Infection Control Today - 01/2002: Healthcare Workers Exposed

Healthcare Workers Exposed: Chemicals Necessary, Dangerous

By Kelli M. Donley

Chemicals are omnipresent in American society. From crop dusters ensuring thenext season's fruits and vegetables, antifreeze protecting engines from thechilly winter, and caffeine coursing through the veins of the tired andoverworked, these substances surround us. However, healthcare workers (HCW) areat an increased risk for encountering the potentially dangerous side ofchemicals.

One extreme example of this danger became evident after Dartmouth researcherKaren Wetterhahn fell ill in 1997. The college scientist had been working withdimethylmercury when one drop of the toxic compound permeated her glove. The48-year-old fell into a coma three weeks after being diagnosed and was dead 10months later from mercury poisoning.

Chemical exposure for HCWs, may it be caused by exposure to a sick patient,an improperly used disinfectant, or a sterilizer that has not been maintainedproperly, is a possible threat at any healthcare center. To educate workersabout the potential dangers surrounding these compounds, the Occupational Safetyand Health Administration (OSHA) requires healthcare facilities to have completeMaterial Safety Data Sheets (MSDS) for each hazardous chemical used and stored.

These sheets must be written in English and must provide the followinginformation: product identity, hazardous ingredients, physical and chemicalcharacteristics, fire and explosion hazard data, reactivity data, healthhazards, precautions for safe handling and use, and control measures.¹

Additionally, the National Fire Protection Association (NFPA) has ranked in avisual diamond chart the health, flammability, reactivity, and related hazardsof specific chemicals. These red, blue, yellow, and white diamonds are common inareas where chemicals are stored. The ranking system varies from 0, signifyingthe chemical is relatively harmless, to 4 meaning the chemical can potentiallycause death.¹ More detailed information about the NFPA's chemicalranking system can be found at: www.nfpa.org.

Patient Exposure

According to the Agency for Toxic Substances and Disease Registry (ATSDR), abranch of the Centers for Disease Control and Prevention (CDC), HCWs who areactive in the emergency room should understand the basics of treating acuteexposure cases. Registry officials developed medical management guidelines toaid emergency room HCWs when a patient in this situation arrives at theirfacility. The guidelines teach professionals how to effectively decontaminatepatients, protect themselves from becoming contaminated, communicate with otherHCWs involved, transport patients to other medical facilities if necessary, andprovide an efficacious medical evaluation and treatment to those exposed.²

The guidelines are available for more than 40 specific chemicals at: www.atsdr.cdc.gov.One of these examples includes the precautions that should be taken when apatient is exposed to an unidentified chemical. In this situation, ATSDRofficials recommend a variety of precautions including isolating any patient whoenters the ER with chemicals on his or her skin and clothing. If a patient iscovered in a chemical substance, other patients and HCWs can easily become illas well. It is important to isolate the patient quickly to protect others in thearea. Those HCWs responsible for the isolation and treatment procedure also needto have proper personal protective equipment (PPE). Officials at the registryalso recommend HCWs keep a worst-case scenario in mind when treating patientswho have been exposed to an unknown chemical in order to provide the highestprotection to others in the surrounding areas.

The American National Standards Institute (ANSI) has also written guidelinesfor HCWs personally exposed to chemicals in the workplace. The organizationrecommends the following flush time after exposure:

• 5 minutes for mild irritants

• 20 minutes for moderate to severe irritants

• 20 minutes for non-penetrating corrosives

• 60 minutes for penetrating corrosives

If there are any questions about the chemical's irritation level, the MSDSshould be reviewed and the manufacturer can be contacted. However, penetratingcorrosives are usually alkalies, hydrofluoric acid, and phenol. Most acids,according to ANSI, are penetrating corrosives. Non-penetrating corrosives form aprotective layer over human tissue. This usually limits the extent of damage.³

ANSI officials also recommend immediate first aid with oxygen if a HCW isexposed to:

• Ammonia, phosgene, and chlorine--these chemicals can interfere with the ability of oxygen to cross through the lungs to the bloodstream, causing pulmonary edema.

• Carbon monoxide can reduce the blood's ability to transport oxygen, causing anemia, or methemoglobinemia.

• Cyanide and sulfide can compromise the use of oxygen used by body tissue.

If a HCW is exposed to any of these chemicals, oxygen and/or emergency careshould be administered.

Chemicals in the Workplace

HCWs are responsible for washing their hands repeatedly through the day,wearing gloves, using disinfectants, and keeping their areas free ofinfection-causing pathogens. These sterile steps to a clean healthcare centercan leave HCWs working with a plethora of potentially harmful chemicals.

For example, disinfectants used to clean surfaces contain many chemicals thatcan cause bodily harm if used incorrectly. Kirsten Buck, a principle technicalaffairs specialist at Ecolab in Mendota Heights, Minn., said there are severalprecautions HCWs should keep in mind when working with Huntington phenolicdisinfectants.

