#31234: OSHA and Healthcare Facilities

Death and disability due to unsafe or unhealthy workplaces remain ongoing issues in the United States. In 2021, there were 2.6 million job-related nonfatal injuries and illnesses in the private sector alone [1]. The U.S. Bureau of Labor Statistics reported a total of 4,764 employee deaths in 2021, slightly down from the number of fatal injuries reported in 2017. This figure may not include the deaths of workers due to occupationally acquired diseases [2]. The continuous efforts of the Occupational Safety and Health Administration (OSHA) to promote employee safety are part of what makes it such an important regulatory entity.

At one time OSHA compliance was considered an issue important and applicable to industry only. Healthcare facilities did not normally use heavy equipment or have issues regarding noise levels and high-level chemical spills and, therefore, felt safe. Smaller facilities may have felt protected from inspection because of the number of surveys required.

However, bloodborne pathogen compliance, waste management, tuberculosis control, and ergonomics regulations have increased awareness among healthcare facilities about the impact of OSHA. Entities such as OSHA, Medicare, and the Joint Commission now cooperate and review OSHA regulatory issues when conducting surveys.

In 1970, Congress established OSHA as part of the Occupational Safety and Health Act (i.e., the OSH Act). The Act was signed by President Nixon on December 29, 1970, and became effective on April 28, 1971. OSHA has defined its mission as assuring that working men and women are provided with safe, healthful working conditions. The agency fulfills its mission by applying and enforcing standards developed under the Act. It also provides information, education, training, and assistance to employers so they can maintain safe and healthful workplaces [3].

The OSH Act established three permanent federal agencies: OSHA, within the Department of Labor; the Occupational Safety and Health Review Commission (OSHRC); and the National Institute for Occupational Safety and Health (NIOSH), within the Department of Health and Human Services. The OSH Act covers most private sector employers and their workers, in addition to some public sector employers and workers. Its reach includes all 50 states and certain territories and jurisdictions under federal authority [3].

The duties of OSHA include writing standards, inspecting workplaces for compliance with standards, and prosecuting violations. The OSHRC is responsible for resolving disputes between OSHA and violators of the OSH Act (usually employers). NIOSH conducts research on occupational hazards and makes recommendations for standards (e.g., N95 respirators to be used when caring for tuberculosis patients) [4,5].

Workplace inspection is the responsibility of the Secretary of Labor and may result either from an employee complaint or from a problem identified during a previous inspection. An OSHA inspector may either order compliance with a regulation or issue a penalty, such as a fine. There is only one criminal penalty available under the Act, and this is applied if a worker dies from an employer's willful violation [6].

As mentioned, the healthcare industry had not previously considered OSHA regulations as affecting it. After all, hospitals did not use large machinery, assembly lines, or equipment that would put employees at risk for major injuries. However, research has identified a wide range of biologic, physical, psychosocial, and chemical hazards in the healthcare work environment [7,8].

With the introduction of the human immunodeficiency virus (HIV) and a new focus on bloodborne pathogens, hospitals and other healthcare facilities were faced with the implementation of OSHA standards that would potentially cost both time and money. Many healthcare industries and organizations did not believe that the federal government should be quite so prescriptive and felt that some of the regulatory requirements for general industry might not be appropriate in a healthcare setting. To ensure that regulatory requirements are appropriate for healthcare settings, organizations such as the Association for Practitioners in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC) work together with OSHA to develop standards.

In 1989, OSHA published a proposed rule regarding occupational exposure to bloodborne pathogens in hospitals and other healthcare settings. The proposed rule, based on the concept of Universal Precautions, raised concerns in the infection control community. The imbalance toward precautions that protected personnel and away from precautions that protected patients, the lack of proven efficacy of Universal Precautions, and the costs for implementing the proposed regulations were all concerns. After a series of public hearings by OSHA and a review of written comments, the proposed rule was modified and finalized in 1991. Although the final rule was expected to improve occupational safety during the care of patients infected with bloodborne pathogens, the impact on the cost of patient care and on nosocomial infection control remained undefined [9,10].

The OSHA Bloodborne Pathogens Standard brought OSHA visibility to healthcare settings and required education about the implementation of and compliance with OSHA regulations. OSHA has become one of the most important organizations in the fight against bloodborne pathogens as a result of its ability to set standards for the use of barrier precautions and enforce the use of such precautions for employee and patient safety.

