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Congress, health worker advocates press OSHA, call for hospital-specific regs
Critics say OSHA fails to keep up with hazards
Has the U.S. Occupational Safety and Health Administration become a weak-willed agency that fails to protect workers from many modern-day workplace hazards? That was the resonating question as the Democratic-controlled Congress bore down on the agency with oversight hearings.
Subcommittees in both the House of Representatives and the U.S. Senate held hearings this spring, raising sharp questions about OSHA's emphasis on voluntary compliance and its lackluster regulatory activity.
Worker advocates specifically targeted health care as a key concern, as they asserted that OSHA has failed to adapt and address hazards that affect workers in service jobs such as health care. "They have abandoned their leadership role in safety and health in addressing the major workplace hazards," Peg Semanario, MS, director of occupational safety and health for the AFL-CIO in Washington, DC, told the Senate Subcommittee on Employment and Workplace Safety.
In fact, last fall, the General Accounting Office included workplace safety among "suggested areas for oversight." It urged Congress to determine whether OSHA has adapted to changes in the work force and whether its compliance assistance programs are effective in improving the health and safety of workers.
Lawmakers already are seeking to expand OSHA's reach. A bill titled the "Protecting America's Workers Act," which has been introduced in the U.S. House and Senate, would extend OSHA's coverage to public employees, add new whistle-blower protections, increase penalties for violations, and require employers to provide personal protective equipment free of charge.
Semanario noted that OSHA recently denied an AFL-CIO petition to create a standard related to pandemic influenza preparedness. In late May, the agency issued an extensive pandemic guidance document for health care. (See related article below.)
Respirator resistance: Why HCWs don't like N95s
In its pandemic influenza guidance, the U.S. Occupational Safety and Health Administration offers this advice about respirator compliance among health care workers:
Health care workers fail to wear respirators for a number of reasons, and it is important to understand the nature of this resistance in order to overcome it. The following are the most frequently cited reasons for not wearing respirators:
1. They are hot and uncomfortable.
Health care employers should work hard to overcome employee resistance to wearing respirators and promote full compliance with the respiratory protection program. Strategies should be implemented to promote respirator use, such as staff education, reminders in the workplace, and routine observation and feedback.
"It is a potential threat that is looming that could have a bigger devastation than anything we've ever seen," said Semanario. "This is something we need to be focusing on now to make sure the protections are in place."
Semanario and others also hammered OSHA on its failure to address musculoskeletal disorder hazards. OSHA created an ergonomics standard, but it was repealed by Congress in 2001. Since then, there have been no citations of hospitals under the general duty clause for ergonomic hazards, although patient handling injuries are the No. 1 cause of injury in the hospital sector.
At a hearing before the House Subcommittee on Education and the Workforce, OSHA administrator Edwin Foulke defended the agency's record by noting that injuries and illnesses overall have declined by 13% since 2002. "The statistics show that the balanced approach we've taken has been extremely successful," he said.
Where is the hospital ergo guideline?
Although hospitals have higher injury rates than construction and manufacturing, most hospitals are unlikely to encounter an OSHA inspector.
In 2005, OSHA inspectors conducted 162 inspections in hospitals, issuing 323 citations. That represents about 0.4% of the total inspections for 2005 — although with 259,000 reported injuries, hospitals account for more reported injuries than any other industry, according to the U.S. Bureau of Labor Statistics. About 7% of all reported injuries occur in hospitals.
Currently, there are no local or national emphasis programs that provide an OSHA focus on hazards in the hospital sector.
"OSHA is essentially obsolete when it comes to dealing with the major hazards these workers face," contends Bill Borwegen, MPH, safety and health director for the Service Employees International Union (SEIU) in Washington, DC.
For example, nurses and nursing assistants are among the top 10 occupations that suffer from work-related musculoskeletal disorders. Although a number of states have passed legislation requiring hospitals to establish safe patient handling programs, OSHA has been largely silent on the subject.
In 2004, the National Advisory Committee on Ergonomics (NACE) identified hospitals as the top priority for ergonomic guidelines. OSHA issued guidelines for the nursing home, poultry and grocery industries, but has not issued any new guidelines since 2004. The agency is working on a guideline for shipyard workers but is not currently working on a guideline for acute care hospitals, according to OSHA spokesman Kelly Rowe.
