Ask Susan Wilburn about the occupational safety and health issues facing healthcare workers and she tells you to keep in mind one thing: "People don"t consider hospitals and other healthcare settings to be dangerous, and they are."
As Wilburn, the occupational safety and health specialist for the American Nurses Association points out, most people think of hospitals as places where you go to get well. Few consider them to be workplaces where employees routinely face dangers that, if different in nature from construction workers or steelworkers, are potentially no less deadly.
Estimates are that approximately 800,000 to 1 million needlestick injuries occur each year among the nation"s 9 million healthcare workers, exposing them to potentially deadly bloodborne infectious diseases. Surveys indicate that one-third of needlestick injuries are not reported.
"Of the 1 million workers who are stuck every year, 1,000 will contract serious diseases such as hepatitis B and C and HIV, and 100 workers will actually die... from needlesticks," said Andrew Stern, president of the Service Employees International Union (SEIU).
In 1997, more than 650,000 injuries and illnesses were reported in the healthcare sector. Many of these injuries were musculoskeletal in nature, resulting from handling patients. Wilburn cites estimates that as many as 30 percent of all nurses have back pain that limits their ability to work.
Healthcare workers also face a variety of other hazards, including latex allergy, tuberculosis, lasers, radiation, toxic chemicals, slips and falls, workplace violence and job stress.
Some critics fault OSHA for being slow to address healthcare hazards. Bill Borwegen, SEIU director of safety and health, complains that OSHA continues to focus enforcement on manufacturing and construction at the expense of the much larger service sector. He charges that OSHA fails to vigorously address healthcare safety, in part, because "they don"t know what they are doing when they go into a healthcare facility." He also
says agency officials have a mindset that, because healthcare employs large numbers of women, it cannot be as dangerous as male-dominated industries.
Melody Sands, OSHA director of health compliance assistance, said the agency is aware that healthcare "is a larger part of our responsibility now." She noted that OSHA over the last decade has mounted a series
of enforcement and regulatory initiatives in the industry, including a national emphasis program on bloodborne pathogens and the release of guidelines for the prevention of transmission of tuberculosis. The agency has also targeted the nursing home industry with training and consultation efforts and increased inspections.
Over the past two years, federal and state OSHA inspectors have conducted 3,404 inspections in healthcare facilities, including 1,038 in hospitals. In FY 1998, federal OSHA inspectors conducted 149 inspections in hospitals. Wanda Bissell, an industrial hygienist at OSHA"s national office, pointed out that, while this number may appear modest, most OSHA inspections are complaint-driven and complaints by healthcare workers "seem to have slowed down" from when OSHA"s bloodborne pathogen standard was issued in 1991.
OSHA"s slow pace in promulgating standards also worries job safety advocates. For example, when strains of multidrug-resistant tuberculosis began to appear in the late 1980s, unions called for a standard that would mandate infection control procedures. In January 1994, then-Labor Secretary Robert Reich said that OSHA would "expedite" a tuberculosis rulemaking. Agency officials initially promised a tuberculosis proposal that fall, but the agency was not able to issue a proposal until October 1997. OSHA sources now say the final standard, expected to save 130 lives annually, will not be issued until late this year or early 2000. Asked what was holding up the standard, an agency spokesman said OSHA simply needed more time to review the record and prepare the standard"s preamble.
"It just boggles the mind that it could take this long to get a TB rule out," said SEIU"s Borwegen. He said the agency"s standards-setting staff is simply not large enough to move rules more expeditiously. "We"ve given up, to a large degree, on OSHA," he said.
By far, said T.L. Bragg, a nurse and safety consultant for Wausau Insurance Co., the biggest loss driver that his firm sees in healthcare is musculoskeletal injuries associated with patient handling, followed by injuries related to material handling.
Healthcare safety advocates, such as ANA"s Wilburn, said the reason so many musculoskeletal injuries occur is that "the amount of lifting that healthcare workers are required to do is not physically possible." She noted that the NIOSH lifting equation indicates the average person can lift about 55 pounds safely. A box that weight, she pointed out, is "stable, doesn"t shift, doesn"t pass out, doesn"t suddenly decide to be uncooperative." In a hospital, she said, there are no adult patients "within that safe range."
