Regulations you need to know: OSHA (Part 3) (Proceedings)

Since most OSHA inspections are the result of an employee (or former employee) complaint or a reported injury or illness, very often the inspection will focus on a specific area of concern within the workplace. Just as medical professionals specialize, the inspector's expertise in occupational health or general safety rules will also play a role in what portions of a hospital safety program are evaluated. With that in mind, we'll discuss the elements of an entire hospital safety program. Remember, this is not an overnight project. There are few definitively right or wrong answers. The important objective is to document the policies and practices that are in effect now. Changes and revisions will come with time. When you have completed a section's policy statements and training materials, add it to the Hospital Safety Manual binder. This will demonstrate a comprehensive program.

Hazards for the Medical Staff

Animal Handling

Although handling animals in itself is not a dangerous job, the unpredictability of some animals or situations can turn a routine episode into a very dangerous event. There are many situations that OSHA doesn't address directly, but getting caught in a run with a vicious dog is definitely dangerous. The hospital director should make sure all people (including volunteers) who handle animals are properly trained in restraint procedures. There should be a mechanism for workers to summon assistance when they get into trouble. Could someone yelling for help from the kennels be heard in the front of the hospital above the chorus of barking dogs? What about weekends or off-hours when there may be only one person in the building?

Noise

OSHA standards require a hearing conservation program when workers are exposed to noise levels above 85 decibels (db) based on an eight hour time-weight average (TWA). As a general rule, the louder the noise, the shorter exposure is permitted.

Although it will vary from one breed to another, as well as one animal to another, noise level from a barking dog can reach 80 or 90 decibels. It doesn't take much of a chorus of barking dogs to exceed the threshold limit for a noise hazard area. In hospitals the author has consulted with, noise levels in the kennels typically ranged from 95 to 115 decibels measured at the center of the room. At the upper end of this range a person could work approximately 15 minutes in the area without hearing protection during an average 8 hour work day.

The hearing conservation program can take many forms, including medical evaluations and periodic audiograms for employees, safety equipment, reduction in noise levels by absorption or dissipation, training of employees, and posting of warning signs identifying noise hazard areas.

Noise hazard areas must be identified by means of a poster, placard or sign. The wording should reflect the degree of danger. Typically, a sign stating "Warning: Noise Hazard Area. Hearing protection required for prolonged exposure" is sufficient for most areas. Place the sign at all entrances to the areas, including exterior doors.

Anesthesia

The NIOSH established limits for occupational exposure to waste anesthetic gasses is less than 2.0 parts per million (ppm) for all halogenated agents (methoxyflourane, halothane, isoflorane). Exposure to the nitrous oxide must also be maintained below 25 ppm. Most hospitals are unaware of the actual concentration levels of waste anesthetic gasses in the workplace, but with a comprehensive WAG management program, the risk of unnecessary exposure can be minimized. A comprehensive WAG management program should consist of the following elements:

     • Application of a well designed WAG scavenging system. This is the single most effective means of reducing exposures of WAGs in the workplace. A proper scavenging system will capture the excess gasses directly at the source and transport them to a safe exhaust port, usually outside the building. There are three general methods of WAG removal currently in use: active scavenging, passive exhaust and absorption. Each has a place, but rarely does one method fit all circumstances.

     • Routine maintenance and evaluation of anesthesia equipment. Anesthetic machines must be checked for leaks and serviced periodically. Although there is no "set" interval, the machine manufacturer's recommendations should be followed. At a minimum, daily "pre-use checks" for leaks in the hoses or connections should be performed, and examination or calibration by a qualified medical equipment repair technician should be completed every four months.

     • Developing or revising work practices that minimize leaks and non-scavenged operations. Detailed training for staff members who operate or clean anesthesia equipment is a must. Training should include all areas of anesthesia agent use, including storage of the liquid agents, refilling of the vaporizers, emergency procedures if a bottle is dropped and broken, as well as general operating instructions for the machine.

     • Training of the staff in proper principles of anesthesiology so that only the minimum amounts of anesthetic agents are used. Many hospitals use the "about that much" method of gas anesthesia and can significantly reduce the quantity of anesthetic agents used if flow rates were calculated prior to induction.

     • Adequate general ventilation in the work areas. Some procedures , like masking, defy collection of waste gasses. In those instances, make sure the ventilation in the room is good. Exhaust fans for evacuating room air to the outside are recommended. Be conscious of air handling systems that recirculate the air; exposure of others may be the result. Induction chambers can be connected to the scavenging system or absorption canisters to reduce the levels of escaping gasses.

Compressed gas cylinders

Compressed gas cylinders should be stored in a dry, cool place, away from potential heat sources such as furnaces, water heaters, and direct sunlight. They must be secured in an upright position by means of a chain, or strap. Cylinders stored inside closets should also be secured since they can still fall against the door and injure someone who opens the door. Transportation carts and floor mounting collars are also acceptable methods of securing compressed gas cylinders. If equipped with protective caps, they must be in place when the cylinder is not in use. Large cylinders should be moved with the aid of a cart.

Special care should be taken when connecting or disconnecting tanks, as gasses compressed to several thousand pounds can cause serious injury to eyes and extremities. Impact resistant protective goggles should always be worn when handling compressed gas tanks.

Radiology

This area is sometimes confusing to veterinarians since there is often a state registration and inspection requirement for radiation machines. Veterinarians in states with Atomic Energy Commission approved radiation protection plans would be in compliance with OSHA's requirements if they followed the guidelines of their state regulations. Currently, such approved plans are in effect in Alabama, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Kansas, Kentucky, Louisiana, Maryland, Mississippi, Nebraska, New Hampshire, New York, North Carolina, North Dakota, Oregon, South Carolina, Tennessee, Texas and Washington.