OSHA continues to urge improved safety in all categories of the workplace. In October 2010, the Assistant Secretary of Labor for OSHA reported that the agency's priorities for the coming fiscal year were to return to basics, update workplace safety and health regulations, and impose fair and strong enforcement [11].

The purpose of the Bloodborne Pathogens Standard, which was published by OSHA in final form in 1991, is to limit occupational exposure to blood, bodily fluids, and other potentially infectious materials, because any exposure could result in bloodborne pathogen transmission. This standard applies to all reasonably anticipated occupational exposures to blood or other potentially infectious materials that may result from the performance of an employee's duties [12]. "Good Samaritan" acts, such as resuscitating a co-worker, might not be considered occupational exposure [13,14,15].

The Association of periOperative Nurses asserts that all healthcare personnel must follow the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard when there is a risk of exposure to blood or other potentially infectious materials.

(https://www.guidelinecentral.com/guideline/308628 Last Accessed: January 25, 2023)

Level of Evidence: Expert Opinion/Consensus Statement

The standard requires employers to implement an exposure control plan that mandates Universal Precautions (i.e., treating all body fluids as if they are potentially infectious). The standard also stresses hand hygiene, recommends the use of Personal Protective Equipment (PPE), sets forth processes to minimize needle sticks and blood splashing, ensures appropriate packaging of specimens, and regulates waste by employing biohazardous labeling before shipping [10,12].

Employers must require the use of, and provide at no cost, barrier items or PPE for employee protection. This includes gowns, masks, mouthpieces, goggles, resuscitation bags, and the proper gloves for the job being performed. Also included in the standard are methods for disposing of contaminated sharps and other regulated waste in OSHA-compliant containers [10].

Another aspect of the Bloodborne Pathogens Standard is the requirement that Hepatitis B vaccination be made available at no cost and within 10 working days of assignment to all employees who have occupational exposure to blood. Postexposure evaluation and follow-up must be made available to all employees who have had an exposure incident. Included in the evaluation and follow-up are laboratory testing, counseling, evaluation, and prophylaxis, if deemed necessary and if the employee consents [9,12].

Some of the most common bloodborne pathogens include hepatitis C, HIV, and hepatitis B [10].

The United States has been waging a war against tuberculosis (TB) for more than 150 years. After it was found that a multidrug regimen could effectively kill the Mycobacterium tuberculosis organism, the number of those infected decreased dramatically, and many sanitariums were closed. By 1980, prevention programs were ended, and pharmaceutical companies had stopped manufacturing streptomycin. By 1985, the number of new cases of TB had increased, and by the early 1990s, the development of multidrug-resistant TB caused the epidemic to begin anew [32]. Due to recent attention and increased vigilance, incidence rates for TB infection in the United States have begun to decline. In 2021, a total of 7,882 cases of TB were reported in the United States, a 12.4% decrease from 2019. It should be noted that a decrease in 2020 (incidence rate: 7,171 cases) followed by a slight increase in 2021 was observed, but the increase is most likely due to under-reporting, delayed healthcare access, and/or missed diagnosis in 2020 as a result of the COVID-19 pandemic. Overall, the incidence rate has remained relatively stable, at approximately 2.5 cases per 100,000 persons [33]. However, it has been estimated that up to 13 million persons in the United States have latent TB infection, with 5% to 10% at risk for future disease [34,35]. Furthermore, the increasing incidence of multidrug-resistant strains of the disease remains a problem.

Some of the increase in TB cases in the 1980s and 1990s could be partially attributed to immigration from developing countries, where routine immunization and treatment of communicable diseases was enforced less vigorously than in the United States. It could also be attributed partially to the susceptibility of immunocompromised patients, such as those with HIV. Substance abuse, homelessness, poverty, and a deterioration in public health infrastructures were other factors in the resurgence of TB [36].

This increase in TB prompted the CDC, in 1989, to issue a strategic action plan with the goal of decreasing the case rate of TB to less than 1 per million population by the year 2010. However, the plan was not fully implemented, and the number of TB cases increased. In 1993, the CDC outlined basic guidelines for TB control, including the recommendation that all facilities have a formalized plan for the control of TB [36,37,38].