For the most part, hospitals, nursing homes and other healthcare employers have dealt with back injuries by offering employees training on body mechanics and proper lifting techniques. But Bragg said the problem is not that healthcare workers don"t know how to lift properly, but that these techniques are often not applied because employees are overworked and dealing with unpredictable hazards. Instead, he said the answer is a "zero-lift policy, which means patient handling devices."
Mechanical lifts and other devices that move patients, such as from their beds to wheelchairs, have been on the market for many years. Guy Fragala, Ph.D., director of environmental health and safety for the University of Massachusetts Medical Center, noted that new, improved devices give safety directors more options for both employee and patient safety.
"We can begin by looking at aspects of the bed in long-term care," Fragala explained. "Do we have height-adjustable beds that will allow people easier egress in and out, depending on their levels of dependence? Can we design ambulatory assists where somebody can grasp on to something and, using his own strength, pull himself out of bed to maintain independence for longer periods?"
In a recent study, Fragala and associates looked at how to get residents in long-term care facilities between their beds and chairs more safely. They employed a chair that folds out into a stretcher. They also introduced a fabric transfer aid with low friction and handles that reduced the horizontal reach involved in sliding the patient from the chair to the bed. Workers not only reported less exertion, said Fragala, but "residents felt much more comfortable and secure with this new method of transfer."
While back injuries and other musculoskeletal problems are costly, high workers" compensation bills may do little to stimulate employers to make changes in the work environment. Experts say hospitals often assign costs to a central workers" comp pool, rather than charge back injury costs to the departments where they occur. "It is not reflected on the department where the injury occurred, so there is no incentive to that department to invest in a safer device to protect the nurse," said Wilburn. Conversely, that same department may be unlikely to offer a light-duty assignment to an injured worker because it is paying a full-time salary, but not getting a worker at full capacity.
Ellen Dayton, a nurse practitioner at San Francisco General Hospital, was moonlighting at a local substance abuse clinic in 1996 when she accidentally stuck herself with a hypodermic needle. While the hospital had begun to use safety needles (needles with protective shields or a mechanism that automatically retracts the needle into the barrel after use) several years earlier, the clinic was using less-expensive traditional needles.
"She reported promptly, she started on medications, but she became so ill she nearly died," recalled Lorraine Thiebaud, RN, a coworker and activist for safety needle legislation. Dayton contracted both hepatitis C and AIDs from the needlestick. "In the last two years, our friend Ellen Dayton has been too sick to work," said Thiebaud. "She has lost over 60 percent of her hearing from the experimental drugs that were used to save her life for now, and her partner, a doctor, had to drop out of a residency program to help care for her."
Cases such as Dayton"s have prompted the Service Employees International Union (SEIU) and other groups to fight for passage of legislation that requires the use of safety needles in all healthcare facilities. Their first major victory came in California, where a new law, AB 1208, requires the use of safety needles by July 1. Under the emergency standard promulgated by the California Occupational Safety and Health Standards Board, employers must keep a log of sharps injuries and develop a procedure for determining the "frequency of use of the types and brands of sharps involved in the exposure incidents documented" in the log. They must also establish an "effective procedure for identifying currently available engineering controls, and selecting such controls, where appropriate, for the procedures performed by employees...."
SEIU officials say that law should be extended nationwide. "Except in cases where the old needles are medically necessary, the manufacturers must stop producing needles that kill. Hospitals must stop buying them. And the government must ban them," said SEIU Secretary-Treasurer Betty Bednarczyk. SEIU expects to campaign in 19 states for needlestick laws and will seek national legislation, as well.
Activists had hoped that OSHA or the Food and Drug Administration would ban conventional needles. Under OSHA"s bloodborne pathogen standard, employers are required to evaluate the effectiveness of safety needle devices at their facilities. However, OSHA officials say it is difficult for them to enforce this provision of the standard because it is written in performance-oriented language. OSHA is currently considering changes to the compliance directive for bloodborne pathogens that would strengthen the enforcement of this provision.
