Healthcare Safety

1
Healthcare Safety
2
Agenda

• 100 Intro, Safety, Back Ergonomics
• 150 Break
• 200 Slip/Trip/Falls Workplace Violence
• 250 Break
• 300 Bloodborne Pathogens TB
• 400 Chemical Exposures
• 430 Questions/Answers

3
OSHA Guidelines - Overview

• Covers a broad spectrum of workers
• (nearly 8 million)
• Psychiatric facilities
• Hospital emergency departments
• Drug treatment centers
• Community care and mental health facilities
• Pharmacies and long-term care facilities

4
Background

• The nursing home industry is one of Americas
  fastest growing industries.
• In 1994, approximately 1.6 million workers are
  employed at 21,000 work sites.
• By the year 2005, industry employment will rise
  to an estimated 2.4 million workers.

5
Bureau of Labor Statistics (BLS) Data

• In 1994, over 221,000 nonfatal occupational
  injuries and illnesses nursing facilities
• In 1999, 2,637 non-fatal assaults on hospital
  workers a rate of 8.3 assaults per 10,000
  workers
• 27.0 assaults per 10,000 workers - nursing

• In 2003, over 221,500 nonfatal occupational
  injuries and illnesses nursing facilities
• In 2003, a rate of 8.5 assaults per 10,000
  workers - hospitals
• 22.4 assaults per 10,000 workers - nursing

6
Jobs with the Most Injuries

• Nursing aides, orderlies, and attendants
  accounted for 70 of lost time injuries

7
Major Sources of Injuries and Illnesses

• Resident handling strains - 60
• Falls - 15
• Contact with objects equipment 12
• Assaults violent acts by persons 6
• Exposure to harmful substances 4
• Others 3

8
Cause of Injury
Source 1994 BLS Survey of Occupational Injuries
Illnesses, unpublished table.
9
BLS Update - Nursing

• 1994
• 221,200 nonfatal injuries and illnesses
• 1,648,800 annual aver. employment
• 83,450 cases with days away from work

• 2003
• 221,500 nonfatal injuries and illnesses
• 2,776,500 annual aver. employment
• 69,400 cases with days away from work

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Components of Safety Process

• Management
• Hazard Analysis
• Inspections
• Hazard Reporting
• Accident Investigation
• Hazard Controls
• Safety and Health Training

11
Hazard Analysis

• Job Safety Analysis
• Workplace Observations

12
Inspections

• To identify new or previously missed hazards and
  failures in hazard controls.
• An effective safety and health program will
  include regular site inspections.

13
Hazard Reporting

• A system that enables employees to notify
  management of conditions that appear hazardous,
  without fear of reprisal.

14
Accident and Record Analysis

• Accident Investigation
• Data Analysis

15
Accident Investigation

• An effective program will provide for
  investigation of accidents and near miss
  incidents, so that their causes, and the means
  for their prevention, are identified.

16
Data Analysis

• Analysis of injury and illness records for
  indications of sources and locations of hazards,
  and jobs that experience higher numbers of
  injuries.
• This function is usually handled by the Safety
  Committee.

17
Hazard Prevention and Control

• Hazard Exposure Control
• Maintenance
• Medical Surveillance Program

18
Hazard Control

• Workforce exposure to all current and potential
  hazards should be prevented or controlled by
• engineering controls, wherever feasible and
  appropriate
• work practices and administrative controls
• personal protective equipment

19
Maintenance

• An effective safety and health program will
  provide for facility and equipment maintenance,
  so that hazardous breakdowns are prevented.

20
Medical Program

• An effective safety and health program will
  include a suitable medical tracking program where
  it is appropriate for the size and nature of the
  workplace and its hazards.

21
Emergency Response

• Emergency preparedness - There should be
  appropriate planning, training/drills, and
  equipment.
• First aid/emergency care should be readily
  available to minimize harm if an injury or
  illness occurs.

22
Emergency Response Resources

• Safety and Health Topics OSHA
• Emergency Preparedness and Response
• OSHA 3152 Hospitals and Community Emergency
  Response

23
Safety and Health Training

• Most effective when incorporated into other
  training about performance requirements and job
  practices. It should include all subjects and
  areas necessary to address hazards at the site.

24
Contractor Safety

• An effective safety and health program
  protects all personnel on the worksite, including
  contractors. It is the responsibility of
  management to address contractor safety.

