BEYOND BLOODBORNE PATHOGENS: OSHA REGULATIONS IN HEALTHCARE

BEYOND BLOODBORNE PATHOGENS: OSHA REGULATIONS IN HEALTHCARE Roberta Smith, RN, MSPH, CIC, CIH Occupational Health Program Manager Colorado Department of Public Health and Environment

LEARNING OBJECTIVES Understand federal guidelines that pertain to healthcare facilities beyond the bloodborne pathogen standard. Learn to build an effective internal auditing tool to ensure continued compliance with federal standards. Identify how to effectively engage infection control, safety and occupational health programs to participate in the goal of protecting healthcare workers.

HEALTHCARE BY THE NUMBERS Healthcare occupations and industries are expected to have the fastest employment growth and to add the most jobs between 2014 and 2024.(BLS, 2015) Healthcare occupations had employment of 12 million in May 2015, representing nearly 9% of total national employment. (BLS, 2015)

SOURCE: OSHA: FACTS ABOUT HOSPITAL WORKER SAFETY, SEPTEMBER 2013.

OSHA AND HEALTHCARE- TOP CITATIONS Standard Citations Description 1910.1030 46 Bloodborne pathogens 1910.1200 16 Hazard Communication 1910.146 14 Permit-required confined spaces 1910.303 14 General requirements 1910.305 14 Wiring methods, components, and equipment for general use. 1910.134 13 Respiratory Protection 1904.39 12 Recording and Reporting Occupational Injuries and Illness 1904.29 9 Recordkeeping Forms and Recording Criteria 1910.132 9 PPE- General Requirements 1910.147 8 Control of Hazardous Energy 1910.1048 8 Formaldehyde Source: OSHA. NAICS Code:622 Hospitals for period 10/2014-09/2015.

OSHA IN HEALTHCARE May 6, 2010, Federal Register, OSHA 2010- RFI to collect information from the healthcare industry on Occupational exposure to infectious agents in settings where healthcare is provided. March 2013- Letters to 9,413 workplaces experiencing high rates of days away, restricted or transferred (DART) injuries and illnesses- told to develop better safety and health plans. 2012 nursing home national emphasis plan- 3 year ergonomic hazards related to patient handling, BBP &TB exposures, slips, trips and falls. Regional Emphasis Program implemented by Region 4 focusing on BBPs and sharps/needlestick injuries at ASCs, emergency are clinics and primary care medical clinics. March25, 2011- Sept. 30, 2012. Source: Harris S.; Safety Culture in Healthcare: the $13 Billion Case. Professional Safety October 2013 ASSE

OSHA IN HEALTHCARE June 25, 2015- OSHA memo establishing guidance for inspections conducted in inpatient healthcare settings (NAICS) major groups 622 and 623. Indicated all such inspections, programmed and unprogrammed, will cover the focus hazards included in the National Emphasis Program (NEP). Musculoskeletal disorders (MSDs) relating to patient or resident handling, Workplace violence (WPV), Bloodborne pathogens (BBP), Tuberculosis (TB), and Slips, trips and falls (STFs). Source: https://www.osha.gov/dep/enforcement/inpatient_insp_06252015.html

OSHA IN HEALTHCARE These focus hazards will be addressed in addition to other hazards that may be the subject of the inspection or brought to the attention of the compliance officer during the inspection. The goal of this policy is to significantly reduce overexposures to these hazards through a combination of enforcement, compliance assistance, and outreach.. Other hazards that may be addressed: Exposure to multi-drug resistant organisms (MDROs), such as Methicillin-resistant Staphylococcus aureus (MRSA). Exposures to hazardous chemicals, such as sanitizers, disinfectants, anesthetic gases, and hazardous drugs. Source: https://www.osha.gov/dep/enforcement/inpatient_insp_06252015.html