Bacille Calmette-Guérin (BCG) is the vaccine for TB disease, although it is not commonly used in the United States. It is most often given to infants and children in countries where TB is common, and it should be considered for only select people in the United States. Healthcare workers may be considered as candidates for the BCG vaccine if they work in a setting in which a high percentage of patients are infected with TB strains that are resistant to both isoniazid and rifampin; there is ongoing transmission of drug-resistant TB strains to healthcare workers and infection is likely; or comprehensive TB infection-control precautions have been implemented but have not been successful [84].

In 2019, the CDC updated their guideline for the prevention of TB transmission in healthcare settings [64,72]. The updated guideline recommends baseline (preplacement) TB testing and screening for all U.S. healthcare personnel. Although routine follow-up screening is not recommended, healthcare facilities should aim to identify latent tuberculosis infection among personnel and to encourage treatment. Postexposure screening and testing should be conducted for any healthcare personnel with known exposure to a person with potentially infectious TB disease. Healthcare personnel with a newly positive test result should undergo a symptom evaluation and chest radiograph to assess for TB disease. Personnel with latent TB infection and no prior treatment should be offered, and strongly encouraged to complete, treatment with a recommenced regimen, unless a contraindication exits. Finally, the CDC also recommends that healthcare facilities should provide annual education on TB, including risk factors, signs, and symptoms [64,72].

The Employee Health Department of the healthcare facility has a critical role in the interpretation and implementation of OSHA guidelines. The employee health professional is the point person for many issues discussed in the first sections of this course. Depending on the facility's policies and structure, its Employee Health Department may be responsible for the oversight (in conjunction with the Infection Control Department) of many OSHA-related issues, from employee injuries and bloodborne pathogen exposures to high-efficiency particulate air (HEPA)-type mask fit-testing records.

Because the Employee Health Department is usually the keeper of records related to employee injuries, it becomes responsible for tracking bloodborne pathogen exposures and ensuring that employees are treated appropriately, that laboratory testing follows the appropriate guidelines, and that prophylaxis, if needed, is available. These records should be retained and recorded on the OSHA 300 Log.

In 2002, OSHA revised the rule addressing the recording and reporting of occupational injuries and illnesses. The goal of this revision was to simplify the overall recordkeeping for employers, generate more accurate information about occupational injuries, and better protect employee privacy. In 2015, OSHA again updated the recordkeeping rule to include two changes. The first change updated the list of industries that are exempt from routinely keeping OSHA injury and illness records. The second change expanded the list of severe work-related injuries and illnesses that all covered employers are required to report to OSHA. In 2016, OSHA published the new "injury and illness reporting rule." It does not change core recordkeeping requirements, but it does require that select recordkeeping forms be submitted to OSHA annually [45]. In 2019, OSHA published a rule to eliminate the requirement for establishments with 250 or more employees to submit certain forms electronically that may be used to protect personally identifiable information and data, although electronic submission of other forms is still required [45]. Code of Federal Regulations, title 29, sec. 1904, addresses recordkeeping [9].

One of the most confusing parts of recordkeeping is determining whether an injury or illness is recordable based on first aid or medical treatment. The revised standard sets new definitions of medical treatment and first aid to simplify recording decisions. An injury or illness is considered work-related if an event or exposure in the work environment either caused or contributed to the condition or significantly aggravated a pre-existing condition [9].

Work-related injuries and illnesses should be recorded if they result in [9,45]:

Work-related fatalities should be reported within eight hours. Work-related injuries and illnesses that are significant or meet any of the additional criteria listed below should also be recorded. Any significant work-related injury or illness that is diagnosed by a physician or other licensed healthcare professional or that involves cancer, chronic irreversible disease, a fractured or cracked bone, or a punctured eardrum should be recorded as well [9].

The following conditions should be recorded when they are work-related [9,46]:

Hearing loss has occurred when the audiogram reveals that the employee has experienced a standard threshold shift (STS) in hearing in one or both ears (averaged at 2,000, 3,000, and 4,000 Hz), and the employee's total hearing level is 25 decibels or more above audiometric zero (also averaged at 2,000, 3,000, and 4,000 Hz) in the same ear(s) as the STS [46].

