves not only recognizing the hazards themselves but also learning their specific characteristics and identifying the population at risk so that control programs can be designed. See also sections 5 and 7 of this document for further details on obtaining necessary hazard information.

2.1.2.1 Walk-Through Inspections

Hospital safety and health personnel should conduct an initial survey of safety hazards such as those outlined in Section 3. The hospital safety and health committee should assist with this in consultation with workers form each department. The first step in identifying hazards is usually a physical inspection called a walk-through survey. Persons conducting the survey actually walk through the unit and note as many hazards as possible.

During a walk-through survey, survey personnel should communicate with supervisors and workers in each department, follow a checklist, and ask any additional questions that may arise. For example, have common health problems been noticed among the workers in the department? Do any hazards exist that are not on the checklist? How is the department different from a typical department of its type? A diagram of each department should be developed to include the number and location of workers and the sources of potential exposure. Several organizations listed in Section 7 have developed sample checklists for walk-through inspections.

2.1.2.2 Published Sources of Information

The following references should be consulted when considering the potential toxicity of substances used in the hospital:

1. Occupational Diseases: A Guide to Their Recognition (NIOSH 1977)

2. NIOSH/OSHA Occupational Health Guidelines for Chemical Hazards (NIOSH 1978a)

3. NIOSH Pocket Guide to Chemical Hazards (NIOSH 1985)

4. Chemical Hazards of the Workplace (Proctor and Hughes 1978)

In 1975, NIOSH developed a basic format for material safety data sheets (MSDS’s) to provide information on the content, potential toxicity, recommended handling methods, and special precautions for substances found in the workplace (NIOSH 1974). In 1986, OSHA promulgated a hazard communication standard requiring that the following information be included on MSDS’s (29 CFR* 1910.1200):

• Product identity from the label, including chemical and common names of hazardous ingredients

• Physical and chemical characteristics of ingredients (e.g. vapor pressure and flash point)

• Physical hazards of ingredients (potential for fire, explosion, and reactivity)

• Health hazards associated with ingredients (including signs and symptoms of exposure and any medical conditions generally recognized as being aggravated by exposure to the product)

• Primary routes of entry to the body

• The OSHA permissible exposure limit (PEL), the ACGIH threshold limit value (TLV®), and any other exposure limit used or recommended by the chemical manufacturer, importer, or employer preparing the MSDS

• An indication as to whether the product and/or ingredients are listed in the National Toxicology Program (NTP) Annual Report on Carcinogens (latest edition) or are designated as a potential carcinogen by OSHA or in the International Agency for Research on Cancer (IARC) Monographs (latest editions)

• Any generally applicable precautions for safe handling and use known to persons preparing the MSDS (e.g. appropriate hygienic practices, protective measures during repair and maintenance of contaminated equipment, and procedures for cleanup of spills and leaks)

• Any known, generally applicable control measures (e.g. appropriate engineering controls, work practices, or personal protective equipment)

• Emergency and first aid procedures

• Date of MSDS preparation or last amendment

• Name, address, and telephone number of a responsible party who can provide additional information on the hazardous chemical and on appropriate emergency procedures

*Code of Federal Regulations. See CFR in references.

Manufacturers are now required by Federal law to provide MSDS’s with their products (29 CFR 1910.1200). The regulation requires that a specific chemical identity be made available to health professionals, workers, and their designated representatives in accordance with the provisions given in the occupational safety and health standard. This regulation also requires employers to develop a written hazard communication program and provide workers with training and information. NIOSH also recommends that hospitals provide completed MSDS's or their equivalent to personnel in materials management and purchasing or central supply before products are purchased or reordered. The hospital safety and health committee should also maintain a file of MSDS’s. Most MSDS’s now available do not include information on the chronic health effects of low-level exposure, but they do provide information on the acute effects of relatively high levels. 2.1.2.4 NIOSH Policy Documents NIOSH has prepared criteria documents and other recommendations on many hazardous substances. These extensive evaluations of the scientific literature include recommendations to the US Department of Labor for controlling exposures. NIOSH documents are available for the following substances and agents that may be found in hospitals:

2.1.2.5 Occupational Health Organizations

A list of occupational health organization appears in Section 7 of this document (Directory of Occupational Safety and Health Information for Hospitals).