OSHA STANDARDS Beyond Bloodborne Pathogens

BEYOND THE BBP STANDARD OSHA Requirements that Apply to Many Health Care Employers*: 29 CFR 1910.1200 29 CFR 1910.146 29 CFR 1910.132 29 CFR 1910.134 29 CFR 1910. 1048 29 CFR 1910.95 29 CFR 1910. 1096 Hazard Communication Confined Spaces General Requirements (PPE) Respiratory Protection Formaldehyde Occupational Noise Exposure Ionizing Radiation * By no means a comprehensive listing. For more information visit: https://www.osha.gov/dcsp/compliance_assistance/quickstarts/health_care/hc_step1.ht ml

29 CFR 1910.1200: HAZARD COMMUNICATION STANDARD Standard: Designed to ensure that employers and employees know about hazardous chemicals in the workplace and how to protect themselves. What needs to be done: Prepare and implement a written Hazard Communication Program and comply with other requirements of the standard. Job roles that might be affected: Laboratory workers Janitorial Services Facilities Maintenance CNAs, Nurses, Techs, PT (anyone using cleaning products). Pharmacy Staff

29 CFR 1910.1200: HAZARD COMMUNICATION STANDARD Steps to an effective program: Prepare and Implement a Written Hazard Communication Plan. Responsibilities Location of SDS Requirement to have a master chemical list and SDS for on every product in the facility Explanation on how to read a SDS Requirements for proper labeling of all containers with both the name of the material and the hazard warning Training and frequency How non-routine tasks will be addressed Contractors

29 CFR 1910.1200: HAZARD COMMUNICATION STANDARD Maintain Safety Data Sheets Maintain safety data sheets for each hazardous chemical in the workplace. Ensure that safety data sheets are readily accessible to employees. Ensure Containers are Labeled If a chemical is transferred to a secondary container it must be labeled with the original SDS information. Exception= immediate use. Inform and Train Employees Train employees on the hazardous chemicals in their work area before initial assignment, and when new hazards are introduced. Include the requirements of the standard, hazards of chemicals, appropriate protective measures, and where and how to obtain additional information. Evaluate and Reassess Your Program Review your hazard communication program periodically to make sure that it is still working and meeting objectives. Revise your program as appropriate to address changed conditions in the workplace.

29 CFR 1910.146- CONFINED SPACES Standard: Employers must evaluate their workplaces to determine if spaces are permit spaces. If a workplace contains permit spaces, the employer must inform exposed employees of their existence. Location and the hazards they pose. What needs to be done: A written confined space plan, including: Recognizing and marking all confined spaces on site; Procedures to test and monitor the air inside confined spaces before and during all employee entries; Procedures to prevent unauthorized entries and to have an attendant outside the space at all times; Effective controls of all existing atmospheric or safety hazards inside the confined space; Employee and supervisor training on safe work procedures, hazard controls, and rescue procedures; Effective rescue procedures which are immediately available on site.

29 CFR 1910. 146- CONFINED SPACES Job Roles that Might be Affected: Laundry Facilities Staff Food Service What is a confined space? Is large enough for an employee to enter fully and perform assigned work; Is not designed for continuous occupancy by the employee; and Has a limited or restricted means of entry or exit. What is a permit-required confined space? Contains or has the potential to contain a hazardous atmosphere; Contains a material with the potential to engulf someone who enters the space; Has an internal configuration that might cause an entrant to be trapped or asphyxiated by inwardly converging walls or by a floor that slopes downward and tapers to a smaller cross section; and/or Contains any other recognized serious safety or health hazards.