The following interventions are considered medical treatment and are almost always recordable on the OSHA 300 Log[9,45]:

Medical treatment does not include [9]:

If the incident required only the following types of treatment, it is considered first aid and is not reportable [9,45]:

If an injury is considered reportable, and therefore recordable, it should be recorded on the OSHA 300 Log. In addition, the injury or illness should be recorded on either the OSHA Form 301 or an equivalent. The OSHA Form 301 provides more information about the case and the individual involved. Information such as the events leading up to the injury or illness, affected body parts, and objects or substances involved should be included [45]. Any form, such as a workers' compensation report or accident report, may be used as long as it contains the same information. OSHA Form 300A should be used to record work-related hearing loss [46]. Other items that should be covered following an employee injury include:

An annual summary of injuries and illnesses that occurred during the calendar year should be reported. The annual summary (OSHA Form 300A) is a total of all the columns to the right of the dotted line on the OSHA 300 Log[45]. A company executive should certify that the summary is correct and complete, and it should be posted for 3 months in areas where other employee notices are normally posted. The OSHA 300 Log, privacy case list (if one exists), annual summary, and OSHA 301 Incident Report Form, or other suitable form (e.g., state workers' compensation report, insurance claim report, employer's accident report form) should be retained for 5 years following the calendar year to which they relate [9,45].

In the hospital setting, most PPE is used as a barrier to blood and body fluids, such as blood-tinged mucous, blood, and urine. Code of Federal Regulations, title 29, sec. 1910.132 to 1910.139, originally published in 1994, address PPE. Subsequent revisions to this standard have incorporated current guidelines, hazard assessments for employee work areas, employee training, and properly fitting PPE. Hand equipment should fit properly and provide the proper protection. The type of glove used for protection from blood or body fluids would not be sufficient for a housekeeper handling caustic chemicals. The right glove for the job being performed is an important consideration [9].

The Employee Health Department is often considered to be the expert on PPE. OSHA addresses employee training in Code of Federal Regulations, title 29, sec. 1910.132(f). Employees should be trained regarding [9]:

To ensure that each employee is properly trained, clear and measurable objectives should be developed. Because the regulation requires that employees demonstrate an understanding of the PPE guidelines, objectives should center on these criteria.

The employer should verify that employees have been provided with all the necessary training. A written form of documentation with the name of the employee and date of training is required, as well as documentation of retraining [9].

Depending on the size of the healthcare facility, the risk manager (in conjunction with the Employee Health Department) may also be responsible for safety issues. All employee injuries and illnesses should be assessed with regard to safety and the possibility that it may somehow have been compromised. When evaluating an employee injury, the safety issues that might affect the outcome (e.g., lifting, glove use, ergonomics, or air quality) should be examined to ensure that no overall safety issues exist. Any safety issues discovered should be documented and reported through the facility's Safety Committee to prove that the issues have been addressed and that no hazards are being neglected. Careful documentation will help the facility avoid the perception that it is ignoring OSHA regulations.

The Hazard Communication Standard, also known as the Right-to-Know Law, was first enacted by OSHA in 1983. It was modified in 1987–1989, 1994, and 2012 and is referenced as Code of Federal Regulations, title 29, sec. 1910.1200 [9,52].

The purpose of this standard is to ensure that chemical hazards in the workplace are identified and evaluated. This is the responsibility of chemical manufacturers and importers, who are required to provide hazard information to employers who purchase their products [53]. Employers are then required to inform employees about the hazards of workplace chemicals—from liquid correction fluid to formaldehyde—to ensure that employees can monitor their exposure to hazardous chemicals and protect their health. Employers who neither produce nor import chemicals are only required to ensure that hazard information is transferred to its employees by means of a comprehensive hazard communication program, which should include container labeling and other forms of warning [9]. Regardless of who performs the hazard determination, the procedures used must be described in writing and made available on request to employees and their designated representatives, as well as to OSHA and NIOSH officials [53].

