Worker safety: a road well-traveled, yet so far to go - Products & Sevices

No one had reason to suspect the patient admitted to Henry Ford Hospital was symptomatic of SARS, the disease that has kept the world health community on edge for nearly a year. Even while its relative close proximity to Toronto, a SARS hotbed just across the big lake they call Erie, left Ford and other Detroit hospitals on high alert, they're more accustomed to treating the occasional emergency room patient whose coughs or aches made them automatically fear the worst.

But 24 hours later, that patient had presented all the classic SARS symptoms: high fever, headache, body aches, dry cough, difficulty breathing. The patient was immediately transferred to isolation, and SARS infection control protocols went into high gear. "Our staff has all of the required personal protective equipment and were well-educated on the proper isolation procedures, but they were unknowingly exposed before they could make use of them," said Jennifer Madigan, MPH, one of three infection control specialists at the 903-bed medical center.

Staff were divided into low, medium and high risk categories based on their exposure to the patient during the first 24 hours. Some staff were put on quarantine for 10 days. Others who were deemed low risk were able to return to work but monitored daily for symptoms. Madigan said the CDC continued evaluating cultures taken from the patient, and had not made a diagnosis as of press time.

This wasn't Detroit's first SARS scare. A case reported on April 24 at Henry Ford Health System's hospital in Troy proved not to be SARS. In that case, a female patient who had recently returned from Toronto was isolated within three to five minutes of her arrival at the facility after relatives told workers she might have SARS symptoms. Infection control experts said hospitals' quick response in these and other incidents show the lengths American healthcare workers are taking to quickly isolate for possible SARS symptoms, and helps explain why so few cases are occurring in this country.

In fact, of the 408 suspected SARS cases reported in this country at press time, only 75 were deemed by the CDC as "probable." Two of those probable cases occurred in healthcare workers who provided care to SARS patients.

According to the CDC, the majority of suspected SARS infections in U.S. healthcare workers have occurred in locations where infection control precautions either had not been instituted or had been instituted but not followed. Recommended infection-control precautions include the use of negative-pressure isolation rooms where available, N95 or higher-level respirators, gloves, gowns, eye protection and careful hand hygiene.

Still, the SARS pandemic illustrates one indisputable fact: Hospitals can be some of the most dangerous places in the world to work.

Just ask the nurse who contracted HIV after pricking her finger with an infected needle, the nursing assistant whose nipple was tom off by an enraged psychiatric patient, the transport worker who sustained a debilitating back injury after lifting a 300-pound patient, or the surgical technologist who suffers from hepatitis after a puncture from a contaminated scalpel.

Even with the myriad of laws, regulations and guidelines designed to protect healthcare workers, accidents still happen--accidents that come not from hospital neglect or the lack of innovative protective equipment so prevalent today, but from complacency and job stress. Said Katherine Preney, R.N., the ICP liaison for three Detroit Medical Center facilities, "Staff are so busy trying to do their jobs fast and well, they sometimes forget about doing them safely."

Sobering statistics

According to the Bureau of Labor Statistics (BLS), health services (which include hospitals, nursing facilities, and physician offices) recorded 594,600 cases of non-fatal occupational injuries and illnesses in 2001, the highest number across BLS' individual standard industry classifications and more than 10 percent of the 5.2 million injuries and illnesses reported in U.S. private industry workplaces. Hospital workers, meanwhile, suffered the third highest rate of non-fatal repeated trauma cases in 2001, behind only the motor vehicle and meat packing industries.

According to OSHA, compared with the total U.S. civilian workforce, hospital workers have a greater percentage of workers' compensation claims for sprains and strains, infectious and parasitic diseases, dermatitis, hepatitis, mental disorders, eye diseases, influenza, and toxic hepatitis.

