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
Misconception Healthcare work is safer than other work involving exposures to chemical, ergonomic and physical hazards
Attitude Patient safety is of higher priority than personal safety Ambivalence
Filling in gaps will help us reduce hazards in healthcare
Gap 1 Limited hazard surveillance data
Gap 2 Limited health surveillance data
Gap 3 Unable to compare illness and injury rates to other industrial sectors
Gap 4 Limited epidemiologic data Have seen increased rates of cancer in nurses Not enough information to understand all the underlying causative factors
Gap 5 Unknown health implications from new practices and technologies
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 57:640-652 (2014)
1 Hazardous Drugs - aerosolized antibiotics/ antivirals -
2 Hazardous Chemicals - waste anesthetics gases -
Exposure The condition of being subjected to a chemical, physical or biological agent
Dose Amount of agent that workers absorb through all routes of entry Air exposure
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
Hazardous Drugs For sick patients, the therapeutic benefits of hazardous drugs outweigh the risk of undesirable side effects
Hazardous Drugs Healthcare workers can experience the undesirable side effects of hazardous drug exposure with no health benefits realized
Hazardous Drugs http://www.cdc.gov/niosh/docs/2004-165/pdfs/2004-165.pdf
Hazardous Drugs updated list http://www.cdc.gov/niosh/docs/2014-138/pdfs/2014-138_v3.pdf
Respiratory therapists report concern over aerosolized antibiotics/ antivirals Tobramycin Amikacin Colistin Pentamindine Ribavirin
Hazardous Drug Tobramycin Amikacin Colistin Pentamindine Ribavirin
Ribavirin Administration Bone marrow transplant patient for prevention/treatment of Respiratory Syncytial Virus
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
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
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 15-22 bacterial/viral filter - 99.999% efficiency Aerosol particle size at 1.0-1.3 microns
NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin Personal air samples - attending nurse - - respiratory therapist - Area samples
NIOSH Health Hazard Evaluation Occupational Exposure to Ribavirin Personal air samples resulted in exposures below limit of detection due to short sample times
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
Tenthouse Enclosure
Ribavirin Toxicity Hemolytic anemia results in worsening of cardiac disease Teratogenic and embryocidal effects in many species
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
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
Exposure Controls Double gloves Protective gown Eye protection (goggles) Respiratory protection (N95) Dilution ventilation in room Proper Housekeeping
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
Employer Exposure Controls Written Procedures Training Specialized equipment PPE Ventilation Proper disposal Medical surveillance
Medical Surveillance One aspect of a comprehensive prevention program to minimize/eliminate occupational exposures
Medical Surveillance Collecting and interpreting data to detect changes in health status Establish initial baseline Monitor future health relative to baseline
Medical Surveillance Identify changes in health status prior to disease Identify need for stricter exposure controls
http://www.cdc.gov/niosh/docs/2007-151/pdfs/2007-151.pdf
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
Who s exposed? Anesthesiologists Anesthesiologist assistants Nurse anesthetists Surgeons Dentists Perioperative nurses Recovery room nurses
Major Health Effects Spontaneous abortion (N 2 O) Congenital abnormalities (N 2 O) Headache Fatigue Nausea Cognitive impairment
Name NIOSH REL* (ppm) ACGIH TLV (ppm) Nitrous oxide 25 50 Halothane 2 50 Enflurane 2 75 Isoflurane - - Desflurane - - Sevoflurane - - *During period of administration
Agent UK STEL TWA (ppm) Austria STEL TWA (ppm) Norway STEL TWA (ppm) Finland STEL TWA (ppm) Isoflurane 150 50 20 10 4 2 20 10 Desflurane 30 20 20 10 Sevoflurane 30 20 20 10 Enflurane 150 50 80 20 0.9 0.3 20 10
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
Global Harmonization System Hazard Statements - Sevoflurane May cause allergy or asthma symptoms or breathing difficulties if inhaled
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
Exposure concentration during procedure = 6.2 ppm
Exposure concentration during procedure = 1.2 ppm Full shift TWA exposure = 0.45 ppm
Exposure concentration during procedure = ND
Exposure Controls Anesthesia machine leak points Scavenging system Dilution ventilation Work practices
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
Operating Room Ventilation Minimum of 20 air changes per hour 4 air changes outside air
Work Practice Controls in the OR Turn off gas when: - intubating - repositioning patient - flush breathing system prior to extubation
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
PACU Room Ventilation Minimum of 6 air changes per hour 2 air changes outside air
Work Practice Controls in PACU Distance away from patient when delivering care Patient assignment Report ventilation issues to Facilities Operations
Administrative Controls Routine PM on anesthesia machines Annual education and training Air monitoring Medical surveillance
Understanding Healthcare work is not safer than other work involving exposures to chemical, ergonomic and physical hazards
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