The Hazard Communication Standard defines a hazardous chemical as one that presents either a physical hazard (i.e., fire, explosive, or reactive) or a health hazard (i.e., one with systemic or target organ effects) in the workplace. Certain chemicals have been specifically designated as hazardous. A list of these chemicals is provided by several agencies, including [53]:

If a chemical is encountered that is not found on one of these lists, it is the employer's responsibility to search other scientific literature to determine if the chemical is hazardous [53]. Every chemical used or encountered in the facility should have a Safety Data Sheet (SDS) readily available to employees, which should be updated on a regular basis. Training and documentation of the training should be provided and take place at the time of initial assignment, whenever a new, potentially dangerous chemical is introduced into the workplace.

A hazard communication program may include, but is not limited to [9]:

Approximately 15% of wastes generated by healthcare facilities are considered hazardous materials that may be infectious, toxic, or radioactive. These materials include [54]:

Hospitals and other healthcare facilities, laboratories, research clinics, mortuaries, autopsy clinics, blood banks, and nursing homes are major sources of healthcare waste. The wealthiest nations can produce up to 5 kg of hazardous waste per person per year. Although poorer nations generate lesser amounts of waste, they typically do not distinguish between hazardous and nonhazardous waste [54]. Each facility that generates infectious waste should have a waste management plan that covers: the segregation, packaging, storage, treatment, transport, and disposal of the waste; and employee training on the proper handling of the waste. Sharps should be kept in leak-proof, rigid, puncture-resistant containers that are either red in color or visibly labeled with the word "sharps" and the biohazard symbol. Infectious waste, other than sharps, should be kept in containers that are impenetrable to moisture, strong enough to resist tearing, and stored in a secure area. The area should be air conditioned and inaccessible to animals, rodents, and vermin [10].

The waste should be autoclaved or incinerated before being disposed of in regular landfills, depending on state laws. If waste is transported away from the facility, it should be placed in containers or compartments that prevent scattering, spillage, and/or leakage of waste during transport, and it should not be transported along with noninfectious waste unless all of the waste is handled as infectious [10].

Assessment of a facility's waste management program should include [55,56]:

Determining how to reduce waste is an ongoing concern. Comprehensive education that encourages replacing disposable waste items from dialysis, surgery, or autopsy (e.g., towels, sheets, lab coats, underpads) with reusable items has the potential to reduce red-bag waste to only 6% to 10% of a hospital's total waste [56,57]. It is estimated that only 2% to 3% of hospital waste truly needs to be disposed of as red-bag waste [56].

Employers are responsible to evaluate and measure levels of any radiation or concentrations of radioactive material present, where applicable. Appropriate personnel monitoring equipment, such as film badges, should be available, and each radiation area should be conspicuously posted with a sign or signs bearing the radiation caution symbol [9]. (Employers should refer to state guidelines for information regarding the radiation produced by radiographic [x-ray] machines.)

The Nuclear Regulatory Commission (NRC), OSHA, and individual states all provide regulations regarding radiation safety. It is the responsibility of the healthcare organization to determine which regulations are applicable to its facility. NRC regulations apply to facilities that have radioisotopes on site, such as facilities that are engaged in nuclear medicine and using radioactive sources. OSHA regulations apply to organizations that are merely performing medical imaging, including magnetic resonance imaging (MRI). If the facility is a Veteran's Administration or other federal facility, it should always comply with OSHA regulations. However, if a facility is located in a state that has an agreement with OSHA to set its own occupational safety standards (which must be at least as stringent as OSHA's), then the state's requirements apply [58,59].

OSHA has set standards for radiation exposure levels and requires a radiation monitoring program. However, the radiation monitoring program need not continue indefinitely. Employers are not required to provide monitor badges to employees just because they work in an area where radiation is used. They are only required to provide monitor badges to those employees likely to receive a dose of radiation in excess of 25% of the allowed quarterly exposure limits and to employees who work in a high-radiation area. When an organization has compiled the necessary data through radiation surveys and monitoring results, it may reduce the scope of a program that is costly and time-consuming. The acquired data should document that employee exposure levels to radiation are less than 25% of the allowed quarterly limits set by OSHA [9].

If data are available to show that employee exposures do not exceed 25% of these quarterly limits and that the employees do not work in a high-radiation area, then the employees need not be monitored or provided with monitor badges. Additional monitoring requirements may apply to employees younger than 18 years of age or those working with radioisotopes. They may also apply if new equipment and processes have been introduced [9].