29 CFR 1910. 146- CONFINED SPACES Potential Confined Spaces in Healthcare Utility tunnels Crematory incinerators Water tanks Boilers Cooling towers Crawl Spaces Sump pits Elevator pits Clothes washers/ dryers July 2011: One worker at a commercial laundry died of traumatic asphyxia when he was unloading a large horizontal washer and was pulled into the space and crushed when the washer was inadvertently activated while the worker reached in to unload the machine. California Department of Industrial Relations

29 CFR 1910 SUBPART I/ 1910.132(A) GENERAL REQUIREMENTS Summary: The employer shall assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of PPE. What needs to be done: Select, and have each affected employee use, the types of PPE that will protect the affected employee from the hazards identifies in the hazard assessment. Communicate selection decisions to each affected employee. Select PPE that properly fits each affected employees. Verify that the required workplace hazard assessment has been performed through a written certification that identifies: o o o The workplace evaluated The person certifying that the evaluation has been performed Dates of the hazard assessments

29 CFR 1910 SUBPART I/ 1910.132(A) GENERAL REQUIREMENTS What needs to be done (continued) Training o When PPE is necessary o What PPE is necessary o How to properly don, doff, adjust, and wear PPE o The limitations of PPE o Useful life and proper care, maintenance, and disposal of PPE (how to identify defects)

29 CFR 1910 SUBPART I/ 1910.132(A) GENERAL REQUIREMENTS Job Roles Affected: Direct patient staff - Food Service Pharmacy staff Facilities EVS Techs Potential Hazards in Healthcare- PPE Beyond Infectious Materials: Chemical hazards Radiological hazards Fall hazards Mechanical irritants Noise Respiratory hazards

29 CFR 1910 SUBPART I/ 1910.132(A) GENERAL REQUIREMENTS Protection from Head Injuries Head impact, penetration injuries, electrical injuries. Protection from Food and Leg Injuries Foot guards, safety shoes. Protection from Eye and Face Injuries Optical radiation, splashes, shields. Protection from Hearing Loss Earplugs and earmuffs Protection from Hand Injuries Skin absorption to harmful substances, cuts, lacerations, chemical burns, thermal burns Respiratory Protection Dusts, fogs, fumes, mists, gases, smokes, sprays, vapors.

29 CFR 1910.134- RESPIRATORY PROTECTION Summary: Requires employers to establish and maintain an effective respiratory protection program when employees must wear respirators to protect against workplace hazards What must be done: Written Program- Should include the following o Procedures for selecting respiratory for use in the workplace o Medical evaluations of employees required to use respirators o Fit testing procedures

29 CFR 1910.134- RESPIRATORY PROTECTION What must be done (continued) o Procedures for proper use of respirators in routing and reasonably foreseeable emergency situations o Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding and otherwise maintaining o Training of employees in the proper use of respirators, including putting on and removing them o Procedures for regularly evaluating the effectiveness of the program

Source: https://www.cdc.gov/niosh/npptl/usernotices/

29 CFR 1910.134- RESPIRATORY PROTECTION Job Roles Affected: Direct patient care staff Respiratory Therapy Facilities Maintenance Pharmacy Laboratory- Pathology Other issues to consider: TB program Fit Testing: Qualitative/ Quantitative Medical Evaluation- Must use Appendix C Voluntary Use Provisions- Appendix D

29 CFR 1910.1048: FORMALDEHYDE Summary: Protects workers exposed to formaldehyde. Formalin is typically 37% formaldehyde by weight and 6-13% methanol by volume in water. The formaldehyde component provides the disinfectant effects of formalin. What needs to be done: Identify all workers who may be exposed to formaldehyde at or above the action level (0.75 ppm) or STEL (2ppm) through initial monitoring and determine their exposure. Implement feasible engineering and work practice controls to reduce and maintain worker exposure to formaldehyde at or below the 8 hour TWA and the STEL. (PPE if not possible).

