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HAZARDS RELATED TO THE GENERAL MEDICAL CENTER ENVIRONMENT
Environmental Surveillance and Control
Because Healthcare workers may be exposed to a number of potential hazards, the environmental control program must be able to identify potential hazards, evaluate the nature and extent of the exposure and recommend effective control measures. Specific training and policies should meet OSHA, EPA, CDC and other governmental requirements and guidelines.
Areas of particular concern include:
1) Ventilation, including routine inspection and servicing of laminar flow hoods, heating,
ventilation, air conditioning, and humidification units, etc.
2) Confined space entry.
3) Medical waste management and disposal.
4) Electromagnetic radiation and radioisotopes.
5) Ergonomic issues, including selection and modification of office equipment, lifts and
hoists, etc.
6) Proper hygiene practices around chemical substances.
7) Proper procedures where exposures to blood or body fluids may occur.
8) Noise exposure.
Waste management
Waste management, while costly, impacts the health of employees, patients and visitors. It may also result in regulatory violations and fines. Although a full discussion of this topic is outside the scope of this document, minimizing harm to the environment is an important issue. There are also direct and obvious benefits to employees: reducing the amount of waste that has to be collected and treated as hazardous or infectious, which reduces risk of employee exposure as well as decreases the frequency and intensity of lifting and sorting waste. Goals of effective waste management include reduced environmental impact, increased patient safety, increased patient confidentiality, decreased operating costs, enhanced public image for Healthcare and improved employee morale.
http://www.healthcarewaste.org/en/340_manag_medium.html http://www.noharm.org/
http://www.sustainablehospitals.org/cgi-bin/DB_Index.cgi http://www.epa.gov/oppt/library/pubs/archive/acct-archive/pubs/hospitalreport.pdf
Reproductive hazards
Policies for employee education regarding potential exposures to teratogenic agents (e.g., chemotherapeutic agents and the antiviral agent Ribavirin) and appropriate safety measures should be developed. Corporation and communication with the employee's obstetrician is important.
Many work assignments in a hospital setting entail potential exposures of special concern to pregnant personnel. Infectious exposures, such as cytomegalovirus, parvovirus B19, measles, rubella and others are well established to cause fetal harm among susceptible individuals. Heavy exposures to anesthetic gases and chemotherapeutic agents have also been associated with adverse pregnancy outcomes in some studies. There does not appear to be adequate evidence for adverse pregnancy outcomes among pregnant personnel exposed to MRI, nitric oxide, or among those who work under present-day conditions as x-ray technicians. Currently applicable CDC infection control guidelines for infectious agents, NIOSH and OSHA procedural guidelines for handling chemical agents, and OSHA and NRC standards for monitoring and managing radiation exposure are protective of pregnant personnel, and must be strictly enforced.
Six viruses of special concern to pregnant women are cytomegalovirus, herpes simplex, measles, parvovirus B19, rubella, and varicella zoster.
Cytomegalovirus (CMV) infection during pregnancy may be associated with hearing loss in the newborn or with the congenital CMV syndrome, which may affect multiple organ systems. CMV may be shed by CMV-infected infants or children, or by CMV-infected immunocompromised patients. Studies have shown, however, that the rate of primary CMV infection among those who care for such patients is no higher than the rate among those without such patient contact. Studies in areas with a high CMV prevalence among patients have also shown that healthcare workers do not have higher CMV transmission rates than non-healthcare workers. Although most fetal infections follow primary infection of the mother, some fetal infections have occurred following reactivation of old infection in the mother or reinfection of the mother. There is no clear evidence that reassignment of CMV-negative pregnant personnel to areas of less patient contact confers protection to such personnel. Assiduous adherence to handwashing and to Standard Precautions is necessary for pregnant healthcare workers caring for CMV-infected patients.
Herpes simplex (HSV) infection during pregnancy has been associated with mucocutaneous lesions, sepsis, encephalitis, and rarely congenital malformations. Herpes simplex infection from patient care activities is unlikely. Pregnant personnel caring for patients with HSV infections should adhere to handwashing and Standard Precautions.