The radiation monitoring requirements for the majority of small, rural healthcare organizations are minimal for two reasons. First, these smaller facilities typically use only general radiographic equipment, and second, they do not normally have nuclear medicine programs that utilize radioisotopes.

Part of the healthcare facility's responsibilities for workplace safety rests with its ability to have a plan in place for managing spills of all kinds [9]. Both blood spills and chemical spills (e.g., formaldehyde) contain the potential for employee injury.

Because of the potential for injury, these spills (and their cleanup) are regulated by OSHA [9,10,53]. Factors to consider if a spill occurs include:

Clean-up supplies should include, but are not limited to:

The healthcare facility should follow these guidelines if a spill occurs:

Spill kits for both chemical and blood spills should be placed strategically around the facility. All personnel should be trained in the use of the spill kits, and the training should be documented. Policies should be in place that cover spill cleanup, protective equipment, handling solid or liquid spills, and the storage and handling of any chemicals.

The easiest way to prevent spills is through careful storage and handling. Chemicals should be stored in properly labeled containers with special attention to hazard warnings. Flammables should be stored in special storage areas; this includes items such as paint and turpentine. Water-reactive chemicals require dry storage. Compressed gas cylinders should be secured and properly supported.

According to the American Society of Anesthesiologists, all anesthesiologists should have fire safety education, specifically for operating room fires, with emphasis on the risk created by an oxidizer-enriched atmosphere.

(https://pubs.asahq.org/anesthesiology/article/118/2/271/13592/Practice-Advisory-for-the-Prevention-and Last Accessed: January 25, 2023)

Level of Evidence: Expert Opinion/Consensus Statement

Workplaces that handle flammable chemicals, process hazardous waste, or house patients should be concerned with the risk of fire. Fire safety should be part of any hazard communication training program. Smoke alarms, sprinklers, and/or fire extinguishers should be present. All employees should know about the fire risks associated with chemicals, gases, or equipment used. They should also know how to respond to a fire, which includes how to rescue patients and other employees, and how to locate and properly use fire extinguishers.

Fire safety plans should include fire emergency preparation, including alarm systems, marked exits, and written emergency plans. Many hospitals use acronyms such as RACE (Rescue, Alert, Confine, Extinguish) to help employees remember the proper steps for fire emergency response.

Annual inspections by the fire marshal, quarterly fire drills, annual fire safety in-services, and monthly fire extinguisher documentation are all elements of a successful fire safety program. Staff education and documentation of the education are integral parts of the fire safety plan.

OSHA requires that employers develop and maintain on site a written fire prevention plan. The plan must be available for employee review; employers with 10 or less employees may orally communicate the plan. The plan should include a list of all major fire hazards, proper handling and storage procedures for hazardous materials, potential ignition sources and how to control them, and the type of protective equipment needed to control each type of hazard [9].

Over the last several decades, concerns about the quality of indoor office environments have risen dramatically in the United States. The term "sick building syndrome" (SBS) describes a range of acute health and comfort effects that workers link to time spent in a building. Workers identify the building as the cause of their symptoms because they find relief from the symptoms when they leave the building [60]. SBS may be caused by inadequate ventilation, chemical contaminants from indoor or outdoor sources, and biologic contaminants. Although some symptoms and illnesses have been associated with a building's characteristics (e.g., dampness), medical and environmental tests often are not able to identify an offending contaminant in SBS. In contrast, a building-related illness (BRI) is one in which the symptoms of a diagnosable illness can be both identified and directly attributed to a specific airborne building contaminant. Examples of such illnesses include asthma, hypersensitivity pneumonitis, inhalation fever, rhinosinusitis, and infection [60,61,62].

NIOSH uses the term indoor environmental quality (IEQ) to describe the problems associated with air quality in an office or other building environment. NIOSH investigates potential health hazards in the workplace by means of a Health Hazard Evaluation (HHE), conducted under the authority of the OSH Act. Results of HHEs have indicated that, in addition to concerns about a building's air quality, employees have reported concerns about comfort, noise, and lighting as well as job-related ergonomic and psychosocial stressors [61].

