Quality America OSHA Watch

OSHAWatch
U
P
D
A
T
CDC Coughs Up
New TB Guidelines
Bottom line: you
must comply
with the new
CDC TB
Guidelines
when they
are finalized.
T
he Centers for Disease
Control and Prevention
(CDC) recently revised their
TB Guidelines, last updated
in 1997. The 269-page
tome, issued in draft form, is on the
fast track to becoming a final, official
Guideline. Once finalized, it will
constitute the official U.S. Public Health
Guidelines.
Does OSHA Mandate Compliance?
OSHA dropped their controversial TB
rule last year and issued a Respiratory
Protection Standard. Meant to include TB,
it is not very applicable for ambulatory
medical and dental facilities. For this
reason, outpatient facilities have continued
to follow the CDC Guidelines since
OSHA can cite an ambulatory medical
facility for not following the latest US
Public Health Guidelines. Bottom line:
you must comply with the new CDC
TB Guidelines when they are finalized.
Assuming the draft Guidelines don’t
undergo further changes before they are
finalized, here’s a snapshot of the major
differences you can expect to see:
• A new annual risk assessment form
classifies workplaces into one of three
TB risk categories: low risk, medium risk
and a temporary category for current
TB transmission in a facility (Pg 2, Table 1).
E
S
March/April 2005
Volume 7, No.2
Inside:
CDC Coughs up
New TB Guidelines...............1
Mask up for Flu....................3
Question of the Month ..........5
In the News...........................6
Q: I used to work in
a hospital lab where
we had a safety
shower. I now work
in a doctor’s office
lab and am wondering if we need one.
Ask the Expert.......................8
2004 OSHA Violations .......10
Answer to the Last
Question of the Month ........11
Update:
Important Quality America OSHA
Safety Program Manual update!
We’ve revised Tab 3 to include First Aid.
Please go to: www.osha-compliance.com
and click “OSHA Safety Program
Manual updates.”
• The new Guidelines replace the term
continued on next page
We Make Compliance Easy!
1
CDC Coughs Up New TB Guidelines
“PPD” (purified protein derivative)
with “tuberculin skin test”(TST).
• A new blood test, the QuantiFERONTB, becomes an option for screening
healthcare workers (HCWs) for TB
infection.
Editor’s Note: OSHA Watch staff could
not find this test on the menus of the two
top referral laboratories in the US, so its
availability is limited.
Ambulatory medical settings without
designated isolation rooms (i.e., with
HEPA filtration and/or UV lights), must
segregate suspected TB patients from
employees and other patients before
they are transferred to another facility
for testing and treatment.
• The new Guidelines require HCWs to
seal-check, then don N-95 masks, when
in close proximity to a suspected TB
patient.
• Clarifies that ongoing TB skin test
New information
screening for HCWs in low risk work
places is not needed. Decreases to once
annually rescreening for medium risk
facilities (Table 2).
about multi-drug
• Includes some new terms: “airborne
resistant TB and
HIV infection
infection isolation” (AII) and “latent TB
infection” (LTBI). Those with LTBI have
a positive TB skin test, but do not
have active TB.
has been
• Requires patients with suspected TB
to don surgical masks, or if that is
impossible, that they practice strict
respiratory hygiene (see poster, pg. 3).
included.
• New information about multi-drug
resistant TB and HIV infection has been
included.
All of these changes require a complete
overhaul of the TB policies (Tab 6) in your
OSHA Safety Program Manual. The staff
at Quality America will totally rewrite Tab
6 for you once the CDC finalizes the draft
Guidelines (comments were due back to
CDC by February 3, 2005, and CDC is
expected to quickly issue final Guidelines).
We’ll update you further on this in the
May/June issue of OSHA Watch, or, if the
Guidelines aren’t final by that time, in a
future issue of OSHA Watch.