In all other states, the regulations enforced by OSHA are independent of those required by the state, and the veterinary hospital must follow the most stringent requirements.

A complete hospital radiation safety program must include the following elements:

     • Regular evaluations of equipment and procedures.

     • Approved monitoring devices for all personnel exposed to ionizing radiation. At a minimum, notification to workers of their exposure measurements must be made annually. Many consultants suggest this become part of the employee's annual performance review.

     • Identification and posting of radiation areas. Signs containing the conventional, three blade, radiation caution symbol (magenta or purple on a yellow background) and the words "CAUTION RADIATION AREA" must be conspicuously posted in all radiation areas.

     • Availability of appropriate protective equipment. At a minimum, usable lead gloves and aprons must be available. Thyroid and retinal protection is recommended, but not required.

     • Written safety policies, operating instructions, and training programs. Staff members performing radiographic duties must be made aware of the hazards associated with radiation, the hospital's policies for minimizing exposure, the proper operation of equipment, and the provisions of OSHA's Ionizing Radiation Standard.

     • Some very simple practices will greatly enhance the effectiveness of a radiation safety program. Things like collimating to isolate the area of concern (leave a clear border around the film), proper measuring and settings to avoid retakes, and rotating radiographic duties among all qualified staff members will significantly reduce the dangers.

Sharps and Medical Waste

This is an area of double concern. The OSHA recognizes that the handling of sharps (needles, scalpel blades, etc.) is a serious safety hazard in veterinary hospitals, but the Environmental Protection Administration (EPA) is the agency responsible for most of the attention and regulations for disposable of medical wastes. Although sharps could definitely be a regulated medical waste, not all waste from a veterinary hospital is considered harmful to humans or the environment.

The federal guidelines for handling and disposal of medical specific wastes provide some good "common-sense" principles of workplace safety. New York has enacted a medical waste tracking acts which details medical waste disposal.

The practice of reusing syringes requires that someone remove the needle, clean the syringe, package and sterilize, then re-stock the syringes. This places someone at an increased risk of injury and is usually not allowed after an OSHA inspection.

Current recommendations suggest the immediate disposal of the entire needle/syringe unit into a puncture-proof, leak resistant container is the best method of containing sharps. This is sound advice, and already practiced in many facilities. The term 'puncture-proof, leak resistant" is very misunderstood. Ordinary plastic milk containers are not sufficient. Try pushing a 22 gauge needle through one. The containers made for this specific purpose are the most effective and are usually very economical.

The practice of cutting needles prior to disposal increases the potential for aerosolization of the contents and should be discontinued. Likewise, the practice of collecting sharps in a smaller container and transferring them to a larger container for disposal places someone at an increased risk of exposure and is not recommended.

Chemotherapy

The occupational risks associated with cytotoxic drugs (CDs) are a combination of the drugs' inherent toxicity and the extent to which the worker is exposed to the drug on the job. The chance of exposure can occur at many points in the handling process, and in the veterinary practice, the most probable routes of exposure are through inhalation of drug dusts or droplets, dermal absorption, and ingestion through contact with contaminated food or cigarettes. The first step in controlling or eliminating these probable exposures is to design a workstation that supports the safe completion of the procedure. In this section, we'll discuss the physical or facility concerns that must be addressed to safely use these drugs.

Perhaps the most basic purpose of physical safeguards is to prevent or control environmental exposure. Typically, this exposure comes in the form of splattering, spraying, and aerosol generation of the material. Aerosols can be generated by many activities, exposing not only the employee immediately involved, but also other staff members in the area. Therefore, it is strongly suggested that all CDs be prepared in one centralized area; this will minimize the risk of "extraneous" contamination. A Biological Safety Cabinet (BSC), where only CDs are prepared, should be used. If the BSC does not vent to the outside, then an appropriate HEPA filter must be installed. If the hood is exhausted outside, the discharge opening should be at an appropriate level and away from air intake units.

Aftercare of the patient receiving CD treatments requires a little discussion. Workers who will change soiled bedding or cage materials should be instructed on the hazards of the patient excreting the drugs in body secretions for up to 48 hours after administration. Any staff member who must clean up blood, vomitus, or excreta from patients who have received CDs in the last 48 hours should follow these procedures :

     • Always wear surgical latex gloves and disposable gowns when cleaning up spills involving excretia or blood. The gowns and gloves should be discarded after each use.

     • Always use surgical latex gloves and a disposable gown when cleaning cages or runs.

     • Disposable materials like cage paper should be placed in a separate plastic bag and immediately sealed. The sealed bag should be disposed of according to the hospital hazardous waste plan.

     • When possible, patients receiving CD therapy should be exercised in a separate area from other patients. Feces from patients deposited in exercise areas should be removed promptly following the same precautions.

     • Of course, proper personal hygiene practices should be followed after handling any patient. A thorough hand washing using a detergent soap should be performed after completion of these tasks.

     • Most practices will hospitalize the patient for this treatment, but if it is to be performed on an outpatient basis, or if the patient will go home less than 48 hours after the treatment, then it is important to inform the client of the safety precautions also.

Summary

Just like any other program or procedure, a good hospital safety program doesn't have to be complicated. It should be practical and understandable. If the staff doesn't remember the rules, then training is lacking or the program is too complicated. Only by understanding the requirements and applying the safeguards that are necessary to protect the worker, patient and practice owner can the practice continue with the primary mission of healthy pets. It is the leadership's responsibility to set and enforce the safety rules of the practice and the employee's responsibility to learn and follow those rules.