29 CFR 1910.1048: FORMALDEHYDE What needs to be done (continued): Labeling of mixtures and solutions >0.1 percent formaldehyde- Potential cancer hazard Training of employees PPE evaluation Provide showers and eyewash stations Medical surveillance for those exposed over TWA or STEL

29 CFR 1910.1048: FORMALDEHYDE Job Roles Affected: Laboratory Pathology Morgue

29 CFR 1910. 95- OCCUPATIONAL NOISE EXPOSURE STANDARD Summary: Requires an effective hearing conservation program which includes specific requirements for monitoring noise exposure, audiometric testing, audiogram evaluation, hearing protection, and recordkeeping and training. What needs to be done: Engineering Controls Administrative controls Implement an effective hearing conservation program whenever worker noise exposure is equal or greater than 85 dba for an 8 hour exposure. PPE Training

29 CFR 1910. 95- OCCUPATIONAL NOISE EXPOSURE STANDARD Job Roles Affected: Laundry Helipad Facilities (generator/ mechanical rooms) Landscapers

29 CFR 1910. 95- OCCUPATIONAL NOISE EXPOSURE STANDARD Elements of an effective hearing conservation program: Workplace noise sampling. Informing workers at risk from hazardous levels of noise exposure of the results of their noise monitoring. Providing affected workers or their authorized representatives with an opportunity to observe any noise measurements conducted. Maintaining a worker audiometric testing program.

29 CFR 1910. 95- OCCUPATIONAL NOISE EXPOSURE STANDARD (CONTINUED) Implementing comprehensive hearing protection follow-up. procedures for workers who show a loss of hearing. Evaluation of hearing protection. Training. Data management.

29 CFR 1910. 95- OCCUPATIONAL NOISE EXPOSURE STANDARD Possible solutions: Reduce the amount of sound energy released by the noise source. Divert the flow of sound energy away from the worker. Protect the receiver from the sound energy reaching him/her. Proper maintenance of equipment, equipment replacements. Revised operating procedures, equipment redesign, enclosures. Acoustical shields and barriers. PPE.

29 CFR 1910.1096- IONIZING RADIATION Summary: This standard applies to facilities that have an x- ray machine. It requires affected employers to conduct a survey of the types of radiation used in the facility, including x-rays, to designate restricted areas to limit employee exposure, and to require employees working in designated areas to wear personal radiation monitors. In addition, radiation areas and equipment must be labeled and equipped with caution signs.

29 CFR 1910.1096- IONIZING RADIATION What need to be done: Assess exposures to Ionizing Radiation Warning signs PPE assessment Badge monitoring results recordkeeping. Assign a radiation safety officer Job roles that might be affected: Radiology Dentistry Facilities workers Laboratory

USING AUDITS TO HELP DRIVE COMPLIANCE

BUILDING A SUCCESSFUL AUDIT PROGRAM ISO 19011: Guidelines for auditing management systems. Establishing roles & responsibilities Selecting people to conduct the audit Planning and scheduling audits to meet set objectives Communicating audit results Maintaining audit and audit program documentation.

ARE YOUR PROGRAMS WORKING? Periodic auditing of your Occupational Health programs can help to identify gaps or new hazards. Scheduled vs. Unscheduled visits. Observe, ask questions, review practices. Not just a hunt for non-conformities- what is working well too! OSHA Hazard Identification Training Toolinteractive online game to identify hazards- train staff conducting internal audits. Using RCA to drive auditing.

TOOLS FOR AUDITING Pre-audit checklists Excel Spreadsheets Compliance checklists Safety auditing apps (build your own or prepopulated and hazards selected)

OSHA AND HEALTHCARE- TOP CITATIONS Standard Citations Description 1910.1030 46 Bloodborne pathogens 1910.1200 16 Hazard Communication 1910.146 14 Permit-required confined spaces 1910.303 14 General requirements 1910.305 14 Wiring methods, components, and equipment for general use. 1910.134 13 Respiratory Protection 1904.39 12 Recording and Reporting Occupational Injuries and Illness 1904.29 9 Recordkeeping Forms and Recording Criteria 1910.132 9 PPE- General Requirements 1910.147 8 Control of Hazardous Energy 1910.1048 8 Formaldehyde Source: OSHA. NAICS Code:622 Hospitals for period 10/2014-09/2015.