Table 1. Draft Risk Assessment for Ambulatory Medical and Dental Facilities
Low risk
Medium risk
Potential ongoing transmission
<3 TB patients/year
>3 TB patients/year
Evidence of ongoing M. tuberculosis
transmission, regardless of setting
Table 2. Draft Recommendations for Tuberculin Skin Testing (TST) Healthcare Workers
Low risk
Medium risk
Potential ongoing transmission
Baseline TST Yes, 2-step upon hire
Yes, 2-step upon hire
Yes, 2-step upon hire
Ongoing
screening
TST
Every 12 months
Administer one TST as soon as possible after
exposure to M. tuberculosis. If negative, re-test
8–10 weeks after exposure.
No
Source: Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care
Settings, 2005. Go to: www.cdc.gov/nchstp/tb/Federal_Register/default.htm, Dec. 6, 2004
2
www.quality-america.com • 1-800-946-9956
Mask Up For Flu Patients, Too
F
lu is transmitted just like TB:
by droplets generated when an
infected person coughs, speaks
or sneezes. Those with the flu
can transmit it one day before
symptoms appear and up to seven days
after the onset of illness. If your employees
come within about three feet of a
coughing, sneezing person, they can
become infected.
• Wear a gown if soiling of clothes with
Protecting Your Staff
The best line of defense against flu
is vaccination, but only about 30%
of healthcare workers are vaccinated
annually. To prevent non-immunized
workers from being infected on the job,
CDC suggests that staff:
Evaluate staff who demonstrate an
influenza-like illness and perform rapid
influenza tests to confirm whether the
causative agent is influenza. Then, decide
whether or not to remove them from
duties that involve direct patient contact,
especially with immunocompromised
patients. If removed, do not let them
provide patient care for five days after the
onset of symptoms.
continued on next page
• Wear gloves if hand contact with
respiratory secretions or potentially
contaminated surfaces is anticipated.
a patient’s respiratory secretions is
anticipated.
If your
employees come
• Wear a surgical or procedure mask upon
entering the patient’s room or when
working within three feet of the patient.
Remove the mask when leaving the
patient’s room and dispose of the mask
in a waste container.
within about
three feet of a
coughing, sneezing
person, they can
become infected.
Source: Respiratory poster. Go to: www.cdc.gov/OralHealth/pdfs/RespiratoryPoster.pdf
OSHA Watch Update March/April 2005
3
unwilling to don
Organize Your Reception Area to
Minimize Respiratory Disease
Transmission:
• Hang signs or posters (see pgs. 3 & 4)
instructing patients and persons who
accompany them to inform staff if they
have symptoms of respiratory infection.
a mask, they
• Locate tissues or masks directly under
If a patient is
these signs so patients and visitors who
are coughing or sneezing can cover their
nose and mouth.
should practice
strict respiratory
• Provide dispensers of alcohol-based hand
rubs in waiting areas.
etiquette
Stop the spread of germs that make you and others sick!
• Encourage coughing persons to sit at
least three feet away from others, if
possible.
• If a patient is unwilling to don a mask,
they should practice strict respiratory
etiquette (see etiquette below).
Cough
Etiquette/
Respiratory
Hygiene
• Cover nose and mouth when
coughing or sneezing.
Cover
your
Cough
Cover your mouth
and nose with a
tissue when you
cough or sneeze
or
cough or sneeze into
your upper sleeve,
not your hands.
• Use tissues to contain respiratory
secretions and, after use, dispose of
them in the nearest wastebasket.
• Wash hands with regular
soap and water
(or alcohol hand
rubs) after
contact with
respiratory
secretions
and contaminated
objects.
Put your used tissue in
the waste basket.
You may be asked to
put on a surgical mask
to protect others.
Clean
your
Hands
after coughing or sneezing.
Sources:
Wash with
soap and water
or
clean with
alcohol-based
hand cleaner.
Minnesota Department of Health
717 SE Delaware Street
Minneapolis, MN 55414
612-676-5414 or 1-877-676-5414
www.health.state.mn.us
Minnesota
Antibiotic
Resistance
Collaborative
Updated Infection Control Measures for the
Prevention and Control of Influenza in HealthCare Facilities. January 20, 2005.
Go to: www.cdc.gov/flu/professionals/
infectioncontrol/healthcarefacilities.htm
Go to: www.cdc.gov/flu/professionals/
labdiagnosis.htmhttp
Source: Cover your Cough poster. Go to: www.cdc.gov/flu/protect/pdf/covercough_hcp8-5x11.pdf
4
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CLOSE TO HOME ©2004 John McPherson. Reprinted with permission of UNIVERSAL PRESS SYNDICATE. All Rights Reserved.