25
General Duty Clause

• Section 5(a)(1) of the OSH Act requires that
  Each employer shall furnish to each of his
  employees employment and a place of employment
  which are free from recognized hazards that are
  causing or are likely to cause death or serious
  physical harm to his employees.

26
General Duty Clause (Contd)

• The general duty clause is used only where there
  is no OSHA standard that applies to the
  particular hazard involved.Examples of
  workplace hazards to which the general duty
  clause may apply include occupational exposure to
  ergonomics and workplace violence.

27
General Duty Clause (Contd)

• Four elements are required for issuing general
  duty clause violations
• The employer failed to keep the workplace free of
  a hazard to which employees of that employer were
  exposed
• The hazard was recognized
• The hazard was causing or was likely to cause
  death or serious physical harm
• There was a feasible and useful method to correct
  the hazard

28
Safety and Health Hazards in Healthcare

• Strains, Sprains Back Injuries
• Slips, Trips Falls
• Workplace Violence
• Bloodborne Pathogens
• Tuberculosis
• Others (toxic chemicals, lasers X-rays)

29
Sprain/Strain Back Injuries

• Patient handling
• Transfers
• Falling patients
• Combative patients

30
Physical Therapy
31
Sprain/Strain Back Injuries

• Dietary
• Large containers of food
• Awkward work positions
• Carrying trays, etc during cleaning

32
Laundry
33
Sprain/Strain Back Injuries

• Maintenance and Housekeeping
• Equipment handling
• Awkward work positions
• Reaching
• Stooping

34
Back Injury Solutions

• Perform work task evaluation
• Patient handling checklist
• How often and how hard
• Work task analyzer
• Equipment checklist
• Facility design checklist
• Trained lifting team
• Mechanical lifting devices
• Gait or transfer belts
• Total-body lift

35
Back Injury Solutions (Contd)

• Stand-assist lift
• Draw sheet
• Slide board
• Slippery sheet with handles
• Shower-toilet chair with wheels
• Training on safe work practices
• Return to Work program

36
Guidelines for Nursing Homes

• OSHA released 3/13/2003 recommended elimination
  manual lifting of residents when feasible
• Developing process program to protect workers
• Patient lifting repositioning activities
• Activities other than patient lifting
• Training
• Additional information and program components

37
Ergo Program Development

• Program Administrator should be an individual or
  group that is responsible for the process
• Accountability in place for supervisors
• Identifying stressors in their areas
• Implementing the controls in their areas

38
Ergo Training

• Training for all personnel at risk of an
  musculoskeletal disorder (MSD) covers
• Identification of ergonomic stressors
• How to control the stressor
• How to report problems
• Signs and symptoms of MSDs

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Ergo Training (Contd)

• For new employees before assignment
• Existing personnel in several sessions or as part
  of routine training
• Format should be such that all can understand and
  the employees should be able to demonstrate
  understanding of training
• Training updated as changes occur in workplace

40
Additional Ergo Program Components

• Worksite analysis
• Emphasis on resident handling
• OSHA guide has decision tree flow chart to assist
  with procedures including bed-to-chair,
  chair-to-toilet, chair-to-chair or car-to chair
• Recordkeeping
• Return to Work process

41
Prevention of Slips, Trips and Falls
42
Slips

• Floors
• Terrazzo or tile can be very slippery when wet
• Clean up spills immediately barricade wet areas
  until dry
• Entrance ways are very susceptible
• Post warning cones when raining

43
Trips

• Carpet - tears can catch shoe or heel
• Rugs or mats - can curl at edges or have bumps in
  the middle
• Keep paths clear

44
Falls

• Use ladders in good condition and in prescribed
  manner
• Dont stand on top of chairs or desks for an
  elevated task
• Use caution when walking stairs

45
Slips/Trips/Falls

• Areas of concern
• Dietary department
• Tiled/terrazzo floors
• Employees and general public
• Maintenance department
• Parking lots

46
Dietary
47
Slips/Trips/Falls

• Dietary
• Liquids/wet solids on the floor during food
  preparation
• Time crunch
• Footwear

48
Slip/Trips/Falls Prevention

• Employee Training
• Appropriate Footwear
• Environmental Factors

• Floor Maintenance Inspection
• Walking Surfaces
• Housekeeping

49
Appropriate Footwear

• Management should clearly define what footwear is
  appropriate for the workplace.
• Inappropriate footwear may contribute up to a
  fourth of the reported same level slip/fall
  incidents