2.2 Evaluating Hazards

Once hazards have been identified, they should be evaluated to determine how serious the problems are and what changes can be introduced to control them (See Section 2.3). Methods for measuring exposures to hazards in the workplace are recommended in the NIOSH Manual of Analytical Methods (NIOSH 1984). Health hazards posed by chemicals (in the form of dusts, liquids, or gases), radiation, noise, and heat should be evaluated initially by an industrial hygienist. If no industrial hygienist is available, consultation can be obtained from NIOSH, OSHA, private consultants, or in some cases insurance companies.

After controls are installed, they should be checked periodically to see that they are being maintained and are protecting the workers adequately. A chart or grid should be prepared to list hazardous materials and the departments where they are usually found, exposure limits, precautions to follow, and other relevant factors. Such a chart can be a quick reference and a means of tracking program development.

A hazard evaluation program should consist of the following elements: periodic inspection and monitoring of potential safety and health problems, informal interviewing of workers, medical evaluations, and evaluation of worker exposures and the workplace. The following subsections contain descriptions of each element and definitions of terms commonly used in industrial hygiene standards.

2.2.1 Periodic Inspection and Monitoring of Safety and Industrial Hygiene

When an evaluation reveals a potential hazard and control measures are applied, the hazard should be re-evaluated to determine the effectiveness of the controls. Complex work procedures (e.g. operating-room practices) should be analyzed carefully, noting products and byproducts formed during the procedures.

The frequency with which hazards should be monitored depends, among other things, on the extent of exposure to the agent, the severity of the adverse effects, the complexity of the work process, seasonal variations of temperature and humidity, and protective measures. OSHA regulations mandate inspection schedules for a few substances such as asbestos (29 CFR 1910.1001). Experience and a high degree of awareness will allow each hospital safety and health committee to decide on an appropriate inspection schedule for each department.

2.2.2 Informal Interviews of Workers

In the first assessment of hazards in each work unit, a short questionnaire or informal interview with the workers may identify problems that are not easily noted by visual inspection. For example, questionnaires, informal discussions, or physical inspections may reveal a potential for back strain resulting from poor work practices, stress caused by staffing or shift rotation systems, or inadequate training for handling infectious materials. The following general questions should be posed:

• Since starting the job, has the worker developed any new health problems or have existing problems worsened? What symptoms have been observed? When did the symptoms begin or become more severe? When did the problems improve or become less noticeable?

• Has the worker noticed any health problems in the other workers in the same department that may be related to or caused by their work?

• Is there anything in the job that might affect the worker’s health or the safety and health of other workers now or in the future?

2.2.3 Medical Evaluations

The signs and symptoms that workers experience should be evaluated medically, taking care to avoid preconceptions about which ones are work related. The potential health effects of each exposure should be determined using the references mentioned earlier in this section (Subsection 2.1.2.2). An occupational history should also be maintained for each worker to help evaluate the long-term effects of exposures. This history should contain at least the worker’s prior occupations and job titles, the duration of employment at each job, and the name of any substance or agent to which the worker may have been exposed.

2.2.4 Environmental Evaluations

An industrial hygienist may take area samples, personal samples, or wipe samples to help determine the extent of a workplace hazard. Most methods for chemical sampling require laboratory analysis, which should be performed by a laboratory accredited by the American Industrial Hygiene Association. The safety officer should consider using direct-reading instruments that are available. These are discussed in Air Sampling Instruments for Evaluation of Atmospheric Contaminants (ACGIH 1983).

2.2.4.1 Area Samples

Area samples from the general work space can measure the extent of potential worker exposure to chemicals, extreme temperatures, excessive noise, ionizing and nonionizing radiation, and other environmental stressors. Industrial hygienists may monitor work environments with equipment that provides information immediately, or they may use methods that require laboratory analysis of collected samples. Direct-reading sampling devices include colorimetric detector tubes, mercury "sniffers", infrared spectrophotometers, microwave survey meters, and sound-level meters. Air samples for such substances a nitrous oxide, formaldehyde, ethylene oxide, and asbestos may require laboratory analysis. Sometimes both types of sampling devices exist for the same chemical, and the choice depends on the precision and accuracy required.