One Last
Chance
Quality America
invites
all TN, NC & SC
office managers, office
staff & physicians
to join us at our
live filming début of…
Dr. Dunn Live!
OSHA Annual
Re-training Seminar
Asheville, NC
March 23, 2005
Call: 1-800-946-9956
Limited seating
For more information on sharps
injury prevention products visit
ISIPS, the International Sharps
Injury Prevention Society at
www.isips.org. To receive a free
weekly newsletter on the latest
information on needlestick
injuries, hepatitis, HIV, etc.,
sign up for the ISIPS Newsletter
by going to www.isips.org/
registration.html.
OSHA Watch Update March/April 2005
Q
QUESTION
of the month
How should eye goggles be
disinfected?
Find out in the next edition of
Quality America’s OSHA Watch Updates
5
N-95 TB Respirators: Photo provided by Kimberly-Clark
in the
NEWS
6
Uncle Sam Nixes
Fit-testing for TB Masks
in June 2003. Prior to that, he was in
private law practice in Texas.
Tucked away deep in a 2005 domestic
agency spending bill is a provision that
prohibits OSHA from enforcing annual
fit-testing for N-95 TB respirators.
President Bush signed the bill December
9, 2004 which states that “no funds shall
be used to administer or enforce the
provisions of the General Industry
Respiratory Protection Standard that
require annual fit-testing after the initial
fit-testing of respirators for occupational
exposure to TB.” Explanatory text
that accompanied the bill advised
OSHA to wait until the CDC
completes the draft Guidelines for
Preventing the Transmission of
Mycobacterium tuberculosis in
Health-Care Settings 2005.
Currently, these Guidelines do
not require annual fit testing.
Editor’s Note: See related story in
this issue of OSHA Watch.
Patient Knifes Nurse
OSHA Snares
New Chief
Secretary of Labor, Elaine
L. Chao, announced the
resignation of OSHA
Administrator, John Henshaw, effective
Dec. 31, 2004. Under Henshaw, OSHA
discontinued the TB regulation and
introduced a new General Respiratory
Protection Standard. He will mostly
be remembered for leading OSHA’s
homeland defense efforts by assisting
police, firefighters, and volunteers in
the aftermath of the terrorist bombings
of September 11, 2001. Henshaw also
developed specialized response teams to
address chemical, biological, radiological,
and other types of attacks, such as natural
disasters.
Henshaw admitted disappointment
and frustration over continuing worker
fatalities and in the difficulty of getting
employers to see the value in compliance.
Henshaw is replaced by Jonathan L. Snare
who joined the U.S. Department of Labor
An 80-year old patient stabbed a nurse in
the back with his pocketknife at Bons
Secours Maryview Medical Center in
Portsmouth, VA. Reportedly, the patient
became enraged when leaving
the recovery room after foot
surgery. To keep him from
falling, the nurse grabbed the
patient’s arm. Immediately after,
she felt a blow to her back,
which was later discovered to be
a puncture in her lung from the
pocket knife. Security officers
eventually calmed the patient
and took him to jail, where he
subsequently received five years
of supervised probation.
Editor’s Note: We hear stories too
often of attacks by patients on
healthcare workers. Be sure your
employees receive training about how
best to react to angry people and how to
minimize the chance of anger escalating
to violence. Quality America offers
an Online Training course,
Preventing Workplace Violence.
For more information, visit:
www.quality-america.com.
www.quality-america.com • 1-800-946-9956
OSHA Debuts New
Webpage
OSHA unveiled its newest Safety and
Health Topics page focusing on chemical
hazards. Check it out at www.osha.
gov/SLTC/reactivechemicals/.
Best Practices for First
Receivers in Mass Casualties
Looking to develop emergency plans for
worst-case scenarios? OSHA’s new “Best
Practices” can serve as a template to help
you protect staff while receiving and
treating victims exposed to hazardous
chemical, biological or radiological
substances. Derived from emergency
plans developed by hospitals across the
U.S., “Best Practices” includes practical
examples of decontamination procedures
and medical monitoring for first receivers
who respond to a mass casualty incident.
