Keeping Employees Healthy:

Keeping Employees Healthy:
The Far-Reaching Effects of Occupational Health

By Patricia Tydell, MSN, BSN, MPH

Objectives

1. To identify the components of an injury-illness prevention program.
2. To describe the selected hazards found in the workplace.
3. To state methods designed to prevent workplace injury and illness.

It is estimated that more than 8 million people in the United States arehealthcare workers (HCWs). They work in traditional settings such as hospitalsand nursing homes, but frequently work outside of these areas in places such ashomes and clinics. They are direct caregivers such as doctors, nurses,respiratory therapists, and non-direct caregivers like laboratory staff, centralsupply staff and pharmacists. They can also be students, volunteers, researchersand contracted personnel.

While registered nurses are the least likely of occupations to lose time fromwork due to injury or illness (25.7 percent), nursing aides and orderlies arethe third highest group of all occupational groups to loose time from work dueto injury or illness (75.7 percent).¹ Regardless of job category,these persons have the potential to be exposed to hazardous conditions in theworkplace; hazards such as needlestick injury, TB exposure, laser/electrosurgeryplume, bioterrorism and exposure to other infectious diseases through theenvironment of care and equipment. These hazards are manageable through the useof policies and practices as well as engineering controls. A well-definedprevention program that includes prevention of work-related illnesses andinjury, education of staff, monitoring of the environment, engineering controlsand work practices support the goal of prevention of occupational injury andillness.

Education of Staff

Personnel are more compliant with a program if they understand its rationale.Knowledge of the cost of illness and injury to the employee in terms of time,money and disability helps the employee to accept accountability for practicesrequired. Policies that are clearly written, coordinated between departments andhave employee input have the best chance of being used by employees. While theconsequences for not following established policy must be addressed, themotivation to practice safely in the workplace should be based on knowledge offacts. Many educational programs overlook the importance of indirect caregivers,administrative personnel and patient/families when designing and presentingprograms. In the era of patient safety, all employees need to be responsible forworkplace safety. The patient and/or family often are in a unique position tosee unsafe situations that caregivers do not see. Providing them with anopportunity to speak up about what they see can greatly assist the staff in thistime of staff shortages. Through unit orientation and printed materials, theorganization can communicate their concern about prevention to the patient andfamily.

Prevention is Key

Prevention of injury and illness has always been the goal of occupationalhealth. A comprehensive program of prevention includes risk assessments of theenvironment where necessary, implementation of engineering controls, workpractices designed to reduce the risk and monitoring the environment todetermine if the actions are effective.

An environmental-hazard risk assessment is usually conducted by amultidisciplinary team comprised of housekeeping staff, engineering personnel,infection control practitioners (ICPs), security personnel, fire and safetystaff, and patient safety/risk management personnel. Each professional shareshis or her expertise in developing the assessment tool. Then using the tool whengoing to an area of the hospital, the team documents problems it finds. Forexample, a team going to an acute inpatient psychiatric unit may be looking forenvironmental hazards that could pose a risk to a suicidal patient: items likebreak-away shower curtain rods, slanted or solid grab bars, non-breakablemirrors and glass, drop ceilings that hide sturdy pipes, how high up the patientunit is off the ground floor, doorframes and knobs, dining room areas andbedrooms. They may also look at the use of plastic bags and the need to have anICP determine the best way to assure infection control when disposing ofinfectious waste while still eliminating the risk of a patient using a plasticbag to attempt suicide. Security personnel may need to look at panic buttons andcameras for the safety of the staff, while housekeeping will need to look at thestorage of chemicals in areas that are safe. The team then reviews itsassessment and makes recommendations for action. Dangerous situations can bedealt with at the time of the assessment. Staff can be asked questions aboutsafe practices and policies to determine their level of knowledge.

Engineering controls are valuable in providing a safe work environment foremployees. Laminate flow hoods for mixing toxic chemicals or working withmaterials that produce fine particles is an example of an engineering designbuilt into the environment. Negative airflow rooms are an engineering controlfor airborne infectious organisms such as tuberculosis. The purchase of sharpswith engineered sharps injury protections and needleless systems is an exampleof a common engineer control designed to protect employees from injury andillness.

