• 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 OSHA Directive OSHA Directive CPL 02-02-069].

• 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. OSHA Directive 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.

• A program in place to maximize employee safety during decontamination of patients.
  
  
• A program in place to maximize employee safety during administration, disposal, and preparation of hazardous drugs.

For additional information, see HealthCare Wide Hazards - Hazardous Chemicals, and Hospital Pharmacy.

• 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) - Exit Routes, Emergency Action Plans, and Fire Prevention Plans].

For additional information, see HealthCare Wide Hazards - Slips/Trips/Falls.

• 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.

For additional information, see HealthCare Wide Hazards - Workplace Violence.

• 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 (1996, February 9)]. 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 02-00-106 [CPL 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 02-00-106 [CPL 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: OSHA requires worker education and training to ensure employee knowledge of TB including: signs, symptoms, transmission, controls, and post-exposure protocols. [Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis. OSHA Directive CPL 02-00-106 [CPL 2.106], (1996, February 9)].

For more information, see HealthCare Wide Hazards - Tuberculosis. Additional Information: 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 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 1910.139 are basically the same, however five areas now have more detailed requirements.

• Educate employees and management about job stress.
  
  
• Establish programs to address workplace stress, such as: Employee Assistance Programs (EAP) or Organizational Change Programs.

• An Employee Assistance Program (EAP) can improve the ability of workers to cope with difficult work situations. Stress management programs teach workers about the nature and sources of stress, the effects of stress on health, and personal skills to reduce stress (e.g., time management or relaxation exercises).
  
  
• EAPs also provide individual counseling for employees for both work and personal problems.
  
  
• Organizational Change Programs change hospital policies and procedures to reduce organizational sources of stress.
  
  
  • This is done by bringing in a consultant to recommend ways to improve working conditions. This approach is the most direct way to reduce stress at work. It involves the identification of stressful aspects of work (e.g., excessive workload, conflicting expectations) and the design of strategies to reduce or eliminate the identified stressors. Some strategies include:
    
    
    • Ensure that the workload is in line with workers' capabilities and resources.
      
      
    • Design jobs to provide meaning, stimulation, and opportunities for workers to use their skills.
      
      
    • Clearly define workers' roles and responsibilities.
      
      
    • Give workers opportunities to participate in decisions and actions affecting their jobs.

• Stress At Work. National Institute of Occupational Safety and Health (NIOSH) Workplace Safety and Health Topic Page.
• Stress at Work. US Department of Health and Human Services (DHHS), National Institute of Occupational Safety and Health (NIOSH) Publication No. 99-101, (1999)..

• Exposure of ED staff to MRSA infections from environmental sources (e.g., homeless patients or IV drug abuse patients). Staff can become infected and then become carriers who can infect other staff members or patients. As MRSA becomes more resistant to antibiotics such as methicillin and potentially vancomycin, it will become more difficult to treat.

• Hospitals in different geographical locations will need to establish their own local MRSA data and provide treatment information to clinicians.
  
  
• Recommendations for vancomycin use as initial empiric therapy for suspected staphylococcal infection for health-care workers exposed to MRSA.
  
  
• Practice Universal Precautions to help protect employees from infection.
  
  
• The CDC's recommendations for preventing transmission of MRSA in hospitals consist of Standard Precautions, which should be used for all patient care. In addition the CDC recommends Contact Precautions in special cases, when the facility (based on national or local regulations) deems the multi-drug-resistant microorganism to be of special clinical and epidemiological significance. For more information about the CDC's standard precautions:
  
  
  • Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, (2007).

For additional information, see HealthCare Wide Hazards - MDR0 - Multidrug-Resistant Organisms, and Infection.

• Methicillin-resistant Staphylococcus aureus (MRSA). OSHA. Provides links with general information, answers specific questions for employers and employees, and offers resources for a variety of workplace settings, including healthcare, school, athletic, and childcare.
  
  

• Exposure of ED staff and other hospitals workers to patients exposed to biological agents, chemical agents, and mass causalities as a result of terrorist attacks or events.

• Provide and plan for emergency response for health care employers and emergency responders. The Department of Health and Human Services (DHHS), CDC, the American Hospital Association (AHA), Department of Defense, and OSHA have several resources about how hospitals can plan and prepare for terrorist events:
  
  
• Emergency Preparedness and Response. OSHA Safety and Health Topics Page. Information on medical response to emergencies.
   
• Emergency Readiness. American Hospital Association (AHA).
  
  
• Chemical Terrorism Wall Chart. University of North Carolina, Chapel Hill, has developed a wall chart on chemical terrorism agents.
  
  
• Hospitals and Community Emergency Response [350 KB PDF^*, 30 pages]. OSHA Publication 3152-3R, (2008).
  
  
• Anthrax:
  
  
  • Anthrax eTool: Protecting the Worksite Against Terrorism. OSHA eTool.
    • Health Care Workers. How health care workers can be protected.
      
      
  • Anthrax. OSHA's understanding of currently available national information on Anthrax.
    
  
  
  • Anthrax in the Workplace. OSHA.
     
• Radiological Dispersal Devices (RDD)/Dirty Bombs. OSHA Safety and Health Topics Page.
  • How will health care workers be protected?