Measles exposure during pregnancy has been associated with spontaneous abortion and with prematurity. Measles is transmitted by large droplets and via the airborne route. Measles vaccine is protective, and two doses administered subsequent to the first birthday are considered adequate evidence of immunity. Patients with measles should be cared for by vaccinated personnel under airborne precautions. Non- immune pregnant personnel should not care for patients with measles.
Rubella exposure during pregnancy may cause the rubella congenital syndrome, which affects multiple organ systems. Rubella is spread via respiratory droplets, or (in the case of infants with congenital rubella) by contact. Women immune to rubella by vaccination are not at risk of adverse events if exposed during pregnancy. Patients with rubella should be cared for by vaccinated personnel under droplet and contact precautions. Non- immune pregnant personnel should not care for patients with rubella or with the congenital rubella syndrome.
Varicella zoster (VZV) (the virus which causes chicken pox and herpes zoster) may cause fetal malformations when a non-immune pregnant mother is exposed. VZV is spread by contact or via the airborne route. Patients with chicken pox or with herpes zoster should be cared for by personnel with established serological immunity using contact and airborne precautions. Non- immune pregnant personnel should not care for patients with chicken pox or herpes zoster.
Parvovirus B19, the cause of fifth disease, may cause fetal death if exposure occurs during the first half of pregnancy. Infection is spread by large respiratory droplets and close contact. While rare, transmissions of parvovirus to healthcare workers have been documented. Droplet precautions must be employed during care of patients with parvovirus infection.
Building Associated Illness/Indoor Air Quality
Healthcare facilities must develop an indoor environmental program to ensure a healthy building environment. Central to this mission is the use of ventilation standards, development of good operations and maintenance procedures, establishment of construction and remediation standards and effective management of moisture, mold, and other indoor environmental problems. At present the American Institute of Architects (AIA) maintains recommendations for hospital ventilation that differ from those of the American Society for Heating, Refrigerating, and Air conditioning Engineers, but those standards are under alignment. Hospital ventilation systems are usually far more complex than those of office buildings, hotels, or schools because of the multiple uses and locations, including operating rooms, bone marrow transplant units, and sterilization areas. Systems in hospitals degrade, and construction management requires the development of formal approaches to controlling bioaerosols release in health care. In addition, water intrusion, from construction or systems failure, is not infrequent and requires structured responses
Indoor air quality (IAQ) complaints must be properly evaluated in a timely fashion. Facilities are generally more successful if they have a defined procedure including ways of reporting complaints, designated responders, and a formal approach to providing feedback. Assessment of individuals and of the environment may occur in parallel but require very different skills. Clinicians should assess staff, patients, or visitors to determine whether symptoms may represent building-related disease or irritant symptoms and differentiate between illness to chemical the exposures (e.g., off gassing of carpet, tobacco smoke, combustion products), inadequate ventilation, and illness of microbiologic origin. In many situations, psychosocial factors, including job satisfaction and work organization, contribute to the perception of discomfort and disease. The primary environmental assessment generally requires an engineering assessment of the systems and, often, an industrial hygiene assessment of potential sources. In general, quantitative sampling should be limited to the specific contaminants suspected by the environmental and medical assessments, with a very clear justification for sample collection. Detailed reporting of findings should be made to management and to the affected employees.
http://www.osha.gov/SLTC/indoorairquality/index.html http://www.epa.gov/iaq/molds/ http://www.epa.gov/iaq/pubs/hpguide.html http://www.cdc.gov/niosh/topics/noise/ http://www.cdc.gov/niosh/topics/heatstress/
VIOLENCE PREVENTION
Violence represents a common problem in healthcare. In general 12% to 14% of health care workers in the US experience at least one assault each year, and more assaults occur in healthcare than in any other industry in North America, though the rates of fatal assault are higher in some (cab drivers) and the incidence of deaths is higher in others (construction). NIOSH has classified violence by perpetrator, as a more useful approach. Type 1 violence represents that by clients (students on teachers, patients on providers, prisoners on guards), type 2 criminal, type 3 family/spouse, and type 4 coworkers. Programs for different kinds of violence prevention may require somewhat different approaches although response protocols often have substantial overlaps. Under-reporting of incidents is recognized as quite dramatic with only one in fifteen incidents leading to injuries reported to both security and workers compensation systems.