50
Appropriate Footwear (Contd)

• Rules of thumb
• Soft rubber soles for dry surfaces, not wet or
  greasy
• Hard rubber soles for greasy, but not dry or wet
  surfaces
• Synthetic soles for many conditions, but may not
  be recommended for oily surfaces

51
Appropriate Footwear (Contd)

• Rules of thumb
• Well defined square leading edges
• Wedge sole better for hospitals, catering
• 2mm space between the tread pattern
• 3 mm between the sole of the shoe and bottom of
  the tread

52
Environmental Factors

• Poor lighting
• Should have at least 20 footcandles in walkways
• Eliminate glare sources
• Replace burned out or flickering light bulbs

53
Environmental Factors (Contd)

• Weather related hazards
• Ice
• Snow
• Rain
• Mud
• These factors can impact your outdoor travel and
  can be brought into the building

54
Floor Maintenance

• Follow manufacturers directions, such as
  sweeping first or rinsing, if specified.
• Clean floor as needed or regular basis
• Buffing/burnishing with a traction-enhanced
  polish applied correctly can improve traction.

55
Floor Maintenance (Contd)

• Periodic inspection must be conducted.
• Damaged portions should be clearly identified and
  barricaded.
• Prompt repairs or replacement should be made.
• Accountability must be placed with management for
  follow up of repair completion.

56
Floor Maintenance (Contd)

• Responsibility must be assigned.
• Floor manufacturer is the best resource for
  determining what product is best.
• Many new hard surface floor care products have
  built in traction enhancing properties.

57
Floor Maintenance (Contd)

• Floor maintenance problems
• Cleaning for hard or resilient floor
• Detergents with fragrance-can leave slippery
  residue
• Cleaner not diluted enough or too much
• Wrong cleaner type for floor

58
Walking Surfaces

• Physical characteristics of the walking surface
• Parking lots
• Sidewalks and steps
• Type of flooring
• Hard- concrete, tile
• Resilient-VCT
• Other-wood, carpet

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Walking Surfaces (Contd)

• Parking lots - Should we be concerned about
  parking lots from a workers comp standpoint?
  Yes!
• Pot holes
• Loose rocks and pebbles
• Speed bumps
• Cracks in pavements
• Ramps
• Parking space dividers

60
Walking Surfaces (Contd)

• Sidewalks and steps
• Uneven patterns
• Cracks
• Debris

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Walking Surfaces (Contd)

• Mats
• Place mats and/or runners at building entrances,
  adjacent water fountains, sinks, and any other
  place where spills may occur and is part of the
  workplace

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(No Transcript)
64
Walking Surfaces (Contd)

• Mats
• Should be secured against movement
• Taped edges can be considered if properly
  maintained
• Should have a beveled, flat edge
• Rotate periodically for even wear
• Permanent, recessed mats are preferred

65
Walking Surfaces (Contd)

• Carpet
• Has good traction, even with wet conditions
• Regular inspection and repair/replace as needed
  when damage is noted
• Carpet needs to be kept in good condition
• Small rip can catch a heel causing a trip and
  fall
• Bumps can catch the toe of the shoe causing a
  trip and fall

66
Housekeeping

• Poor housekeeping
• Materials being improperly stored in hallway or
  aisle
• Items being left accidentally or purposely in
  walk area
• Water, grease or other slip hazards on hard or
  resilient surfaces

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Housekeeping (Contd)

• Assigned responsibilities
• Employee training in proper procedures for
  routine cleaning
• What products to use for each type of floor
  surface
• What the manufacturers specifications for use
  may be
• Cleaning Schedule

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Housekeeping (Contd)

• Procedures in place for spills
• Warning signs yellow caution cones or barricade
  tape (29 CFR 1910.144)
• Inspection to make sure clean up is complete
• Storage Procedures
• Aisles should be kept clear
• Materials should be placed in proper space
• Housekeeping is an ongoing process, not hit and
  miss

69
Housekeeping (Contd)

• Other benefits of good housekeeping
• Ease in flow of materials
• Decreased fire hazards
• Better control of tools and materials
• More efficient equipment clean up and maintenance

70
Workplace Violence

• Any physical assault, threatening behavior, or
  verbal
• abuse occurring in the workplace.

