• Provide Engineering and Work Practice Controls
  
  
  • Engineering and work practice controls must be the primary means to eliminate or minimize exposure to bloodborne pathogens. Where engineering controls will reduce employee exposure either by removing, eliminating, or isolating the hazard, they must be used, and changes to the Exposure Control Plan (ECP) must include these engineering controls [29 CFR 1910.1030(c)(1)(iv), 29 CFR 1910.1030(d)(2)(i), and Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. OSHA Directive CPL 02-02-069 [CPL 2-2.69], (2001, November 27)].

• Ensure employees wear appropriate personal protective equipment (PPE), gloves, gowns, face masks, when anticipating blood or OPIM exposure [29 CFR 1910.1030(d)(3)(i)].

• Ensure employees discard contaminated needles and other sharp instruments immediately or as soon as feasible after use into appropriate containers [29 CFR 1910.1030(d)(4)(iii)(A)(1)].

• Provide in their exposure control plan documentation of consideration and implementation of appropriate commercially available and effective engineering controls designed to eliminate or minimize exposure to blood and OPIM [Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. OSHA Directive CPL 02-02-069 [CPL 2-2.69], (2001, November 27)].
  
  
• Practice Universal Precautions: Treat all blood and other potentially infectious body fluids as if they are infected and take appropriate precautions to avoid contact with these materials [29 CFR 1910.1030(d)(1)].

• The Bloodborne Pathogens Standard does allow hospitals to practice acceptable alternatives to Universal Precautions such as Standard Precautions or Body Substance Isolation.

• The Revised Bloodborne Pathogen Standard requires needlestick/sharps injuries be recorded on a Sharps Injury Log 29 CFR 1910.1030(h)(5). The sharps injury log must be established and maintained and the confidentiality of the injured employee must be protected.
  
  
• Follow-up area for needlestick injuries and/or exposure incidents: The Bloodborne Pathogens Standard 29 CFR 1910.1030(f)(3) requires the employer to make immediately available a confidential medical evaluation and follow-up to an employee reporting an exposure incident. This follow-up often occurs in the emergency department.

• Additional follow-up information is provided in:
  
  
  • Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. CPL 02-02-069 [CPL 2-2.69], (2001, November 27).
  • Bloodborne Pathogens and Needlestick Prevention. OSHA Safety and Health Topics Page. Offers the most current CDC recommendations for post exposure protocols.

• Keep floors clean and dry [29 CFR 1910.22(a)(2)].
  
  
• Keep access to exits clear and unobstructed at all times [29 CFR 1910.37(a)(3)].

• Trained staff to recognize and diffuse violent situations and patients.
  
  
  • Be alert for potential violence and suspicious behavior and report it.
    
    
  • Provide intervention measures including verbal, social, physical, and pharmacological interventions.
    
    
  • Warning Signs of Increasing Anger/Violence include:
    
    
    • Pacing and/or restlessness
      
      
    • Clenched fist
      
      
    • Increasingly loud speech
      
      
    • Excessive insistence
      
      
    • Threats
      
      
    • Cursing
      
      
• Adequate staffing levels, with experienced clinicians on each shift.
  
  
• Counseling and treatment for employees who have experienced workplace violence.

• The use of appropriate engineering controls to provide security such as:
  
  
  • Install concealed panic buttons in the ED, on staff, and at the check-in area, that can be pushed for emergency help. These buttons could notify hospital security as well as directly reach the local Police Department.
    
    
  • Improve lighting and video surveillance.
    
    
  • Use an escort or buddy system.
    
    
  • Limit access to ED area and personnel, by implementing:

• A waiting room area with controlled access to ED area. Patients must be buzzed in by receptionist from a secure door.

• ED exits that exit out only, so people off the streets can't access the ED unless they enter through the waiting room area.
  
  
• The use of metal detectors.

• Provide a "secure" room for patients identified to be violent. This room could include controls such as:
  
  
  • Video camera surveillance
    
    
  • Visual surveillance: provide a window
    
    
  • Door locks on patient rooms
    
    
  • Bed with tie down straps
    
    
  • Locked cabinets
    
    
  • Attach furniture and equipment to the floor so patients can't throw them at employees.

• Provide and practice early patient screening in the ED to identify potentially infectious patients, and provide isolation to prevent employee exposures. Consistent with CDC guidelines: ED employees should treat patients as having suspected infectious TB if they have both a persistent cough lasting at least three weeks, and at least two of the following additional symptoms: bloody sputum, night sweats, weight loss, fever, and anorexia.
  
  
• Provide engineering, work practice, and administrative procedures to reduce the risk of exposure. For example:
  
  
  • Patients with a productive cough could be asked to wear a mask to prevent the spread of infection.
    
    
    • Post waiting rooms signs that state, "If you are coughing you may be asked to wear a mask."

• Isolate patient until verification testing is negative.
  
  
• Some EDs provide an isolation room to safely isolate potentially infectious patients. Others can designate an isolation area for infectious patients. Isolation rooms must be respiratory acid-fast bacilli (AFB) rooms that are maintained under negative pressure. AFB isolation refers to a negative-pressure room or an area that exhausts room air directly outside or through HEPA filters if re-circulation is unavoidable.[Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis. OSHA Directive CPL 02-11-106 [2.106], (1996, February 9)].
  
  
• Protect employees from exposure to the exhaled air of an individual with suspected or confirmed TB [29 CFR 1910.134(a)(2)].
  
  
• Isolate patients who have suspected or confirmed TB [Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis. OSHA Directive CPL 02-11-106 [2.106], (1996, February 9)].

• Post a warning sign outside the ED respiratory isolation room 29 CFR 1910.145(a)(1) to prevent accidental entry. 29 CFR 1910.145(f)(4) Requires that that a signal word (i.e. "STOP", "HALT", or "NO ADMITTANCE") or biological hazard symbol be presented as well as a major message (e.g., "Special respiratory isolation," "Respiratory isolation," or "AFB isolation"). An example of a description of necessary precautions is "Respirators must be donned before entering."
  
  
• Employers must provide suitable respirators when such equipment is necessary to protect the health of the employee [29 CFR 1910.134(d)(1)(i)]. The minimally acceptable level of respiratory protection for TB is the Type N95 Respirator.
  
  
• Establish and maintain a respiratory protective program which includes the requirements outlined in [29 CFR 1910.134(c)].
  
  
• Worker education: Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis. OSHA Directive CPL 02-11-106 [2.106], (1996, February 9) requires worker education and training to ensure employee knowledge of TB including: signs, symptoms, transmission, controls, and post-exposure protocols.

For more information see HealthCare Wide Hazards - Tuberculosis.

• Tuberculosis and Respiratory Protection. OSHA Standard Interpretation,  (2004, July 30). Defines the new enforcement policy for tuberculosis under 29 CFR 1910.134. Effective July 2, 2004. Covered establishments must comply with 29 CFR 1910.134 when using respirators for protection from tuberculosis (TB). 
  • Comparison of Respiratory Protection (29 CFR 1910.139) with (29 CFR 1910.134). 132 KB PDF, 29 pages. Most of the requirements in 29 CFR 1910.134 and the former 29 CFR 1910.139 are basically the same, however five areas now have more detailed requirements.