In September 1996, the National Institute for Occupational Safety and Health(NIOSH) released a health hazard alert about the dangers of smoke plume, abyproduct of the thermal destruction of tissue during surgical procedures usinglaser or electrosurgical units.² Smoke plumes contain toxic gases andvapors such as benzene and formaldehyde, dead or alive cellular materials(including blood fragments) and viruses. Exposure during these procedures hasbeen known to cause burning watery eyes, nausea, respiratory problems and viralcontamination. As there were some 24 million surgical procedures done in 1995and 90,000 registered nurses working in operating rooms, the potential affect ofthis occupational hazard is significant.² The engineering controlrecommended is a combination of general room ventilation and local exhaustventilation. A high efficiency particulate air (HEPA) filter or equivalent isrecommended for trapping particulates.³ The use of a room evacuatoror room suction must be combined with the work practice of holding the nozzleinlet within two inches of the surgical site to effectively capture airbornecontaminates generated.³ All tubing, filters and absorbers areconsidered infectious waste at the end of the procedure and must be disposed ofaccordingly. These tubes and filters must be replaced with each new procedure.

Work practices are the most common method of preventing injury and illness.The use of safer devices to protect workers who handle medical sharps is oneexample of a workplace practice. The Occupational Safety and HealthAdministration (OSHA)'s Needlestick Safety and Prevention Act provided directionto healthcare facilities to reduce the incident of needlesticks or sharps injuryto employees. The act calls for employers to solicit input from frontlineemployees in choosing safer devices before purchasing them.⁴ Itrequires employers to establish a log to track needlesticks and help identifyproblem areas or operations. This log must maintain the privacy of the employeewho was injured.⁴ The act seeks to clarify and emphasize theimportance of annually reexamining the organization's exposure control plan andadopt safer needle devices that protect against accidental needlesticks.Requiring employees to use the equipment purchased helps to reduce the incidenceof these types of injuries from occurring.

The use of protective devices is another way that both engineering controlsand work practices combine to provide a safer workplace. The most commonprotective device used in healthcare is the glove. Much has been written aboutthe types of gloves to be worn, when to where them, in what types of situationsand for how long. Problems related to latex gloves and double gloving has alsobeen studied. The use of gloves is now an accepted practice not only inhealthcare but also in workplaces such as food service and housekeepingservices. Used with other devices such as goggles and gowns, they provideprotection from infectious materials for a wide range of employees in a varietyof work situations.

Prior to September 11, employees and employers did not spend too much time ormoney in planning for a terrorist attack even though they knew about the WorldTrade Center bombing in 1993 and the Oklahoma City bombing in 1995.⁵That changed significantly on September 11, 2001. The Federal Bureau ofInvestigations (FBI) defines terrorism as the unlawful use of force againstpersons or property to intimidate or coerce a government, the civilianpopulation, or any segment thereof, in the furtherance of political or socialobjectives.⁶ The definition includes three elements:

• Terrorist activities are illegal and involve the use of force

• The actions intend to intimidate or coerce

• The actions are committed in support of political or social objectives⁶

Because terrorist acts are designed to inflict harm to persons and damage toproperty, these emergencies are different from the ones planned for in the pastin terms of their size and type. These emergencies involve mass destruction ofproperty, widespread injury and death, unsafe conditions for caregivers and theemotional stress brought upon by the intentional devastation. There are fivecategories of terrorist incidents: biological, nuclear, incendiary, chemical andexplosive.⁶ Although nuclear, incendiary, chemical and explosiveincidents are all critically important, biological incidents are the ones mostlikely to impact the occupational health professional and ICP. These biologicaltoxins can enter the body through inhalation, absorption, ingestion andinjection. These routes of entry are key to protecting self and others. The useof toxins is a preferred because they are more easily extracted for use, arehighly effective and are more easily transported. Four common toxins thought tobe potential biological agents are botulism, staphylococcal enterotoxin B (SEB),ricin (derived from the castor bean plant) and mycotoxins.⁶