The following are additional sobering statistics, but bear repeating:

* OSHA estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to the more than 20 pathogens that have been transmitted through sharps or needlestick injuries, including human immunodeficiency virus IHIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). As recently as March 2000, OSHA estimated that more than 385,000 percutaneous injuries had occurred among healthcare workers from needles and other sharps used in the healthcare setting. Data collected by hospitals that participate in EPINet indicate that in the average hospital, approximately 30 needlestick and sharp-object injuries per 100 beds occur each year.

* Hospital-based U.S. healthcare workers experience some 800,000 needlestick injuries each year. Needlestick injuries account for up to 80 percent of all accidental exposures to blood. Based on various studies, researchers have documented that needlestick injuries are under -reported by healthcare workers and the actual number of exposures could be much higher. Several studies found rates of under-reporting as high as 53 percent for nurses and 92 percent for laboratory personnel. Physicians under report needlestick injuries by as much as 95 percent.

* HIV--The CDC reports that as of June 2000, there were 56 documented and as many as 138 possible cases of occupational HIV transmission to healthcare workers. Most involved nurses and laboratory technicians. While the rate of HIV transmission in healthcare is relatively low, the total number of occupationally acquired HIV infections in healthcare workers is increasing each year.

* HBV--For more than 50 years, HBV infection continues to be one of the most common bloodborne pathogens among healthcare workers. Studies conducted prior to implementation of recommendations to prevent bloodborne pathogen transmission show that healthcare workers had a prevalence of HBV infection three to five times higher than the general U.S. population. The number of occupationally acquired HBV cases has declined dramatically over the past 10 years, due mainly to the hepatitis B vaccination mandated by OSHA's bloodborne pathogen standard. However, the CDC estimates that each year, several hundred healthcare workers are still infected with HBV, and many of these will die from their infection.

* HCV--The greatest threat to healthcare workers may well be from hepatitis C virus infection, the most common bloodborne infection in the United States, affecting approximately 4 million people. Healthcare workers clearly have an increased occupational risk for HCV infection, according to the CDC. in 1995, an estimated 560 to 1,120 cases of HCV infection occurred among healthcare workers who were occupationally exposed to blood. No vaccine is available for hepatitis C and no effective post-exposure prophylaxis is known at this time.

* Workplace violence--For many years, healthcare workers have faced a significant risk of job-related violence. In fact, the rates of non-fatal violent crime among physicians, nurses, mental health professionals and mental health custodial workers far eclipse those of any other occupation, according to the Department of Justice's 1993-1999 National Crime Victimization Survey. "As significant as these numbers are, the actual number of incidents is probably much higher. Incidents of violence are likely to be underreported, perhaps in part due to the persistent perception within the healthcare industry that assaults are part of the job," OSHA notes in a 2003 report on workplace violence. From 1996 to 2000, 69 U.S. healthcare workers were murdered on the job. "Although workplace homicides may attract more attention, the vast ma jority of workplace violence consists of non-fatal assaults," the agency added. In 2000 alone, 48 percent of all non-fatal injuries from occupational assaults and violent acts occurred in healthcare and social services, according to the Bureau of Labor Statistics. Most of these occurred in hospitals, nursing and personal-care facilities, and residential-care services.

* Healthcare industry workers sustain nearly five times more overexertion injuries than any other type of worker and comprise six of the top 10 professions at greatest risk for back injury, according to the U.S. Department of Labor.

New diseases, new challenges

Although some infectious diseases such as polio have been nearly wiped out, the vast majority of these diseases will not be eliminated in our lifetime. Compounding the matter is that the viruses behind many diseases are mutating into heartier organisms after years of being bombarded with antibiotics. Indeed, the World Health Organization reports that at least 30 new diseases have been scientifically recognized around the world in the last 20 years. Two of them are SARS and monkeypox.