The vast majority of events in health care represent patient assaults on providers. High risk occupations include nursing (RN, LPN, and NA) and police and security staff. High risk locations include mental health, geriatrics, and emergency rooms. In general, the more intense the contact with patients, the higher the risk of assault. Intervention programs with documented effectiveness include education, flagging/warning of patients who have previously assaulted, and environmental intervention including wall colors, music, development of zero-tolerance policies, and plastic table ware.
Rates of co-worker assaults are lower than in general industry. Still, stressful working conditions and organization conflict are clearly associated with a wide- range of violence, ranging from passive aggressive behavior, including information withholding, to assault and battery with deadly weapons. Interventions include education, stress management, staffing improvement, supervisor training and support, and reporting.
OSHA has published and updated guidelines for the prevention of violence in healthcare. These guidelines address education and training, policy development, environmental management, and response procedures. NIOSH similarly has guidance for violence prevention in the work place. A standard free training tool has evolved in the Veterans Health Administration from the original work on violence prevention in health care developed in the late 1970s. That program served as the core of many of the currently commercially available programs. No side-to-side comparisons of program effectiveness have been undertaken.
Effective programs require careful assessment of an organizations needs, location, and staffing and patients. Model policies should address the following major program elements
• Zero tolerance
Some policies explicitly state that no violence of any kind will be tolerated. Essential is the
establishment of a clear definition of violent acts, clarity on consequences, and an
institutional strategy for implementation. “Zero tolerance” approaches have been misused, in
a number of settings, so that careful implementation is necessary including focusing on
passive-aggressive behavior and provocation• Violence prevention through environmental design
The concept of defensible space, so effective elsewhere, is less useful in healthcare since
contact between providers and patients is essential. Understanding the function of space,
symbolically and practically, and how to use barriers, doorways, and privacy is essential.• Education and training
Initial awareness, acquisition of specific skills, and retraining in some defined frequency is
important. Skills in de-escalating conflict, in personal safety (breaking holds), and reporting
must be acquired.• Patient assessment and warning
One well-documented, very effective approach to reducing the frequency and severity of
repeat assaults is to warn healthcare workers of prior assaults. This may occur though flags
in an electronic medical record or some physical marker on paper charts. This approach
requires the presence of a multidisciplinary committee, usually under senior clinical
leadership, that reviews patient histories, evaluates the adequacy of medical care, and
decides on the presence of a flag and its likely duration (time to re-review)• Threat Assessment
Facilities must have resources to address the degree of real threat, both from patients and
from staff and co-workers. Threat assessment training is available from several
organizations.• Incident Response
Alarms and warnings are essential to notification. These range from minor signage (raising a
red folder in a public space) to use of emergency call buttons and cell phones with speed-dial
systems. Facility wide announcements (“code orange) are standard.
Facilities tend to rely on therapeutic or police containment. The former requires a three-sift
approach with at least three people per incident who use passive force and weight to bring a
patient under control. Police force is self-explanatory. The former is far more respectful of
patient care and ethics but requires a very degree of training, scheduling coordination, and
ongoing attention.• Post-incident management
Post-incident management approaches to the prevention of long-term consequences are
available to patients/employees and bystanders. Victims may develop acute stress reactions,
and warrant clinical treatment, or post-traumatic disorders. Critical incident stress debriefing
has been shown, meanwhile, to perform at least no better than no treatment if not worse. A
psychohygiene approach has been developed for bystanders.• Reporting and surveillance
Facilities should develop some approach to reporting, which may include electronic/remote
call buttons, cell phone, and beepers. Reporting should lead to some structured response.
Facilities should develop a system whereby they can collect information from both workers
compensation and security/police reports to track incident frequency, locations, and
perpetrators, in an attempt to evaluate program effectiveness
http://www.cdc.gov/niosh/topics/violence/ http://www.osha.gov/SLTC/workplaceviolence/index.html http://www.vethealth.cio.med.va.gov/osh/violence-prevention.htm