2.2.4.2 Personal Samples

Personal samples are used to measure contaminants in the worker’s breathing zone. Evaluations of personal exposure to chemical dusts, fumes, gases, and vapors are frequently expressed as an 8-hr time-weighted average (TWA) concentration (which is the average exposure concentration during an 8-hr workday) or as a short-term exposure concentration. The two main types of personal sampling devices are:

1. A pump mounted on the worker’s belt that provides suction and draws air from the worker’s lapel (breathing zone) through a tube and into the collection medium attached to the pump, and

2. A passive dosimeter (often like a large button), which can be clipped to the worker’s lapel and absorbs substances from the surrounding air.

Wipe samples are analyzed to measure the contamination of work surfaces.

2.2.5 Occupational Safety and Health Standards

Worker safety and health is the responsibility of the Occupational Safety and Health Administration (OSHA), which was established in the US Department of Labor by the Occupational Safety and health act of 1970 (Public Law 91-596). The principal function of OSHA is to promulgate and enforce workplace safety and health standards, which are contained in Volume 29 of the Code of Federal Regulations. The Occupational Safety and Health Act also created the National Institute for Occupational Safety and Health (NIOSH). The principal functions of NIOSH are to conduct research and to recommend new and improved safety and health standards to OSHA. Throughout this document, reference is made to OSHA standards and NIOSH recommendations. OSHA standards for exposure to airborne chemicals are generally referred to as permissible exposure limits (PEL’s). NIOSH recommendations for controlling airborne contaminants are referred to as recommended exposure limits (REL’s). The OSHA PEL’s are legally enforceable standards that must also be economically feasible, whereas the NIOSH REL’s are recommended standards based solely on public health considerations.

The American Conference of Governmental Industrial Hygienists (ACGIH) is a professional association that recommends limits for airborne contaminants, called threshold limit values (TLVs). TLVs are intended to serve only as guidelines for the professional industrial hygienist; they are not intended to be enforceable exposure limits.

2.2.5.1 Terms Used in Industrial Hygiene Standards The following terms are sued in Federal standards or recommendations for the workplace.

PEL	Permissible exposure limit. A PEL is the maximum airborne concentration of a substance regulated by OSHA to which a worked may be exposed. These values are enforces by law.
ppm	Parts per million.
REL	Recommended exposure limit. A NIOSH REL is the maximum recommended exposure to a chemical or physical agent in the workplace. The REL is intended to prevent adverse health effects for all occupationally exposed workers.
TLV	Threshold limit value. A TLV is the airborne concentration of a substance to which nearly all workers can be exposed repeatedly day after day without adverse effect (ACGIH 1987). ACGIH recommends and publishes these values annually on the basis of the most current scientific interpretations. TLVs are not OSHA standards and are not enforced by law.
TLV-C	Threshold limit value ceiling. The TLV-C is the airborne concentration of a substance that should not be exceeded even for an instant during any part of the working exposure (ACGIH 1987).
TLV-SKIN	Threshold limit value-skin adsorption. TLV-SKIN refers to the potential contribution of absorption through the skin including mucous membranes and eyes to a worker’s overall exposure by either airborne or direct contact with a substance (ACGIH 1987).
TLV STEL	Threshold limit value short-term exposure limit. The TLV-STEL is the maximum exposure concentration allowed for up to 15 min during a maximum of four periods each workday. Each exposure period should be at least 60 min after the last period (ACGIH 1987).
TWA	Time-weighted average. The TWA is the average exposure concentration during an 8-hr workday. Exposure for more than 8 hr per day or more than 40 hr per week, even at or below the TLV or PEL, may represent a health hazard. NIOSH recommendations typically include 10-hr TWA’s for up to a 40-hr workweek. The TWA for an 8-hr workday is calculated as follows:
sum of {(exposure period) x (exposure concentration)} for each exposure period ---------------------------------------------------------------------------------------------------------- 8-hr workday For example, formaldehyde exposure in a laboratory might be: (5 ppm X 2 hr) + 1 ppm x 6 hr) ------------------------------ 8h-hr workday 10+6 ------ = 2.0 ppm TWA 8