While world health officials have expressed confidence in getting SARS under control, its impact on healthcare workers is leaving a permanent mark. In early June at the Fourth World Congress on Pediatric Intensive Care, Dr. Thomas Stewart, director of critical care at Mount Sinai Hospital and University Health Network in Toronto, told attendees that the SARS outbreak in Toronto has turned the lives of healthcare workers "upside down." At the onset of the outbreak, 69 healthcare workers at Toronto's Mount Sinai Hospital were quarantined, Stewart said. Within 10 days, seven be came sick with SARS. Some remain critically ill. Others, he said, are fearful. Amazingly, Stewart added, many Toronto healthcare workers continued coming to work and kept treating patients with SARS despite the risks and hardships such work imposes. They work in full protective gear, including masks, gowns, gloves and for high-risk procedures on critically ill patients. "Full head cover and/or full suits," he added. In late June, health officials confirmed at least 12 human cases of monkeypox, a West African disease not previously seen in the Western Hemisphere, in Wisconsin, Indiana and Illinois. Nationwide, 72 suspected cases were reported--22 in Indiana, 30 in Wisconsin, 15 in Illinois, two in Ohio and one each in Arizona, Kentucky and Missouri.

Health authorities were investigating whether two Wisconsin healthcare workers may have contracted monkeypox from patients. If true, the event would mark the first known transmission of the virus from one human to another in the United States. One worker was a nurse who, despite wearing protective clothing, including a mask, gloves and a gown, still developed symptoms after caring for a patient with a suspected monkeypox infection.

Pamela Joggerst, an ICP at Shawnee Mission (KS) Medical Center in Kansas City, said she feels fortunate her facility is part of the CDC's National Nosocomial Infections Surveillance System, which allows her to closely monitor outbreaks. "Everyone's antennae are constantly up these days in the hospital," she said. "If we weren't fortunate enough to have the fast acting epidemiologists we have today at the CDC, we'd all be in trouble. Some patients who come to our emergency department are taken aback when staff ask if they've been in contact with a prairie dog or exotic animal recently, but we have to be ever vigilant."

Safety a relative newcomer

For more than a century, very little had been done to recognize the hazards healthcare workers faced. Florence Nightingale introduced basic sanitation measures such as open-window ventilation and fewer patients per bed; the Austrian surgeon, Semmelweis, initiated routine hand washing in the late 1800s. New hazards began to appear in the 1900s when physicians experimenting with X-rays were exposed to radiation, and operating room personnel faced possible explosions during surgery involving anesthetic gases.

Nearly 80 years went by before the most significant guidelines protecting healthcare workers--universal precautions and the bloodborne pathogens standard--were introduced. In November 2000, the Needlestick Safety and Prevention Act was signed into law, requiring stricter OSHA standards on needlestick injury prevention and reporting. A year later, OSHA revised its Bloodborne Pathogens Standard to give more teeth to the needlestick legislation.

While these landmark guidelines and laws have made hospitals safer places in which to work, they've also led to higher costs for hospitals, and their sheer pervasiveness has reaped unintentional consequences such as fear and complacency among nurses, physicians and other caregivers.

Some observers say escalating costs to comply with new safety regulations have many hospitals questioning the need for so much regulation. And in many cases, those concerns are short sighted. For example, many balk at higher budgets to pay for safer needles, yet forget the much higher cost of treating needlestick injuries.

And when the nation's largest healthcare workers union commissioned a survey relating to the nursing shortage, it found that one in five nurses who left hospital work did so because of their concerns about workplace safety. Said Katherine Cox, health policy analyst for the American Federation of State, County and Municipal Employees, "There is not a shortage of nurses, but rather a shortage of nurses willing to work in nursing under the conditions now being offered. Cox said those conditions, many of which have nothing to do with safety but pay and career ladders, include updating and modernizing equipment such as computerized prescription drug dispensing, safer needle systems, and lifting devices.

Still, no worker in today's hospital is immune from the pressures of doing more with less, and doing it well. Said one ICP who spoke with HPN on condition of anonymity, "The workload today in hospitals is so intense that we as infection control practitioners cannot keep up with the needs of our hospitals. ICPs today wear more hats than ever; I handle risk management and occupational health issues at the same time. And we're getting more and more acutely ill patients. Money is the number one reason. Staff cutbacks are making our jobs harder. It's been a real cold shower for all of us and we've shelved our plight for now because of all that's going on in terms of SARS and other crises."