71
Acts of Aggression Which May Indicate Risk

• Disorderly conduct
• Verbal threats to inflict harm
• Fascination with weapons
• Obscene phone calls
• Intimidating presence

72
Types of Workplace Violence Incidents

• Based upon the relationship between the
  assailant/worker/workplace, violent incidents can
  be divided into categories
• violence by strangers
• violence by customers/clients/patients
• violence by co-workers
• violence by personal relationship

73
Types of Workplace Violence Incidents (Contd)

• Homicides
• Leading cause of job-related deaths for women,
  second leading cause for men
• Claimed 1,071 lives in 1994
• Approx. 3 workers died/day under violent
  circumstances in 1994
• Nonfatal Assaults
• Between 1987-1992, one million persons were
  annually assaulted at work

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Establishments Affected by Workplace Violence

• According to the Bureau of Labor Statistics
  (BLS), the highest number of homicides occur in
  night retail establishments.The highest number
  of nonfatal assaults occur in the health care and
  social service sectors.

75
Health Care Establishments

• Nonfatal assaults were primarily by
  patients/residents on nursing staff in health
  care institutions.According to BLS, there were
  69 homicides in the health services from 1996
  2000.

76
Nursing Homes

• BLS 1994 data showed more than 4900 assaults and
  violent acts against employees in nursing homes.
• Nursing Aides and Orderlies accounted for more
  than 50 of the assault victims.

77
Why Health Care Workers are at Risk Of
Work-Related Assaults

• Low level staffing level during times of
  increased activity
• Isolated work with patients
• Lack of training of staff in recognizing and
  managing escalating hostile behavior

78
Why Health Care Workers are at Risk Of
Work-Related Assaults (Contd)

• Prevalence of handguns and other weapons among
  patients, their families or friends
• The increasing care of acutely disturbed, violent
  individuals
• The increasing number of mentally ill patients
  being released with follow-up care

79
Violence Prevention Program Elements

• Management Commitment and Employee Involvement
• Worksite Analysis
• Hazard Preventing and Control
• Training and Education
• Recordkeeping and Evaluation of Program

80
Bloodborne Pathogens29 CFR 1910.1030

• Pathogenic organisms that are present in human
  blood and can cause disease in humans. These
  include, but are limited to, hepatitis B virus
  (HBV) and human immunodeficiency virus (HIV).

81
Bloodborne Pathogens

• Scope and Application
• Definitions
• Exposure Control Plan
• Methods of Compliance
• HIV and HBV Research Laboratories and Production
  Facilities

• Hepatitis B Vaccination and Post-Exposure
  Follow-up
• Communication of Hazards to Employees
• Recordkeeping
• Effective Dates

82
Highlights of 29 CFR 1910.1030

• The standard applies to all employees with
  occupational exposure to blood and other
  potentially infectious materials.

83
Highlights of 29 CFR 1910.1030 (Contd)

• Exposure Control Plan includes
• The written exposure determination
• The procedures for evaluating the circumstances
  surrounding an exposure incident and
• The schedule and method of implementing other
  sections of the standard.

84
Highlights of 29 CFR 1910.1030 (Contd)

• Methods of Compliance
• Universal Precautions
• Engineering and Work Practice Controls
• Personal Protective Equipment
• Housekeeping

85
Highlights of 29 CFR 1910.1030 (Contd)

• Hepatitis B Vaccination
• HBV vaccination must be made available within 10
  working days of initial assignment to all
  employees who have occupational exposure.

86
Highlights of 29 CFR 1910.1030 (Contd)

• HBV vaccination must be made available without
  cost to the employee, at a reasonable time and
  place, and by a licensed health care
  professional.

87
Highlights of 29 CFR 1910.1030 (Contd)

• Post-exposure Evaluation and Follow-upThe
  employer must make a confidential medical
  evaluation and follow-up to employees following
  an exposure incident.