"I'm disappointed they haven't done anything about it," says safe patient handling expert Audrey Nelson, PhD, RN, FAAN, director of the Patient Safety Center of Inquiry at the James A. Haley VA Hospital in Tampa, FL, who served on NACE. "Enough time has passed that something should have happened. To have done nothing about it is a missed opportunity."
Through its alliance with the Association of Occupational Health Professionals in Healthcare (AOHP), OSHA assisted in the development of a patient handling resource guide, which is available from the AOHP web site (www.aohp.org/About/documents/GSBeyond.pdf).
Each year, OSHA conducts a site-specific targeting program, which focuses comprehensive inspections on high-injury workplaces. This year, 10 hospitals were among the 4,150 worksites identified as having a rate of 11 or more injuries and illnesses involving days away from work, restricted work or job transfer per 100 full-time equivalent employees (FTE), or a rate of nine or more injuries involving days away from work per 100 FTE. (The high-hazard workplaces were chosen from a survey of 80,000 workplaces, which included 376 hospitals. Some of those hospitals were in state-plan states and would not have been designated for OSHA inspections.)
Another 50 hospitals with above-average injury and illness rates received warning letters and are on a secondary list for possible inspection.
"In general, hospitals have injury rates below those that the agency currently uses to target inspections," OSHA officials responded in a written comment to Hospital Employee Health. "This means that almost all of the hospital inspections conducted by OSHA are initiated by employee complaints, and the majority of those complaints do not involve ergonomics, but instead hazards such as occupational exposure to bloodborne pathogens and chemical hazard communication."
So far, OSHA has been unable to meet the "high burden of proof" for citations under the general duty clause related to ergonomic hazards, OSHA said.
EHPs want hospital-specific regs
Employee health professionals generally support the idea of a stronger OSHA. Hospitals need regulations that were designed for health care, not for manufacturing or other industries, notes Denise Knoblauch, RN, BSN, COHN-S/CM, clinical case manager, OSF SFMC Center for Occupational Health at Saint Francis Medical Center in Peoria, IL.
"Health care is a specialty that deserves its own standards when industrial-based standards do not apply, such as infectious disease-based respiratory standards," she says.
The bloodborne pathogen standard, first issued in 1991 and revised in 2001, demonstrates OSHA's potential to have a significant impact on health care worker safety, says Robert McLellan, MD, MPH, medical director of employee health at Dartmouth-Hitchcock Medical Center in Lebanon, NH, and president of the American College of Occupational and Environmental Medicine.
"I want to credit OSHA for serving a very important role in helping to begin to change opinions about hospital work and to put in place a very robust standard that has been very helpful," he says. Before that standard was created, "the serious hazards associated with the hospital industry hadn't been widely appreciated," he says.
Now OSHA has an opportunity to provide a similar "minimum foundation standard" in the area of airborne infectious disease, McLellan says.
But he acknowledges that a tension between patient safety/infection control and employee health complicates those efforts.
The answer may lie in a more formal collaboration between the Centers for Disease Control and Prevention, the Joint Commission, and OSHA, suggests McLellan.
OSHA enforcement not consistent
Meanwhile, OSHA's enforcement activity varies widely. While most hospitals never see an OSHA inspector, Dartmouth-Hitchcock Medical Center has had three OSHA inspections in the past two years. Its injury and illness rate is significantly lower than the hospital industry average of 7.5 per 100 FTE. Employee complaints are a key trigger for an OSHA inspection, and those are more likely to occur at a large facility.
Still, safety officer Lindsey Waterhouse, manager of safety and environmental programs, appreciates OSHA's role. In fact, he once worked as an OSHA compliance officer. "I do know their importance," he says. "They're the stick. It is important to have an agency like OSHA as a regulator and overseer."
Hospitals should do the right thing without regulation, he notes. For example, Dartmouth-Hitchcock uses the defunct ergonomics standard as a model for job hazard analysis. But in some areas, such as chemical hazards, hospitals need a regulatory framework that OSHA could provide by updating its standards, he says.