HAZARD COMMUNICATION: AUDIT EXAMPLE QUESTIONS Are SDS sheets available and maintained? Are all chemicals in the facility properly labeled with both the name of the material and the appropriate hazard warnings? This includes materials transferred to secondary containers.

CONFINED SPACE: EXAMPLE AUDIT QUESTIONS Is there a PRCS written program? Is an annual review performed and modifications made as necessary? Are there warning signs posted at each PRCS? Is training provided so that all employees whose work is regulated by this section acquire the understanding, knowledge, and skills necessary for the safe performance of the duties assigned under this section? Is a rescue and emergency service response process with adequately trained res cue personnel in place?

PPE: EXAMPLE AUDIT QUESTIONS Has an assessment been conducted to determine if hazards are present, or are likely to be present, which necessitate the use of PPE? Has PPE training been conducted? Is PPE properly maintained in a sanitary and reliable condition, inspected, and stored? Has appropriate hand protection been selected and required when employees hands are exposed to hazards such as those from skin absorption or harmful substances?

If employees voluntarily wear respirators have they been provided with Appendix D of the standard? RESPIRATORY PROTECTION: EXAMPLE AUDIT QUESTIONS Has a written respiratory protection program been developed an implemented? Have employees using respirators been medically evaluated and fit tested? Has respiratory protection training been conducted for employees who are required to use respirators?

HEARING CONSERVATION: EXAMPLE AUDIT QUESTIONS Has a noise exposure assessment been completed using personal dosimetry? Has an effective hearing conservation program been implemented whenever an employee s exposure equals or exceeds an 8-hour TWA of 85dBA? Has an audiometric testing program been established and maintained for all employees whose exposures equal or exceed and 8-hour TWA of 85dBA? Are hearing protectors available to all employees exposed to an 8-hr TWA of 85dBA or greater?

Does the facility maintain records of the radiation exposure of all employees for whom personnel monitoring is required, and advise all employees of their individual exposure on at least an annual basis? IONIZING RADIATION: EXAMPLE AUDIT QUESTIONS Are appropriate personnel monitoring equipment, such as film badges, pocket chambers, pocket dosimeters, or film rings, supplied and being used? Is each radiation area conspicuously posted with a sign or signs bearing the radiation caution symbol and the following words: Caution Radiation Area.

COLLABORATION TO CREATE A SAFETY CULTURE

COLLABORATION Safety Infection Prevention Occupational Health

HAZARD COMMUNICATION: COLLABORATION EXAMPLE Safety HVAC PPE Infection Prevention Disinfectants being used Chemical Sensitivity Occupational Health

COLLABORATION Audits can be done as a team- assists in identifying gaps. Other types of assessments being done. Crossover with different programs- helps to ensure feedback from stakeholders. Other departments (Laser Safety Officer, Radiation Safety Officer) have overlap as well.

REFERENCES Bureau of Labor Statistics- Employment projections 2014-24 Summary. http://www.bls.gov/news.release/ecopro.nr0.htm Bureau of Labor Statistics- Occupational Employment and Wages- May 2015 http://www.bls.gov/news.release/pdf/ocwage.pdf Harris S.; Safety Culture in Healthcare: the $13 Billion Case. Professional Safety October 2013 ASSE OSHA: Facts About Hospital Worker Safety. September 2013. https://www.osha.gov/dsg/hospitals/documents/1.2_factbook_508.pdf Respiratory Protection Toolkit: https://www.osha.gov/publications/osha3767.pdf OSHA Fact Sheet : Steps to an Effective Hazard Communication Program for Employers that use Hazardous Chemicals https://www.osha.gov/publications/osha3696.pdf OSHA Fact Sheet: Formaldehyde: https://www.osha.gov/oshdoc/data_general_facts/formaldehydefactsheet.pdf OSHA Hearing Conservation: https://www.osha.gov/sltc/noisehearingconservation/index.html OSHA Hazard Identification Training Tool: https://www.osha.gov/hazfinder/