88
Highlights of 29 CFR 1910.1030 (Contd)

• Communication of Hazards to Employees
• Labels and signs
• Information and training

89
Highlights of 29 CFR 1910.1030 (Contd)

• Recordkeeping
• Medical records
• Training records
• Sharps/needlestick records

90
Needlestick Safety and Prevention Act Timeline

• P. L. 106-430 signed November 6, 2000
• Revised Standard published in Federal Register
  Jan. 18, 2001
• Effective date April 18, 2001
• Enforcement of new provisions July 17, 2001
• Adoption in OSHA state-plan states October 18,
  2001

91
Revisions to Standard

• Additional definitions, paragraph (b)
• New requirements in the Exposure Control Plan
  (ECP), paragraph (c)
• Solicitation of input from non-managerial
  employees, paragraph (c)
• Sharps injury log, paragraph (h)

92
Additional Definitions1910.1030(b)

• Engineering Controls - includes additional
  definitions and examples
• Sharps with Engineered Sharps Injury Protections
  (SESIP)
• Needleless Systems

93
Engineering ControlsNew Definition

• means controls (e.g., sharps disposal
  containers, self-sheathing needles, safer medical
  devices, such as sharps with engineered sharps
  injury protections and needleless systems) that
  isolate or remove the bloodborne pathogens hazard
  from the workplace.

94
Needleless SystemsNew Definition

• Device that does not use a needle for
• Collection of bodily fluids
• Administration of medication/fluids
• Any other procedure with potential percutaneous
  exposure to a contaminated sharp

95
SESIPNew Definition

• Non-needle sharp or a needle with a built-in
  safety feature or mechanism that effectively
  reduces the risk of an exposure incident.

96
Means of Transmission - Must Enter Body

• HBV, HIV virus present in blood, body fluids
• Sexual contact with an infected partner
• Accidentally cutting yourself with a sharp object
  that is contaminated with infected blood, body
  fluids

97
Exposure Control Plan1910.1030(c)New Provisions

• The plan must be updated to include
• Changes in technology that reduce/eliminate
  exposure
• Annual documentation of consideration and
  implementation of safer medical devices
• Solicitation of input from non-managerial
  employees

98
Solicitation of Non-Managerial EmployeesNew
Provision

• Identification, evaluation, and selection of
  engineering controls
• Must select employees that are
• Responsible for direct patient care
• Representative sample of those with potential
  exposure

99
Engineering and Work Practice Controls
1910.1030(d)

• Employers must select and implement appropriate
  engineering controls to reduce or eliminate
  employee exposure.

100

• Where engineering controls will reduce employee
  exposure either by removing, eliminating, or
  isolating the hazard, they must be used.
• CPL 2-2.44D cancelled
• CPL 2-2.69 (effective 11-27-01)

101
Engineering and Work Practice Controls

• Selection of engineering and work practice
  controls is dependent on the employers exposure
  determination.

102
Exposure Determination

• The employer must
• Identify worker exposures to blood or OPIM
• Review all processes and procedures with exposure
  potential
• Re-evaluate when new processes or procedures are
  used

103
Engineering and Work Practice Controls (Contd)

• The employer must
• Evaluate available engineering controls (safer
  medical devices)
• Train employees on safe use and disposal
• Implement appropriate engineering controls/devices

104
Engineering and Work Practice Controls (Contd)

• The employer must
• Document evaluation and implementation in ECP
• Review, update ECP at least annually
• Review new devices and technologies annually

105
Engineering and Work Practice Controls (Contd)

• The employer must
• Implement new device use, as appropriate and
  available
• Train employees to use new devices and/or
  procedures
• Document in ECP

106
Recordkeeping 1910.1030(h)

• Sharps Injury Log
• Only mandatory for those keeping records under 29
  CFR 1904
• Confidentiality
• Maintained independently from OSHA 300

107
Sharps Injury Log

• At a minimum, the log must contain for each
  incident
• Type and brand of device involved
• Department or area of incident
• Description of incident

108
Summary of New Provisions

• Additional definitions, paragraph (b)
• New requirements in the Exposure Control Plan,
  paragraph (c)
• Non-managerial employees involved in selection of
  controls, paragraph (c)
• Sharps injury log, paragraph (h)

109
Means of Transmission - Must Enter Body

• Infected blood or body fluid on skin especially
  with open cuts, sores
• Getting contaminated blood or body fluid in eyes,
  mouth
• Sharing infected needles

110
Exposure Solutions

• Universal Precautions
• TREAT ALL BLOOD AND BODY FLUIDS AS POTENTIALLY
  INFECTIOUS.
• Use appropriate PPE (multiple sizes)
• After bloodborne contact
• Wash hands with antibacterial soap
• Flush eyes, and seek medical attention