"Our MSDS/s for all of our chemicals were written quite conservativelyand refer to the concentrate form. Our phenolics have a health rating of 3--theproduct is corrosive to eyes and skin (overexposure to concentrate), causingskin irritation and possible chemical burns. Phenolics may also be absorbedthrough the skin. It may be harmful if swallowed, with damage to mucosal tissue.Large doses may cause circulatory shock, respiratory depression, andconvulsions. If inhaled, the vapor or mist may cause irritation," she said.

The Association for Professionals in Infection Control and Epidemiology (APIC)has specific guidelines for the use of disinfectants to protect HCWs from suchexposure. The organization has classified disinfectants by their activeingredients: alcohol, chlorine and chlorine compounds, formaldeyde,glutaraldehyde, hydrogen peroxide, iodophors, phenolics, and quaternary ammoniumcompounds. Each of these ingredients carries its own danger. For example,alcohol is flammable, chlorine is reactive to other chemicals, and formaldeydeis a carcinogen. Yet these chemicals can be used properly and safely with theright direction.

Lauren Crawford, a research and development chemist for Metrex/OBF, based inOrange, Calif., said even the most basic chemical compounds can be fatal if notmonitored.

"Potential dangers may occur when any chemical is not used properly.Even a harmless chemical such as water may drown and harm a careless person.Thus, healthcare workers should be aware of label directions and precautions andfollow them closely. For example, glutaraldehyde products require the use ofadequate ventilation and proper personal protective equipment such as gloves oreye protection," she said.

HCWs should be trained at each center what PPE is required and necessary forworking with such chemical products. Buck also says staff members are willing toteach these guidelines if administration requests their help.

"Our sales force is also prepared to conduct in-service training foremployees on the safe and effective use of our products. Depending on the typeof product, wall charts and other literature are available, many in languagesother than English," she said.

While some chemicals can be heat and light sensitive, most disinfectants havebeen designed to be efficacious after sitting at room temperature.

"For the most part, normal warehouse conditions are appropriate for ourproducts. In the development of a new product, the packaging engineers assume awide range of conditions and choose appropriate materials to ensure safetransportation and handling. If the product is flammable or if the integrity iscompromised by freezing, the MSDS will indicate specific storageinstructions," Buck said.

Jack Kinville, a marketing manager at Ruhof in Long Island, NY, says theirproducts do not have a specific temperature at which they should be stored.Although Ruhof products are enzymatic-based cleaners, they also come withprecautions.

"Our products are always accompanied by tech sheets and MSDS, educatingworkers how to use them. At the full-strength concentrate, Endozime and ourother enzymatic products contain 10% isopropanol (2-propanol) that can irritatethe eyes and the skin. We recommend the use of goggles and plastic or rubbergloves when diluting and using the product," he said.

PPE is also an important element to safely using many cleaning products.

"In general, when using any cleaning solution, goggles and gloves aresuggested as an added safety measure," Kinville said.

No matter how the MSDS are written for the product, having the HCW wearappropriate gloves is essential.

"With reference to disinfectants, because our MSDS/s are written quiteconservatively, we recommend eye protection and skin protection when handlingany of the concentrates. We usually recommend gloves also for handling usesolutions-mostly to protect the skin from repeated damage from the mechanicalaction of cleaning, as well as repeated exposure to moisture and the product.Keeping the skin intact is the objective-wearing gloves will prevent anyirritant dermatitis as well as possible infection related to fissures in theskin," Buck said.

However, also just as important as wearing appropriate PPE is reading thedirections concerning how the chemical product is diluted and used. If this stepis skipped, a HCW can be seriously harmed.

"It is possible that individuals with asthma, allergies, or respiratorysensitivity can develop an allergic reaction to enzymes (proteins) that areinhaled in spray, mist, or dust. With our liquid enzymatic concentratedproducts, normal handling and use as directed do not involved generation ofspray, mist, or dust. Therefore, there is very little inhalation risk. However,we recommend respiratory protection (a NIOSH approved mask) for individuals withasthma, allergies, or respiratory sensitivity. If staff members are allergic orsensitive to fragrances, use of our unscented, colorless versions instead of theregular enzymatic products can be considered," Kinville said.

Crawford agrees that understanding and following the directions are crucial.

"Read the instructions of the labels carefully, follow directions, anduse appropriate protective equipment. The labels for many of the regulateproducts go through rigorous screening and are very carefully worded to tailor aspecific usage for the customer. Thus, it is important to followdirections," she said.

HCWs who use chemicals in healthcare centers should double check they are incompliance with both the manufacturer and their administrative policies.Understanding the possible dangers surrounding these necessary compounds iscrucial to keeping healthcare centers functioning at their highest and mostefficient levels and maintaining the health and well being of staff members.