Source: OSHA Best Practices for HospitalBased First Receivers of Victims from Mass
Casualty Incidents Involving the Release of
Hazardous Substances. Go to: www.osha.gov/
dts/osta/bestpractices/firstreceivers_hospital.
html
Sources: 1.Press Release, Association for
Professionals in Infection Control and
Epidemiology (APIC). November 17, 2004.
2. ASHE study. Go to: www.ashe.org/ashe/
currentevent/abhi.html
Long Shifts Boost Errors
In previous In the News columns, we’ve
reported on studies linking long hours
logged by medical residents to medical
errors. (Since July, 2003, medical residents
have been restricted from working more than
30-hours straight or 80-hours per week, but
not all hospitals are complying with the new
restrictions—Editor’s note).
Not surprisingly, nurses who work
long shifts also have higher error rates. As
many as 40% of all hospital nursing shifts
exceed 12 hours, and these workers have
error rates three times as high as their
counterparts who clock in for shorter
shifts. The odds of making an error are
also greater whenever nurses work more
than 40 hours in a week. Most errors
involve medication, such as giving the
wrong drug or dose or giving the
medication later than scheduled.
Source: CNN News, July 12, 2004
Alcohol Cleansers in Exit
Corridors?
Don’t Wear Rubber Charity
Bracelets to the Hospital!
It’s now okay to hang alcohol-based hand
rubs in exit corridors. In fact, a new
regulation from the Centers for Medicare
and Medicaid Services (CMS) promotes
rather than prohibits the practice, since
convenient access to alcohol-based hand
rubs results in better hand hygiene
compliance. The National Fire Protection
Agency had already modified their codes
to permit hallway
placement, based
on a study by the
American Society
for Healthcare
Engineering
(ASHE) which
showed minimal
risk of fire from hallway placement of
alcohol-based hand rubs.
While the familiar yellow LiveStrong
bracelets are the most popular, rubber
wristbands of every color are worn by over
40 million Americans in all 50 states. People
sport pink bands for breast cancer, red bands
to support US troops, white for tsunami
victims, purple for cancer research and
almost every other color of the rainbow to
support a particular cause. But in some
hospitals, a yellow or purple band means
“do not resuscitate” and a green or red band
could indicate that the patient has an allergy.
These bands could confuse staff, especially
in a highly-charged code-blue-type situation.
There have been several reports of near
misses due to these bracelets and one where
a patient was not resuscitated due to
wearing a LiveStrong bracelet.
OSHA Watch Update March/April 2005
The odds of
making an error
are also greater
whenever nurses
work more than 40
hours in a week.
7
Q
Custom Kits, Sharps Containers,
Cleaning Whirlpools, Safety Showers,
Evacuation Route Maps
Q: Our custom kits come packaged with
sharps that are not the safety version. Is
this a valid exemption for not using safety
needles?
ask the
A: Custom kits with pre-packaged
unprotected sharps violate OSHA’s
Bloodborne Pathogens Standard, so order
custom kits that contain the safety needles
your employees have chosen. If you have
several kits in stock containing non-safe
needles, supplement each kit
with a protected sharp by,
for example, taping the
protected sharp to the
outside of the kit; and
require employees to use it
when they open the kit.
EXPERT
Q: I disagree with the answer you gave to
last issue’s Question of the Month, listing
the areas where sharps containers should
NOT be placed (backs of room doors, near
light switches and thermostats, under
cabinets, etc.). Where in the OSHA
regulations does it say this?
Dr. Sheila Dunn
A: OSHA’s Bloodborne Pathogens
Standard [1910.1030(d)(4)(iii)(A)(2)]
says that sharps containers must be:
• easily accessible to personnel,
• located as close as is feasible to
the immediate area where sharps
are used or can be reasonably
anticipated to be found,
• maintained upright through use,
• replaced routinely and not be
allowed to overfill.
Note how vague OSHA’s
standard is! What does “easilyaccessible” mean? How close is
“feasible”? The National Institute
for Occupational Safety and Health
8
(NIOSH) comes to the rescue by
providing specifics for exactly how to meet
OSHA’s standard. For instance, instead of
“located as close as feasible,” NIOSH
specifies that sharps containers be placed
within a few feet of where the sharp is
used in a particular procedure. NIOSH
also recommends that, wall-mounted,
sharps containers be hung 52-56 inches
off the floor. Bottom line: OSHA relies
on outside agencies (e.g., CDC, NIOSH,
ANSI, etc.) for these types of specifics
since it takes an act of Congress (literally)
for OSHA to update their standards.
These agencies can update their
recommendations as often as needed.
Source: Selecting, Evaluating, and Using Sharps
Disposal Containers. U.S. Department of
Health and Human Services, Public Health
Service. Centers for Disease Control and
Prevention. National Institute for Occupational
Safety and Health. January 1998. Atlanta,
Georgia. DHHS (NIOSH) Publication No.
97-111. Go to: www.cdc.gov/niosh/sharps1.html
Q: One of our employees keeps a
handful of gloves in her pocket to use
whenever the need arises. I think that
gloves should be kept in the box until
needed. The alternative seems
non-hygienic in practice. What’s your
opinion?
A: I agree with you that gloves shouldn’t
be carried in workers’ pockets since they
could be punctured, or exposed to heat or
cold, which could cause deterioration.
Q: Can you throw out a biohazard bag
that was used to transport a specimen but
was not contaminated by the specimen,
with the regular trash or does it need to
be treated and disposed of as a true
biohazard?
www.quality-america.com • 1-800-946-9956
answer
A: Since it isn’t contaminated, it could be
thrown out with the regular trash, according to OSHA. With that said, however, I
don't recommend it, because the biohazard label connotes the message “contaminated” to employees and patients, so they
will be concerned if they see biohazard
bags in your regular trash. This could elicit
complaints and might bring OSHA to
your door (which you definitely don’t want
to happen!).
Hazard Communication Standard, which
does not require showers (only eyewashes).
If your lab uses or stores large amounts of
hazardous chemicals, (hematology reagents
don’t apply here), then you are subject to
the Chemical Hygiene Standard and need
a safety shower. If that is the case, check
the shower weekly for proper functioning.
OSHA
Q: We will soon be opening four new
locations and need to know where to post
evacuation routes. Do we need to post
them in every room or only certain places
in the hallway?
doesn’t specify
where to post
evacuation routes
Q: I used to work in a hospital lab where
we had a safety shower. I now work in a
doctor’s office lab and am wondering if we
need one.
A: Labs that use bulk chemicals must have
a safety shower to comply with OSHA’s
Chemical Hygiene Standard. Physician
office labs usually don’t buy chemicals in
bulk, and are subject only to OSHA’s
OSHA Watch Update March/April 2005
A: OSHA doesn’t specify where to post
evacuation routes nor how far apart to
space them. In typical OSHA fashion, the
Agency says: “evacuation routes and exits
are posted in the workplace and are easily
accessible to all employees”. Some medical
practices hang them in every exam room
and some in one central location. The
bottom line is that your employees know
the best way to get out of the building
in the event of a fire or emergency, so
including this information as part of
your employee orientation training and
providing Exit signage in all hallways
would decrease the
number of evacuation
maps that need to be
hung. For more
information, refer to
page 3-16 in your
OSHA Safety
Program Manual.
Remember, facilities
with less than 11
employees do
not need to post
evacuation routes.
nor how far
apart to
space them.
9
2004 OSHA Violations
Those who follow
Quality America’s
OSHA Safety
Program Manual
need not worry;
all of these
standards are
covered in
detail!
O
SHA inspectors were
busy last year, citing US
workplaces for 86,708 violations. Citations were up
3.8% over 2003 and 9.5%
over the last five years. Serious violations
were up 3% in 2004 over 2003, while the
number of willful violations increased
14% over the same time period.
Called the “Dirty Dozen,” OSHA also
published its top 12 violations for 2004,
most of which do not apply to healthcare
facilities. OSHA standards that do apply
to medical and dental workplaces were
lack of HazCom training, incomplete first
aid and eyewash facilities, and lack of
MSDS for hazardous chemicals. The most
frequently violated standard in general
industry was failure to have a written
OSHA INSPECTION STATISTICS
Quality America’s OSHA Safety Program Manual
safety program (Hazardous Chemical
Standard).
Those who follow Quality America’s
OSHA Safety Program Manual need not
worry; all of these standards are covered
in detail!
FY2000
FY2001
FY2002
FY2003
FY2004
Total Inspections
36,555
35,974
37,614
39,817
39,167
Total Programmed Inspections
18,436
17,946
20,539
22,436
21,576
Total Unprogrammed Inspections
18,112
18,027
17,075
17,381
17,590
Fatality Investigations
1,195
1,130
1,134
1,021
1,060
Complaints
8,441
8,374
7,896
7,969
8,062
Referrals
4,250
4,434
4,447
4,472
4,585
Other
4,226
4,089
3,598
3,880
3,829
OSHA VIOLATION STATISTICS
FY2000
FY2001
FY2002
FY2003
FY2004
Total Violations
79,206
77,893
77,633
83,539
86,708
Total Serious Violations
50,977
52,180
53,845
59,861
61,666
365
537
331
404
462
1,825
1,872
1,867
2,147
2,360
25,427
22,776
21,128
20,552
21,705
Total Willful Violations
Total Repeat Violations
Total Other-than-Serious
Source: www.osha.gov/OshDoc/data_Enforcement_Activity/index.html
10
www.quality-america.com • 1-800-946-9956
Nurses Speak
Out on Their
Workplaces
70% cite acute and chronic effects
of stress and overwork
67% work some type of mandatory
or unplanned overtime every
month
Six Devices
Cause 80% of
Sharps Injuries
32%
Disposable syringes
19%
Suture needles
12%
Winged steel needles–butterflies
60% fear a disabling back injury
45% are afraid of contracting HIV
or hepatitis from a needlestick
injury
37% are concerned about being
infected with TB or another
disease at work
25% fear an on-the-job assault
21% are apprehensive about
developing a latex allergy
7%
Scalpel blades
6%
Intravenous (IV) catheter stylets
3%
Phlebotomy needles
* Overall, hollow-bore needles are responsible for 59%
of all sharps injuries.
Source: EpiNet Data, 2003
40% were injured on the job
(including needlesticks)
17% were physically assaulted
57% were threatened
or verbally
abused
A
A N S W E R
T O
T H E
L A S T
QUESTION
of the month
Q: Do we have to retest employees annually for TB?
Source: American Nurses Association
On-line Health & Safety Survey of
4,826 nurses. August, 2001.
OSHA Watch Update March/April 2005
A: Not unless your workplace is classified as “medium” risk, (i.e.,
you had more than three TB patients enter your facility in the last
year). If your workplace is classified as “low” risk, annual employee
TB testing is not needed. Stay tuned for additional guidance on
this issue once the new CDC TB Guidelines are finalized.
11
OSHA Alerts:
Dr. Dunn Live!
Coming Soon on DVD
Dr. Dunn makes OSHA
Re-training CLEAR, FUN
and EASY!
If you’re tired of boring, irrelevant
OSHA seminars in the past
that simply reiterate the Federal
Register…
Now You Can…
• Enjoy a fast, convenient and
practical DVD that gives you
advice about procedures to
ensure worker safety.
• Learn easy methods to apply in
your facility in order to avoid
stiff OSHA fines.
• Enjoy an interactive game,
Stayin’ Alive, where Dr. Dunn
demonstrates and reinforces the
concepts of personal protective
equipment.
• Review the basic universal
precaution, chemical safety and
respiratory precautions.
• Receive over 40 pages of useful
OSHA information and earn
Contact Hours (2)
Quality America is approved as a
Provider of continuing education
programs in the clinical laboratory
sciences through the ASCLS
P.A.C.E.® program.
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Next Issue:
• Final TB Guidelines
(if available)
• Substance Abuse in the Workplace
Dr. Sheila Dunn, President & CEO
PO Box 8787 • Asheville, NC 28814
1-800-946-9956
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