111
Exposure Solutions (Contd)

• After an accident, clean area with disinfectant
• Restrict access to the area
• Use disposable towels - dispose of properly
• Be alert for sharp objects in trash
• Do not pick up broken glass - use brush or broom
  dustpan
• Dispose of sharps safely
• Frequent hand washing is best defense against
  spreading infection

112
Hypodermic syringes with Self-Sheathing safety
feature
Self-sheathed protected position
113
Hypodermic syringes with Retractable Technology
safety feature
Retracted protected position
114
Phlebotomy needle with Self-Blunting safety
feature
Blunted protected position
115
Add-on safety feature
Attached to syringe needle
Attached to blood tube holder
116
Retracting lancets with safety features
Before During After
Before During After
In use After use
117
Disposable scalpels with safety features
Retracted position
Protracted position
Protracted position
118
Common Questions about BBP

• My company supplies contract employees to
  healthcare facilities. What are my
  responsibilities under BBP?
• The employer who maintains a continuing
  relationship with its
• employees has the primary responsibility for the
  employees. The
• client location has the responsibility to provide
  any site specific
• training. Contracts should clearly define each
  parties roles to
• ensure all requirements of the regulation are met.

119
Tuberculosis
120
Tuberculosis (TB)

• Infectious disease caused by the bacterium,
  Mycobacterium tuberculosis
• Spread by airborne droplets generated when a
  person with TB disease coughs, sneezes, speaks,
  or sings

121
Tuberculosis (Contd)

• Infection occurs when a susceptible person
  inhales droplet nuclei containing the bacteria
  which become established in the body
• Mantoux tuberculin skin test detects TB
  infection, positive results indicate infection.
  Other tests needed to confirm TB disease

122
TB Occurrence

• Since 1985, the incidence of TB in the general
  U.S. population has increased 14 reversing a 30
  year downward trend.
• However, during 1994 and 1995, there has been a
  decrease in TB cases in the U.S. likely due to
  increased awareness and efforts in prevention and
  control of TB.

123
Why Is TB Such a Concern?

• Multiple contributing factors
• Homelessness
• Intravenous drug use
• Overcrowding in institutional settings
• HIV infection
• Reduced resources for TB control and treatment
• Immigration from high TB prevalence areas

124
Tuberculosis - OSHA Enforcement

• On 2/9/96, OSHA issued agency-wide CPL 2.106,
  Enforcement Procedures and Scheduling for
  Occupational Exposure to Tuberculosis.This
  enforcement directive cancels the enforcement
  guidelines issued on 10/8/93.

125
Tuberculosis - OSHA Enforcement (Contd)

• OSHAs CPL 2.106 is based on the Centers for
  Control and Prevention (CDC) Guidelines for
  Preventing the Transmission of Mycobacterium
  tuberculosis in Health-Care Facilities issued on
  10/18/94.

126
Workplace Identified by CDC with High Incidences
of TB

• Health Care Settings
• Correctional Institutions
• Homeless Shelters
• Long-term Care Facilities for the Elderly
• Drug Treatment Centers

127
Highlights of CDC Guidelines and OSHA Requirements

• Determine the risk of exposure
• Early diagnosis, isolation, treatment
• Requirements for isolation
• Training of workers
• Exposure Control Plan
• Non-mandatory

128
Highlights of CDC Guidelines and OSHA Requirements

• Respirators - OSHA standard 1910.134
• Skin testing
• Other applicable standards
• Recordkeeping
• Employee access to records
• Accident prevention signs

129
Hazardous Chemicals

• Waste anesthetic gases
• Formaldehyde (1910.1048)
• Ethylene Oxide (1910.1047)
• Glutaraldehyde

130
Waste Anesthesia Gas
131
Surgical Suite
132
Waste Anesthesia Gas (WAG)

• Types
• Halogenated / Nitrous Oxide
• Uses
• Hospitals, operating rooms, dental offices,
  veterinary clinics
• Concerns
• Reproductive system effects
• Nervous system effects
• Other suggested systemic effects

133
Engineering Controls

• Scavenger system
• Collection device (mask)
• Negative pressure suction in closed /
  re-circulating breathing circuit
• Soda lime scrubber
• Gas-tight connections, tubing, breathing bag,
  etc..
• Room ventilation

134
Work Practice Controls

• Place seal mask to patient before gas turned-on
• Flush anesthesia machine circuit with oxygen
  before patient extubation
• Inflatable skirt masks for optimal seal
• Adequate patient mask types and sizes
• Low/high pressure leak testing of machines in
  pre-op checkout procedure