When NIOSH conducts an HHE, it investigates a building's pollutant sources and pathways, its heating, ventilating, and air conditioning (HVAC) system, and its occupants. The HVAC system impacts how pollutants are distributed throughout the building as well as how they are removed from the building's air supply. Common pollutants and their sources include carbon dioxide, molds, bacteria, cleaning products, copy machines, and pesticides. An improperly maintained HVAC system may also be a source of pollutants [61].

An area of IEQ concern for hospitals is the operating room, where workers may be exposed to waste anesthetic gases, including nitrous oxide and halogenated anesthetics (e.g., halothane, enflurane, and isoflurane), while administering anesthesia. Exposure may also occur in the recovery room when the patient exhales the gases.

Some studies have reported miscarriage, genetic damage, and cancer among workers in operating rooms who have experienced long-term exposure to low concentrations of these gases. Exposure to high concentrations may cause headache, irritability, fatigue, nausea, drowsiness, difficulties with judgment/coordination, and liver and kidney disease. NIOSH has recommended the following safeguards to reduce worker exposure to waste anesthetic gases [63]:

The word ergonomics is derived from the Greek words ergon (work) and nomos (principle or law). It was first coined by a Polish scientist and educator in 1857 [65]. The science of ergonomics was not widely applied until World War II, when the fast pace of war manufacturing created physical and psychologic problems among workers [65]. Ergonomics is now defined as the science of fitting workplace conditions and job demands to the capabilities of the working population. Successful fits assure high productivity, reduced worker illness and injury, and increased worker satisfaction [66].

Although the scope of ergonomics is broad, OSHA primarily uses the term to define and assess work-related factors that put individuals at risk of musculoskeletal disorders (MSDs), which account for 33% of all worker injury and illness cases annually [65]. Examples of ergonomic risk factors have been identified in jobs and tasks that require prolonged, repetitive movements; recurrent heavy lifting, pushing, or pulling; and prolonged, awkward working positions. Employee exposure to vibration and cold may also be risk factors [66].

When seeking to identify conditions that may be contributing to MSDs, OSHA has recommended that employers [66]:

Medical management, employee training and education, and workstation design are important components of an ergonomics program. Many hospitals and physicians' offices have gone paperless, and millions of workers in the United States work with computers every day [65]. OSHA has developed guidelines for helping employers and employees create workstations that are both safe and comfortable [67]. Although no single correct posture or workstation arrangement exists, adhering to some basic design goals may help to minimize or eliminate problems. Adjustable chairs, footrests, armrests, and computer monitors may help to reduce injuries. Lighting, work processes, and worker posture are additional factors to consider when conducting an ergonomic assessment of the workplace [68]. Employees should be trained on ergonomic issues to help them identify problem areas within their jobs. Failure to recognize some of the early warning signs (e.g., numbness, blurred vision, aching or tingling, and weakness) may allow a small problem to become a serious injury [68].

In 1999, OSHA published a proposed Ergonomic Program Standard. This proposed standard applied to general-industry employers whose employees performed manufacturing or manual handling tasks and reported MSDs [69]. In 2000, the House voted to block federal rules aimed at preventing some of the 1.8 million workplace injuries that American workers were suffering annually. In 2001, President George W. Bush signed a joint resolution of Congress that disapproved OSHA's proposed Ergonomics Standard. As a result, the standard is no longer in effect, and employers and employees are not bound by its requirements [65,70].

Although no standards exist to universally regulate ergonomics, OSHA has established a protocol for developing industry and task-specific ergonomic guidelines [63]. OSHA has developed guidelines for poultry processing, retail grocery stores, shipyards, and nursing homes [66]. Although specific ergonomic standards for healthcare professionals have yet to be established, in 2014, OSHA published a new educational web resource that contains a variety of guidance products and materials to help hospitals prevent worker injuries, assess workplace safety needs, and enhance safe patient handling programs. The products and materials are available at https://www.osha.gov/hospitals [71].

Despite the lack of a final standard, employers are still obligated to follow the General Duty Clause, Section 5(a)(1), of the OSH Act, which requires employers to maintain a workplace that is free of serious hazards, including ergonomic hazards, whether or not voluntary guidelines exist. OSHA will continue to cite for ergonomic hazards [73,74].

