When two Dallas nurses became infected last fall while caring for the nation’s first domestic Ebola patient, the public grew alarmed about the possibility of spread in neighborhoods, stores and airplanes. But the U.S. Occupational Safety and Health Administration was concerned about a more present danger: Workplace transmission.
Two OSHA officials visited Texas Health Presbyterian Hospital but didn’t conduct an inspection or issue citations. In conjunction with infectious disease experts from the Centers for Disease Control and Prevention, they identified weaknesses in infection control and personal protective equipment and provided advice, Jordan Barab, deputy assistant secretary of labor, told HEH.
“There were a number of potential issues. It wasn’t so much a breach in protocol as not having the right protocol,” he says.
Initially, CDC director Tom Frieden, MD, MPH, cited a “breach in protocol” as the source of the worker infections, a comment that angered nurses around the country because it seemed to be blaming the workers. Frieden apologized, and the agency subsequently revised its PPE guidelines and emphasized proper donning and doffing. As of late February, the CDC had not published the findings of an investigation into the transmission.
OSHA responded to the Ebola outbreak in the same manner as it would to a natural disaster, such as a hurricane or flood, says Barab. “It was a crisis and CDC was in charge,” he says. “We did want to be there and provide any support to the hospital that we could, support for CDC, and to see what else we could learn.”
That spirit has continued, as OSHA seeks to help hospitals improve their worker protections, he says.
“We’re continuing to go into [designated Ebola] treatment or assessment centers around the country in compliance assistance mode,” he says. “We want to make sure the hospitals know how to be in compliance.”
In fact, current OSHA standards require hospitals to have adequate protections, including engineering and administrative controls such as properly ventilated isolation rooms, and training. Barab notes:
Ebola should be a part of bloodborne pathogen exposure control plans. Because Ebola is spread through blood and body fluids, it is covered by the Bloodborne Pathogen Standard. The exposure control plan should be comprehensive and should not just focus on personal protective equipment, Barab says. He also notes that unlike HIV and hepatitis, Ebola can be transmitted through vomit, perspiration and tears.
The OSHA PPE Standard requires employee understanding of donning and doffing procedures. A compliance directive issued in 2011 makes it clear that if employees don’t know how to properly use the PPE, the employer can be cited for deficiencies in training. “The [compliance officer] shall determine whether each employee performs work requiring the use of PPE can demonstrate an understanding of the required training, and the ability to use PPE properly,” the directive states. “Lack of an employee’s knowledge in or use of, assigned PPE would be indicative that the employee has not retained the requisite understanding or skill.” (www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-050.pdf)
In the last fiscal year (October 2013 to September 2014), OSHA issued citations under the PPE standard to only three hospitals. During the Ebola crisis, OSHA released a matrix with detailed information about what type of PPE is recommended for various job tasks. (www.dol.gov/osha/pdf/OSHA_FS-3761_PPE_Selection_Matrix_-_Ebola_(11-24-14).pdf.) (See related article below.)
The OSHA Respiratory Protection Standard requires written procedures for proper use, cleaning and storage of respirators. A 2014 compliance directive states that inspectors should verify compliance through personal observation in a walk around and by interviewing employees. “Questions asked during the interview should focus on determining how familiar the person is with the respirator program and the use of the respirators at the particular workplace,” the directive says. Four hospitals were cited under the Respiratory Protection Standard in the past fiscal year.
Meanwhile, OSHA continues to move forward on an infectious disease standard, which also would cover contact and aerosol exposures. (See related story on page 43.)
Travelers from Ebola-stricken areas in West Africa are being monitored for symptoms, which makes it less likely that a patient with a suspected case of Ebola will enter an emergency department without forewarning, Barab says.
But extra training and resources devoted to Ebola preparedness will lead to better infection control and worker protections, he says. “The measures that have been taken since [the Ebola transmission] should instill a pretty good level of confidence,” he says. “We’re much better prepared now than we were.”