Climate of complacency

Truth be told, many infection control practitioners admit that their greatest enemy may not be drug-resistant pathogens or world pandemics, but staff complacency.

"Our society has become so desensitized to disease and therefore, careless," Detroit Medical Center's Katherine Preney told HPN. Preney said complacency starts when a healthcare worker fails to engage a critical safety feature on a device because it's either too cumbersome or they are rushed. "Everyone assumes our healthcare system will cure all that ails us, but that's not necessarily the case. It's hard as an infection control practitioner to keep up the level of concern with staff and patients and with everything else that's going on. There's a fine line between creating a panic and downplaying unnecessary fears."

Shawnee Mission's Joggerst said she believes administrators and healthcare workers need to step up to the plate in terms of their level of concern. "Hospital workers today think they are dressed in armor," she said. "Some think the precautions we follow are overkill, but that's the reality of things today. Healthcare workers are inundated with information. I have found that they are highly resistant to new protective gear or behaviors until you give them a valid reason for them. That's why we practice evidence-based infection control today."

In some cases, complacency among healthcare workers is replaced by fears, some of which are unnecessary.

When Wisconsin state health officials offered smallpox vaccinations in an early June clinic to about 90 healthcare workers who had been in contact with animals or other people infected with monkeypox, no one came. Some reportedly declined to participate after reviewing CDC information on side effects, which in rare cases can be serious or even deadly.

The American Federation of State, County, and Municipal Employees says it believes the federal program to inoculate 500,000 healthcare workers against smallpox poses "serious safety and workplace issues." Approximately 500,000 healthcare workers were to be vaccinated in the first phase, followed by a second wave of an additional 10 million healthcare and other emergency responders.

Early on, two hospitals in Atlanta and Richmond, Va., dropped out of the smallpox program, arguing that a smallpox attack seems unlikely whereas the vaccine can cause severe and even fatal complications in a few who receive it (roughly two deaths for every million people vaccinated). They also pointed to the small risk that careless hospital workers might spread vaccinia virus to some of their patients, causing potentially severe harm to those with weakened immune systems or certain skin disorders.

Henry Ford's Jennifer Madigan told HPN that the Detroit hospital system's recent smallpox vaccination program yielded a poor response among volunteers. "We were expecting at least 200 employees to volunteer throughout the Henry Ford Health System, but quite a few less than that came," she said.

In the case of the smallpox vaccination program, however, at least some of the fears are well founded. (Several deaths may be linked to recent smallpox vaccinations, which also now preclude patients with major cardiac risk factors such as hypertension, diabetes, hypercholesterolemia and smoking.)

"Smallpox is a very dangerous disease. Our staff are very knowledgeable and attentive and investigate everything," said Joggerst. "When you tell a healthcare worker they could contract vaccinia, it's devastating to them. This kind of thing puts healthcare workers on edge. You give a staff person a smallpox vaccine shot, tell them they'll have to continue working and if they get sick, we're not sure if they'll be covered, how do you think you'd react?" (A $42 million supplemental spending bill was recently passed providing compensation for smallpox volunteers who suffer side effects from the vaccine.)

In other cases, fear sometimes leads to overkill. For example, some observers think healthcare workers deliberately choose high-level personal protective equipment for procedures that don't call for such precautions. "In the past, end users have sometimes erred on the side of caution by using impervious gowns for a wide range of procedures," noted J.R. Sommers, Ph.D., a scientist with Kimberly-Clark Health Care. "But only 15 percent of surgical procedures, such as those involving high fluid and high pressure, actually call for the highest level of protective gowns."