135
Other Actions

• Environmental air sampling
• New machines (when possible)
• Routine maintenance

136
Medical Surveillance

• Pre-placement / annual frequency
• Pregnancy outcome histories
• Hepatic system
• Renal system
• Hematopoietic system

137
Formaldehyde 29 CFR 1910.1048
138
Formaldehyde

• Review of the OSHA Formaldehyde Standard
• Potential Health Effects
• Medical Surveillance
• Personal Protective Clothing and Equipment
• Safe Work Practices for Specific Operations
• Spill Procedures

139
OSHA Formaldehyde Standard(29 CFR 1910.1048)

• Scope
• Applies to all occupational exposures to
  formaldehyde (i.e. formaldehyde gas, its
  solutions and materials that release formaldehyde)

140
Permissible Exposure Limits

• TWA - 0.75 ppm, as an 8-hour time-weighted
  average
• STEL - 2.0 ppm, any 15-minute period during the
  work shift
• Action Level - 0.5 ppm, as an 8-hour TWA

141
Potential Health Effects Inhalation

• Air Concentration (ppm)
• 0 - 0.5
• 0.05 - 1.50
• 0.05 - 2.0
• 0.10 - 5.0

• Reported Health Effects
• None
• Odor threshold
• Eye sensation/irritation
• Irritation of the nose and throat
• Difficulty in breathing, burning sensation in the
  nose and throat, and coughing

142
Potential Health Effects Inhalation

• Air Concentration (ppm)
• 25 - 50
• 50 - 100
• 100

• Reported Health Effects
• Tissue damage and serious respiratory tract
  injury such as pneumonitis. Pulmonary
  edema/inflammation - severe lower airway effects
• Death

143
Potential Health Effects Inhalation

• Carcinogenic Effects
• Long-term exposure to formaldehyde is reported to
  be associated with an increased risk of cancer of
  the nose and accessory sinuses and nasopharyngeal
  and oropharyngeal cancer in humans.

144
Potential Health Effects Skin Contact

• Acute Exposure
• Vapors or solutions may cause smarting, white
  discoloration, roughness, hardness anesthesia,
  and first degree burns.
• Chronic Exposure
• Prolonged or repeated exposures may cause second
  degree burns, numbness, and itching rash,
  fingernail damage, hardening of tanning of the
  skin and sensitization.

145
Regulated Areas

• Shall be established where airborne formaldehyde
  concentrations exceed the TWA and STEL
• Post danger signs at entrances and access ways
• Access limited to authorized persons

146
Control Methods

• Institute engineering controls and work practices
  to maintain exposures below the TWA and STEL
• Where necessary, supplement controls with
  respiratory protection
• Possibility of splash with solutions greater than
  0.1
• Eyewash facilities
• Possibility of splash with solutions greater than
  1.0
• Shower

147
Personal Protective Clothing and Equipment

• Provide employees with a means of protecting
  themselves against unnecessary exposures to
  formaldehyde
• Skin Contact
• Protective gloves, sleeves, aprons
• Eye Contact
• Safety glasses/goggles, face shields
• Inhalation
• Local exhaust ventilation (LEV), respirators

148

Respiratory Protection

• Where respirators are required, they will be
  provided at no cost to the employee, will be used
  properly, and will reduce formaldehyde exposures
  to levels at or below the TWA and STEL.
• Whenever respirator use is required, a
  respiratory protection program conforming with
  OSHA regulations will be instituted.

149

Housekeeping

• Regular preventative maintenance of equipment,
  including surveys for leaks
• Provisions made to contain spills, decontaminate
  the work area and dispose of waste
• Employees repairing equipment leaks and cleaning
  up spills will be properly trained and issued PPE
• Contaminated waste placed in labeled sealed
  containers

150
Medical Surveillance

• Institute medical surveillance programs for all
  employees exposed to formaldehyde at
  concentrations at or exceeding the Action Level
  or exceeding the STEL
• Medical disease questionnaires
• Medical examinations
• All medical procedures will be performed by or
  directly supervised by a licensed physician