While safety needles are up to three times as expensive as conventional needles, safety experts say they could prevent 75 percent of the current needlestick incidents. Wilburn noted that one hospital she contacted is spending an average of $4,000 on postexposure prophylaxsis for needlesticks. That money, she said, would better be spent on preventive engineering controls. "The purchasers who look at a device that is more expensive and won"t buy it are not counting the savings of preventing needlesticks," she said.
While infectious diseases such as hepatitis and AIDS have received much of the attention, another "emerging disease" is striking the healthcare community: latex allergy. Since the advent of "universal precautions" to protect healthcare workers from AIDS and other bloodborne pathogens, latex gloves have been used to protect workers from contact with bodily fluids. Latex gloves offer dependable and inexpensive protection. Large institutions may use millions of pairs of latex gloves in a year.
Some 8 to 12 percent of health care workers, however, react positively to blood tests for latex allergy. A smaller set of workers show allergic reaction symptoms, such as hives or asthma, in the presence of latex proteins. For a small number of individuals, exposure to latex can be fatal.
In 1997, NIOSH issued an alert recommending ways to reduce worker exposure to latex. Dr. Boris Lushniak, a dermatologist with NIOSH, noted that many questions remain concerning latex allergy. For example, not everybody with a positive blood test for latex allergy develops symptoms and some individuals "who are symptomatic, who seem by history and clinical examination to have latex allergy, don"t have positive blood tests," he said.
Factors such as a history of allergies, asthma or skin rashes seem to indicate a higher risk to develop latex allergy. People with multiple surgical procedures also seem to be at higher risk. Genetic disposition may also play a role. Lushniak pointed out that all these factors need further study.
NIOSH is also looking at routes of exposure. Do latex allergies result from breathing in latex proteins or from skin penetration? "A lot of people who develop latex allergy initially have dermatitis of the skin, either because of glove use or because of the harsh detergents or soaps that they utilize in cleaning their skin," he noted.
NIOSH has recommended that healthcare facilities switch to reduced-protein, powder-free latex gloves where they are used. That is because small amounts of the powder used to make gloves easier to put on and more comfortable is released into the air when employees don them. Latex proteins attach to the powder. These proteins, explained Lushniak, could then be breathed in by people who are allergic or who are genetically predisposed to being sensitized to latex.
"Non latex products, synthetic products that have no proteins, are ideal, but latex is still the best known barrier out there to a lot of biohazards, as well as some chemical and physical hazards," said Logan Boss, director of marketing for glove manufacturer Marigold Industrial, Norcross, Ga. "Given that, you want to have the lowest protein levels possible in your products, and that is what we are trying to do."
Dealing with the Basics
While some safety issues facing healthcare are unique to the industry, many are familiar to general industry. Lisa Wheeler, president of Occupational Technology in Livermore, Calif., a consulting firm that works primarily with rural hospitals and nursing homes, said one of the biggest safety concerns in these facilities is getting senior management to make department managers accountable for safety performance.
Another widespread problem is the development of written safety programs. "Many of the smaller rural hospitals and nursing homes have taken template programs or programs from other facilities. They haven"t customized it to meet their own unique needs." As a result, she said, facilities may fail to, for example, evaluate the risks of fluids contaminated with bloodborne pathogens splashing on employees. "Instead of giving employees the option for full faceshield or goggles, they may have just one type of glasses available," she explained.
Most observers believe there is greater, if uneven, recognition in the healthcare industry in recent years that it faces serious safety and health issues. These experts say, however, that economic changes in the industry have mitigated against more aggressive actions by employers.
"With the downsizing and restructuring that has gone on in the last 10 years in the workplace, essentially what we have is a speedup of the work," said ANA"s Wilburn. "The patients who remain are sicker than they used to be. They are going home sooner, so the intensity of the care that they are given is higher. We have also downsized by 10 to 15 percent, so we"ve got fewer nurses taking care of more patients. It"s just like speeding up an assembly line, so there is a greater risk of injury and illness."
Safety experts say a number of potential actions by OSHA, including more healthcare inspections, development of an ergonomics standard and a tuberculosis standard, as well as changes in enforcement policy to require the use of safety needles would help focus this mammoth industry on worker safety issues. But as ANA"s Wilburn lamented, "Everything at OSHA takes much longer than I have patience for."