In late May, OSHA withdrew a proposal aimed to stiffen its 1997 tuberculosis precautions because it did not meet the burden of risk to justify the enactment and publication of a final standard. The proposal required such things as isolation rooms to be kept under negative pressure, the use of N-95 respirators, as well as other airborne disease control measures. Critics of the proposal pointed to a steady decline in TB cases since the early 1990s, while supporters argued that TB remains a serious risk to healthcare workers.

Brisk innovation

The OSHA and CDC guidelines in the late 1980s and the past decade have sparked a level of innovation rarely seen in the medical device industry. More than 1,000 U.S. patents for safer medical devices have been issued since 1984. Those efforts have brought a host of safer devices designed to prevent sharps injuries--from syringes and phlebotomy devices and lancets, to vascular access devices, suture needles and sharps disposal containers.

Franklin Lakes, NJ-based Becton Dickinson, probably the largest manufacturer in the sharps safety arena, estimates that U.S. hospitals have transitioned over 80 percent of their sharps from conventional to safety-engineered designs for products such as IV catheters, "needleless" IV connectors, blood drawing needles, winged needle sets, and lancet devices. According to Tammy Lundstrom, M.D., vice president and chief quality and safety officer at Detroit Medical Center, sharps injury prevention devices widely proliferated for many clinical procedures, but the momentum slowed in the late 1990s as managed care and healthcare reform initiatives intensified pressure to reduce costs, and shrinking healthcare resources were spread over many other competing patient and worker safety issues.

In recent years, however, the pace has picked up. Two large suppliers--BD and Abbott Labs, Abbott Park, IL--recently announced plans to phase out many products that contain needles, mirroring OSHA's goal of eliminating needles entirely in medical devices by the end of this decade. Abbott's phase-out includes all IV sets that contain or require needles. BD's plan includes a phase-out of many conventional sharps, including IV catheters, winged needle sets and lancets. BD said it plans to replace these with safety-engineered devices.

And the industry's safety zeal is beginning to reap innovations in the form of new kinds of sharps devices, including Huber needles, which pose a high risk for accidental needlestick injury due to the rebound effect experienced when removing the needle from an IV port. Such needles pose a particular risk an IV port. Such needles pose a particular risk for exposure to bloodborne pathogens since they are often used for venous access with AIDS/HIV patients. For example, B. Braun Medical, Bethlehem, PA, introduced in June its passive Surecan Safety, Huber Needle Infusion Set, which automatically retracts the needle when it is withdrawn.

Other recent innovations have addressed staff hygiene, including one of the oldest, least inexpensive, and most effective ways of preventing the spread of disease--hand washing.

The CDC's October 2002. guidelines emphasizing the use of alcohol-based hand rubs as a way to stem healthcare-associated infections has literally swept the nation's hospitals. John Boyce (one of the CDC guideline's authors) estimated at an APIC post-conference meeting in mid-June that more than 95 percent of hospitals now use alcohol hand agents.

Henry Ford's Madigan said the hospital installed alcohol rub dispensers throughout the facility before the ink dried on the CDC guidelines. "We decided it was worth doing based on the data because of the money we'd save in terms of reduced nosocomial infections," she said. "Some of our older nurses in the ambulatory care sites initially resisted them because they didn't think they were necessary? but after we showed them the conclusive data about the efficacy of alcohol rubs, they were convinced."

One of the more significant innovations in staff protection yet to come will be in the area of surgical gowns. For years, manufacturers have touted the various properties of their gowns as "fluid resistant, "fabric reinforced," and "impervious." For the first time, by early next year, all surgical gown makers will begin following industry-accepted laboratory test methods to form the basis for barrier claims under a barrier performance classification system for protective apparel and drapes.