151
Hazard Communication

• Formaldehyde gas, all mixtures or solutions
  composed of greater then 0.1 percent
  formaldehyde, and materials capable of releasing
  formaldehyde into the air at concentrations
  reaching or exceeding 0.1 ppm shall be considered
  a health hazard
• Employer shall comply with requirements of 29 CFR
  1910.1200 (Hazard Communication)

152
Employee Information and Training

• Employees assigned to workplaces where there is a
  formaldehyde health hazard
• Training at the time of initial assignment and
  whenever a new hazard from formaldehyde is
  introduced
• Information and training will be provided at
  least annually for employees exposed at or above
  the action level or STEL

153
Employee Information and Training (Cont'd)

• Affected employees will be informed of the
  location of written training materials and at
  their request, will be provided with this
  materials at no cost
• Information and training will be provided at
  least annually for employees exposed to
  formaldehyde concentration at or above the action
  level or STEL

154
Recordkeeping

• The employer will establish and maintain an
  accurate records of the following
• All measurements taken to monitor employee
  exposure to formaldehyde
• If no exposure monitoring is performed, the data
  used to determine that monitoring is not required
• Medical surveillance information
• Respirator fit testing information

155
Recordkeeping

• Exposure records and determinations for at least
  30 years
• Medical records for the duration of employment
  plus 30 years
• Respiratory fit test records until replaced by a
  more recent record

156
Ethylene Oxide29 CFR 1910.1047

• Sterilant
• Used primarily in larger hospitals
• Carcinogen
• Flammable and reactive

157
Ethylene Oxide

• ACGIH classified as A2-human carcinogen
• OSHA exposure limits
• 1 ppm as an 8-hour time weighted average
• 5 ppm as averaged over any 15-minute sampling
  period - STEL
• 0.5 ppm as an 8-hour time weighted average
  Action Level

158
Central Processing
159
Ethylene Oxide

• Control methods to reduce exposures
• Proper work practices
• Wait at least 15 minutes after cycle is done with
  door cracked for chamber to aerate
• Pull load with cart instead of pushing
• Dont carry newly sterilized equipment

160
Ethylene Oxide (EtO)

• Controls
• Routine personnel sampling
• Continuous area monitoring
• Room under negative pressure
• Emergency procedures in place
• Proper maintenance of equipment
• Exhaust
• Alarms
• Appropriate PPE

161
EtO Health Concerns

• Acute exposures
• Respiratory irritation/lung injury
• Headache, vomiting, cyanosis
• Chronic exposures
• Cancer
• Reproductive effects, neurotoxicity
• Sensitization

162
Other EtO Program Requirements

• Recordkeeping
• Air sampling
• Medical exams
• Equipment maintenance
• Medical Surveillance
• Similar as described in formaldehyde

163
Glutaraldehyde

• Uses in healthcare
• Cold sterilant
• Tissue fixative
• Curing agent

164
Soaking Station
165
Soaking Tray

166
Health Effects

• Throat and lung irritation
• Asthma, asthma-like symptoms
• Nose irritation, sneezing and wheezing
• Burning eyes
• Rash
• Brown or tan staining of hands
• Headaches

167
Exposures

• Pouring solution into or out of pans
• Removing sterilized equipment from pans
• Mixing activation of solutions
• Tissue fixation in histology
• Development of x-rays
• Cleaning of histology/pathology lab tables tops

168
Controls

• Local exhaust ventilation (100 fpm)
• General room ventilation (10 ac/h)
• PPE
• Good work practices
• Cover sterilization pans
• Wash hands after use
• Use only the amount needed

169
Exposure Standards

• No current 8 hour TWA
• Ceiling limit of 0.2 ppm by NIOSH
• Ceiling limit of 0.05 ppm by ACGIH
• No current OSHA PEL
• 5(a)(1) General duty clause applies

170
Pharmacy
171
Chemotherapy drugs

• Potential adverse effects to handler
• Mutagenic
• Carcinogenic
• Teratogenic
• Special preparation hoods and PPE are needed

172
X-Ray
173
X-Ray

• Texas Department of Health monitors radiation for
  Texas facilities. (Title 25 Texas Administrative
  Code)
• Requires exposures to be As Low As Reasonably
  Achievable (ALARA)

174
Questions?
175
Resources on CD

• Back Safety
• Emergency Response
• Cardiac Arrest
• Recordkeeping
• Ergonomics
• Workplace Violence
• Medical Screening and Access to Records
• Bloodborne Pathogens

176
Thank You for your attendance!