Biological indicators that could signal the use of a toxin may include anunusual number of sick or dying people or animals, dissemination of unscheduledand unusual sprays, especially outdoors or at night, and abandoned spray deviceswith no distinct odors⁶

A comprehensive public response to a biological terrorist act involvesepidemiological investigation, health care treatment, and prophylaxis foraffected individuals, and the initiation of disease prevention or environmentaldecontamination measures.⁶ The Centers for Disease Control andPrevention (CDC) will assist state and local health agencies in developingresources and expertise for investigating unusual events and unexplainedillness. When a terrorist attack is confirmed, the CDC will coordinate withother federal agencies. The FBI will be the lead agency for crisis planning andthe Federal Emergency Management Agency (FEMA) will ensure an adequate federalresponse to the disaster.

There are actions that employees can take to protect themselves and othersfrom the effects of terrorist attacks prior to the arrival of help. Theseprotective measures are time, distance and shielding from the biological,nuclear, incendiary, chemical and explosive incident. These protective measuresare linked.⁶

Time spent in the area of the event is critical if the hazard is expected togradually diminish over time. The use of rapid entries to execute rescue ortreatment minimizes the effects of the hazard to the worker. The greater thedistance from the source of harm, the less chance of exposure to it. If at allpossible, being uphill or upwind from the site is preferable. Adding to the timeand distance advantages, shielding with physical barriers such as vehicles,buildings, walls and personnel protective equipment helps reduce the harm causedby the incident.⁶

Given the likelihood that the terrorist acts will continue, being familiarwith local, state and federal plans for disaster will help the organizationrespond more effectively.

Exposure to infectious disease through the environment of care and equipmentis a hazard that affects all areas of the organization. All employees arepotentially susceptible to infectious agents or can cause the spread ofinfection. Controlling this hazard is important because of its widespreadaffects on the organization. It can also be more difficult. One of the mostimportant behaviors to decrease exposure to infectious agents is basicinformation on how to prevent the spread of infection. Practices as simple andcommonplace as using tissues to cover the nose and mouth when sneezing, noteating or drinking in the work area, keep the environment clean and of course,handwashing.

Immunization programs play a role in preventing infections from occurring inemployees. Optimal use of vaccines can prevent transmission ofvaccine-preventable disease and eliminate unnecessary illness and workdisruptions. An immunization program is far more cost effective than casemanagement and outbreak control. In addition to the childhood vaccinations thatall employees should have (unless they were born before 1957), immunizationssuch as hepatitis B, and influenza are recommended.⁷

Completing the prevention program is monitoring of the environment to assurethat practices to reduce the incidence of injury and illness are actually beingused. Monitoring activities include rounds, mock drills, reports and feedback tothe staff.

During multidisciplinary rounds, the staff is asked to participate inidentifying workplace problems that could cause injuries or illness. Having thesupervisor of the area along on the rounds is helpful to increase the awarenessabout the work area. Engineering controls and workplace practices that should bein place can be assessed. For example, are gloves being used correctly? Theserounds can be used to inspect for cleanliness and safety in the area. Forsituations that the staff is expected to handle but may encounter infrequently,mock drills are useful for checking their performance. Aside from the requiredfire drills, mock drills for other emergency situations like lose of electricityfrom a terrorist attack provides a great deal of information to the staff andsupervisors about the glitches in the back-up systems and the staff's knowledgeof who is to do what, when and how. Having a real-time drill gives the staff theopportunity to experience the problems of having to move patients and call instaff that they may not have by just reading the disaster plan. They know betterwhat to expect.

Using written and verbal reports on aspects of the environment like air andwater quality provides employees with information about their environment. Thesereports are quickly disseminated to a wide group. As with any monitoringactivity, the purpose is to assure that what is suppose to be occurring isactually happening in the work area.

The hazards facing our workplace and the people in it have become morecomplex. Along with the well-known hazards are the new challenges brought aboutby modern threats and actions that go beyond any unexpected workplace emergencyof the past. Keeping our employees healthy has taken on new directions and newrisks.

Patricia Tydell, MSN, BSN, MPH is risk manager for the North ChicagoVeterans Administration Medical Center in North Chicago, Ill.