The system, under development by the Association for the Advancement of Medical Instrumentation (AAMI), will provide manufacturers with a consistent basis for creating device labeling claims regarding barrier efficacy against liquid-borne microorganisms. Through labeling requirements, the standard is also intended to assist end-users in selecting the appropriate protective apparel and drapes. The new AAMI classification system will establish tour levels of protection, with Level 4 the most stringent (meeting ASTM F1671, a standard test for simulated viral penetration for. resistance of materials used in protective clothing), said Kimberly-Clark's Sommers. For more than a decade, K-C has marketed three types of Level 4 gowns, including the Ultra Impervious, Ultra Impervious Zoned, and MicroCool gowns. While Kimberly-Clark gowns have always met established ASTM tests for barrier claims, the new AAMI standards "will force all manufacturers to perhaps be a little more stringent and thorough in their product claims," Sommers said. "This may drive up costs a bit for some companies, but will demystify the classification process for end users."

Kimberly-Clark spokes person Judith Webb believes the new labeling standards will be a welcome development for busy OR personnel. "End users need a quick way to assess what they're taking off the shelf when preparing for a surgical case," she said. "For decision makers and purchasing people, the label standards will give them the ability to make apples-to-apples comparisons when evaluating gowns."

"The [gown] industry is coming together over the labeling issue; it's also a way to better position their product lines and ensure that labeling is consistent with their own product claims," added Ron Evans, vice president, corporate development for Clearwater, FL-based Maxxim Medical, a diversified manufacturer, assembler and marketer of single-use drapes and gowns, specialty medical/surgical products such as custom and standard procedure trays, medical and surgical gloves, vascular access and critical care products.

Evans said he agrees that the new standards will help healthcare workers in a number of ways. "Surgical staff should not be encumbered by these kinds of on-the-spot decisions when so many other critical care decisions need to be made," he said. "Over the years, products have made reference to their supposed viral properties, but there are probably some inconsistencies out there."

Evans said the new standards will not only put infection control claims on a level playing field, but also save hospitals money in the long run. "There are untold dollars spent unnecessarily every year on treating post operative infections that may result from the failure of PPE in surgery," he said.

Has innovation peaked?

As brisk as innovation has been in safety devices, many infection control practitioners are begging for more. According to the CDC, technology has not advanced to the point where sharps with engineered safety protection are available for all types of procedures performed in hospitals. These include such things as safety spinal needles for lumbar puncture and safety devices for drainage of fluid from deep body cavities.

"I'm not entirely comfortable with the rate of innovation. The industry has a long way to go still," said Preney, who says she has witnessed a lot of so-called safety devices that are "marginal in quality and not worthy of even a trial at our institution.

"Many of these devices I've seen need to have a bit more human engineering put into them," Preney added. "If the safety needles and sharps aren't easy to use, intuitive, and easy to convert from an existing product, we won't bother with them. It's better to revert to an established device that staff is comfortable with."

Joggerst agrees. "Some workers will always be better than others at drawing blood and using needles in general," she said. "Manufacturers are working as fast as they can to develop new safety features, but if workers don't engage those features, what's the point? If a product isn't easy to use or works well, it simply won't get used." Joggerst and other ICPs sound a fervent call for manufacturers to involve front-line workers more in the development of all safety devices, not just needles.

Are hospitals safer places to work? Ask any infection control practitioner if hospitals are safer places than they were 20 years ago and all will say 'yes.' With a few caveats, of course. "We live in a different world today. We have immunocompromised people, strange diseases, and an aging population with higher levels of acuity," said Joggerst. "Many people today have learned to question the medical care they receive, yet they don't take care of themselves and avoid risks on the outside."

"Are hospitals safer places to work these days? Yes and no," said Sommers. "The world was a vastly different place 20 years ago. We didn't have AIDS, SARS or bioterrorism threats. We didn't have multi-drug resistant organisms. We didn't see emergency room physicians and nurses pummeled by violence while trying to take care of someone off the street. Yes, we have more sophisticated safety devices than ever before. But hospitals are hazardous places in which to work. We wouldn't have the breadth of personal protective equipment we have it they weren't."

John Hall is a former senior editor of Healthcare Purchasing News and a Chicago-based freelance writer specializing in healthcare.

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