Concern over public health issues and the need for occupational PPE has led to an increase in the use of latex gloves among healthcare workers. This increase has in turn resulted in high reports of skin reactions to latex among this population [75]. OSHA has estimated that 8% to 12% of healthcare workers may be sensitive to latex [76]. Most reactions are not serious and can be prevented. However, for some individuals, exposure to latex may be life threatening. Sensitivity to latex has been found to persist for as long as five years beyond discontinued use among some healthcare workers [77].

Individuals with a high risk of developing a latex allergy include healthcare workers, those with a history of allergies, and anyone who frequently comes in contact with latex products. Latex allergies commonly begin with a rash on the hand after wearing a latex glove. The three main types of reactions are irritant contact dermatitis, allergic contact dermatitis, and hypersensitivity immune system response [78].

Irritant contact dermatitis is a nonallergic, inflammatory response characterized by dry, itchy, flaky skin (usually on the hands) with cracks and sores. It may be caused by skin irritation from wearing gloves, exposure to other products and chemicals in the workplace, or repetitive hand washing and drying. Powders added to gloves, combined with sweat, may aggravate existing dermatitis. Wearing cotton liners, choosing a nitrate or vinyl glove, and avoiding the use of gloves when possible may provide relief for the dermatitis [78,79].

Allergic contact dermatitis, also referred to as delayed hypersensitivity or chemical sensitivity dermatitis, is not easily distinguished from irritant contact dermatitis because the reactions resemble those caused by poison ivy. However, in spite of the similar symptoms, allergic contact dermatitis is caused by a cellular immune response in the body, activated by repeated exposure to the allergen, latex [78,79].

Hypersensitivity immune system response is an actual latex allergy. This type of response is characterized by pruritus, inflammation, swelling, hives, and wheezing, usually immediately after exposure. Even low levels of exposure may trigger allergic reactions in some sensitized individuals. The response may progress to anaphylaxis in susceptible individuals, which is evidenced by hypotension, confusion, and extreme airway constriction. Individuals experiencing anaphylactic shock require immediate treatment. Allergy to latex should be suspected in any individual who develops specific symptoms, such as nasal irritation, hives, shortness of breath, wheezing, or unexplained shock [78,79].

Changing to a nonlatex glove to eliminate reactions may not work because some nonlatex gloves may still contain chemical sensitizers. Gloves labeled hypoallergenic do not necessarily eliminate allergic reactions. The use of hypoallergenic gloves may minimize the likelihood of an allergic reaction but will not eliminate the possibility of a reaction. Additional protective measures recommended by NIOSH include [78]:

Employers should take all measures to find the kind of glove that may be worn safely by employees without exposing them to the external hazards of harmful material or the internal hazards of a reaction to the equipment providing protection [9].

Employee training and education are emphasized throughout the OSHA standards. Employers should consider the following components when developing a training program [9]:

When OSHA visits a facility, it expects the facility to be able to produce a written training program that addresses all aspects of safety, including fire safety, hazard communication, and disaster plans. OSHA will additionally expect employers to provide proof of employee education (e.g., lesson plans, inservice dates, sign-in sheets, and education evaluations). The Bloodborne Pathogens Standard requires employee education to occur immediately on hire and at least annually thereafter. Documentation should reflect that this has occurred [80].

In today's litigious society, any facility is at risk for lawsuits. If an employee is injured on the job and able to show that a lack of safety equipment or training or unsafe conditions caused the injury, the facility is at risk for litigation. Lack of proper treatment of the injury and continuing unsafe conditions might also contribute to an employer's risk for litigation.

Attorneys who investigate incidents of employee injury will expect to be able to examine available documentation, including incident reports, medical records that include treatment of the employee, and training and education records. Safety conditions that might have caused the injury, any perceived unsafe conditions that exist, the safety committee minutes that show how the facility has addressed the condition, and further actions to correct the condition may also be reviewed.

Knowing what the standards prescribe for a particular facility and properly documenting all programs (e.g., written plans, the education program, or follow-up of existing conditions) will provide the employer with the best protection possible. Employers should carefully read the standards and provide training seminars and other relevant employee resources to ensure that their facilities are in compliance.

The most important resource is the Code of Federal Regulations, title 29, sec. 1910. Additional resources include: