Hazards in Healthcare

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1 Hazards in Healthcare CYNTHIA ELLWOOD, PHD, CIH ASSOCIATES IN OCCUPATIONAL + ENVIRONMENTAL HEALTH, LLC ROBERTA SMITH, RN, MSPH, CIC, CIH OCCUPATIONAL HEALTH PROGRAM MANAGER- COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT

2 Misconception Healthcare work is safer than other work involving exposures to chemical, ergonomic and physical hazards

3 Attitude Patient safety is of higher priority than personal safety Ambivalence

4 Filling in gaps will help us reduce hazards in healthcare

5 Gap 1 Limited hazard surveillance data

6 Gap 2 Limited health surveillance data

7 Gap 3 Unable to compare illness and injury rates to other industrial sectors

8 Gap 4 Limited epidemiologic data Have seen increased rates of cancer in nurses Not enough information to understand all the underlying causative factors

9 Gap 5 Unknown health implications from new practices and technologies

10 Q. What are the health and safety topics we ll talk about today? A. Occupational exposure to NIOSH Health and Safety Practices Survey of Healthcare Workers: Training and Awareness of Employer Safety Procedures, AJIM 57: (2014)

11 1 Hazardous Drugs - aerosolized antibiotics/ antivirals -

12 2 Hazardous Chemicals - waste anesthetics gases -

13 Exposure The condition of being subjected to a chemical, physical or biological agent

14 Dose Amount of agent that workers absorb through all routes of entry Air exposure

15 What is it that is not a poison? All things are poison and nothing is without poison. It is the dose only that makes a thing not a poison. Paracelsus

16 Hazardous Drugs For sick patients, the therapeutic benefits of hazardous drugs outweigh the risk of undesirable side effects

17 Hazardous Drugs Healthcare workers can experience the undesirable side effects of hazardous drug exposure with no health benefits realized

18 Hazardous Drugs

Hazardous Drugs updated list http://www.cdc.

19 Hazardous Drugs updated list

20 Respiratory therapists report concern over aerosolized antibiotics/ antivirals Tobramycin Amikacin Colistin Pentamindine Ribavirin

21 Hazardous Drug Tobramycin Amikacin Colistin Pentamindine Ribavirin

22 Ribavirin Administration Bone marrow transplant patient for prevention/treatment of Respiratory Syncytial Virus

23 NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin At a children s hospital, BMT unit Average age 7 yrs 3-4 months at a time 2 gram dose over two hours 1-3 treatments per day

24 NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin Administered by respiratory therapist using small particle aerosol generator Patient received dose through loosefitting vinyl Airlife Face Mask

25 NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin NOVA Tenthouse scavenging system with patient s face and torso enclosed by the Tenthouse Suction system fitted with Pall HME bacterial/viral filter % efficiency Aerosol particle size at microns

26 NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin Personal air samples - attending nurse - - respiratory therapist - Area samples

27 NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin Personal air samples resulted in exposures below limit of detection due to short sample times

28 NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin Area samples resulted in exposures ranging from 11.7 to 1125 ug/m3 Leaking from Tenthouse enclosure If nurse and respiratory therapist remained in room, exposures would be close to area concentrations

29 Tenthouse Enclosure

30 Ribavirin Toxicity Hemolytic anemia results in worsening of cardiac disease Teratogenic and embryocidal effects in many species

31 Ribavirin Toxicity - Acute Headaches, eye irritation, lacrimation, nausea, dizziness, fatigue, rash, bronchospasm, chest pain, and nasal congestion Precipitate on contact lenses eye irritation Adverse acute health effects resolved within minutes to hours of discontinuing exposure to aerosolized ribavirin

32 Occupational Exposures and the Precautionary Principle Where there are exposures and threats of adverse health effects, uncertainty should not be a reason for postponing action to prevent exposure

33 Exposure Controls Double gloves Protective gown Eye protection (goggles) Respiratory protection (N95) Dilution ventilation in room Proper Housekeeping

34 Exposure Controls Local exhaust ventilation (scrubber) with slightly greater airflow than aerosol generator Confirm tent depressurization Time - turn off aerosol generator, wait 5 minutes before opening tent

35 Employer Exposure Controls Written Procedures Training Specialized equipment PPE Ventilation Proper disposal Medical surveillance

36 Medical Surveillance One aspect of a comprehensive prevention program to minimize/eliminate occupational exposures

37 Medical Surveillance Collecting and interpreting data to detect changes in health status Establish initial baseline Monitor future health relative to baseline

38 Medical Surveillance Identify changes in health status prior to disease Identify need for stricter exposure controls

40 Generic name Commercial name Year introduced Nitrous oxide Nitrous oxide 1844 Halothane Fluothane 1956 Enflurane Ethrane 1974 Isoflurane Forane 1980 Desflurane Suprane 1992 Sevoflurane Ultane 1995

41 Who s exposed? Anesthesiologists Anesthesiologist assistants Nurse anesthetists Surgeons Dentists Perioperative nurses Recovery room nurses

42 Major Health Effects Spontaneous abortion (N 2 O) Congenital abnormalities (N 2 O) Headache Fatigue Nausea Cognitive impairment

43 Name NIOSH REL* (ppm) ACGIH TLV (ppm) Nitrous oxide Halothane 2 50 Enflurane 2 75 Isoflurane - - Desflurane - - Sevoflurane - - *During period of administration

44 Agent UK STEL TWA (ppm) Austria STEL TWA (ppm) Norway STEL TWA (ppm) Finland STEL TWA (ppm) Isoflurane Desflurane Sevoflurane Enflurane

45 Global Harmonization System Hazard Statements Causes severe eye irritation Suspected of damaging fertility or the unborn child May cause damage to organs through prolonged or repeated exposures

46 Global Harmonization System Hazard Statements - Sevoflurane May cause allergy or asthma symptoms or breathing difficulties if inhaled

47 OSHA states that the risks have not been established since there is limited toxicological data, and recommends that until more information is available, it is prudent to attempt to minimize occupational exposures to these gases as with all anesthetic agents

48 Exposure concentration during procedure = 6.2 ppm

49 Exposure concentration during procedure = 1.2 ppm Full shift TWA exposure = 0.45 ppm

50 Exposure concentration during procedure = ND

51 Exposure Controls Anesthesia machine leak points Scavenging system Dilution ventilation Work practices

52 Anesthesia Machine Leak Points High pressure piping at wall outlet High pressure piping at machine connection All connections - low pressure side Check daily for leaks

53 Operating Room Ventilation Minimum of 20 air changes per hour 4 air changes outside air

54 Work Practice Controls in the OR Turn off gas when: - intubating - repositioning patient - flush breathing system prior to extubation

55 Work Practice Controls in the OR Select proper fitting mask Properly inflate the tracheal cuff Clean up spills when filling vaporizer Do not change scavenging canisters during a procedure

56 PACU Room Ventilation Minimum of 6 air changes per hour 2 air changes outside air

57 Work Practice Controls in PACU Distance away from patient when delivering care Patient assignment Report ventilation issues to Facilities Operations

58 Administrative Controls Routine PM on anesthesia machines Annual education and training Air monitoring Medical surveillance

59 Understanding Healthcare work is not safer than other work involving exposures to chemical, ergonomic and physical hazards

60 Occupational Exposures and the Precautionary Principle Where there are exposures and threats of adverse health effects, uncertainty should not be a reason for postponing action to prevent exposure

MANAGEMENT OF WASTE ANESTHESIA GAS NO DISCLOSURES

MANAGEMENT OF WASTE ANESTHESIA GAS NO DISCLOSURES Michael C. Tan, MD, MPH Perioperative Care Conference - Thursday, April 6, 2017 ANESTHESIA GASES Generic or chemical name Commercial name Year of introduction